1、“Care”和和“Service”nCare LONGMAN DICTIONARY OF TEMPERARY ENGLISH Worry;anxiety;sorrow;grief;Charge;keeping;protection;responsibility;Serious attention;Carefulness in avoiding harm,damagenCARE 大英汉词典nICU “Intensive Care Unit”nCCU “Cardiac Care Unit”药学服务药学服务n范围广泛，所有与药学有关的服务。如，卫生行政药事管理部门，企业的制药技术服务，医院的药学服务
2、等。n医院药学部门所提供的系统的服务，包括药品的配制和分发，提供与药物和疾病有关的信息，所有病人用药剂量的监测，审查医生处方并录入数据库等。（临床药学临床药学n临床药学是由药学专业人员实施的，帮助临床最大效益的使用药物，并且将药物的毒性降到最小的学科。（临床药学服务临床药学服务n选择用药 n药代动力学评价给药剂量和方法 n对病人用药的咨询和教育 n其他优化药物治疗的方法。药学监护药学监护n1990年Robert Cipolle，Linda Strand将药学监护定义为“以病人为中心的实践，实践者负责病人与用药有关的需求并为之负责”n药学监护实践是一次实践针对一个病人。由三部分组成：评估病人的需
3、求，制定监护计划，跟踪评价。Pharmaceutical servicesClinical pharmacy servicesPharmaceutical careA Typical Day of a Clinical Pharmacist in UK 英国临床药师的一天 Morning 8:30 12:00 (Coffee break 10:00 10:30)nSee the blackboard nFor those who discharge today nFor those who were admittednWard roundnReview the other patients w
4、ho has potential problemsAfternoon 13:00 16:30nWard meetingsnNurse meetingsnPharmacists meetingsnDispensingnLibrary For the individual patient The Minnesota ModelHolistic Approach病人条件病人条件 选择合适的药选择合适的药59岁女病人DA,因前胸剧烈疼痛,疼痛放射性的传播到左臂,急救中心到家中急救并送到SGH 医院急诊.病人主诉:胸部剧烈疼痛,呈放射性传到左 臂,恶心.急救医生给diamorphin后 疼痛缓解.asp
5、irin 300mgCase 入院检查:BP 137/81 mmHg pulse 62 bpm respiratory rates 16 temperature 36 SaO2 97%on air Her JVP,HS were normal her chest was clear.病史.Mrs DA 过去没有疾病记载 用药史 Mrs DA 住院前没有用过药物 ECG 显示 ST 段升高,诊断 急性下壁心肌梗塞诊断病人社会关系与丈夫一起住吸烟 每天25 支 喝酒 每周20 units.nUnit8g or 10 ml of pure alcoholHalf a pint of ordinary
6、 strength lager/beer/cider(3.5-4%A.B.V.)=1 unitA 25ml pub measure of a spirit(40%A.B.V)=1 unitA small glass of wine(8-9%)=1 unit n 1pintnDay 1(09/01/04)streptokinase 1.5 mu iv 链激酶 metoclopramide 10mg iv 甲氧氯普胺 metoprolol 25mg 美托洛尔 Enoxaparin 40mg,依诺肝素 aspirin 75mg,阿司匹林 simvastatin 40mg 辛伐他丁 ramipril
7、2.5mg 雷米普利 Paracetamol 1g 扑热息痛n稍后复查,ECG 显示病人恢复良好,病人生命体征很好nBP 113/81 mmHgnpulse 73bpm nRR 17 nDay 2(10/01/04)nDay 4(12/01/04)nDay 5(13/01/04)10/0112/0113/01Na (135-145)mmol/l 138135140141K (3.5-5.0)mmol/l 4.24.04.1Urea (3.3-6.0)mmol/l 4.36.34.64.5Gluc (3.9-5.0)mmol/l 11.210.7Creat (70-110)mol/l 56716
8、258TnT (180mmHg),感染性心内膜炎 yesStreptokinase 1.5MU 50ml 0.9%NaCl or 5%glucose over 1 hour Alteplase within 6-12 hours,10mg iv,then 50mg intravenous infusion over 60 minutesSince the presence of antistreptokinase antibodies from day 5 to 12 months post administration may render further treatment during
9、this time ineffective,it is important to document the patient had been given streptokinase and to issue the patient with a“streptokinase card”which includes the date of administration.LifestylenImproving diet nDelivering dietary Give consistent healthy eating advice that is tailored to the patients
10、needs and that can be extended advice to the whole family.Offer patients an individual consultation to discuss diet,including their current eating habits,and advice on improving their diet.nControlling alcohol Advise patients to keep weekly alcohol consumption within safe limits(no more than 21 unit
11、s of consumption alcohol per week for men or 14 units per week for women)and to avoid binge drinking.nImproving physical activity levels nCardiac rehabilitation programmes have been consistently shown to reduce mortality rates in CHD patients.nCardiac rehabilitation is the coordinated sum of interve
12、ntions required to ensure the best possible physical,psychological and social conditions to enable the CHD patient to preserve or resume optimal functioning in society.n It also aims to slow or reverse progression of the disease.Cardiac rehabilitation cannot be regarded as an isolated form or stage
13、of therapy,but must be integrated within secondary prevention services,of which it forms only one facet(WHO definition,1993).nCardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component nOffer all patients who have had a
14、n acute MI treatment with a combination of the following drugs:ACE inhibitor aspirin beta-blocker statin.Offer ACE inhibitors early after presentation and titrate upwards to the maximum tolerated or target dose.Do not routinely prescribe ARBs unless the patient is intolerant or allergic to an ACE in
15、hibitor.Continue ACE inhibitors indefinitely in patients with preserved LV function or LVSD,whether or not they have heart failure symptoms.Early after an acute MI,do not routinely use the combination of ACE inhibitor/ARB for patients with heart failure and/or LVSD.Assess LV function in all patients
16、 who have had an MI.Measure renal function,serum electrolytes and BP before starting an ACE inhibitor or ARB and again within 1 or 2 weeks.Monitor patients as the dose is titrated and more frequently for patients at increased risk of deterioration in renal function.Monitor patients with chronic hear
17、t failure For patients after a STEMI treated with the combination of aspirin and clopidogrel during the first 24 hours,this combination should be continued for at least 4 weeks.Thereafter standard treatment including low-dose aspirin should be given unless there are other indications to continue dua
18、l antiplatelet therapy.For patients with a history of dyspepsia,consider a PPI and low-dose aspirin.For patients with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are H.pylori negative,consider a full-dose PPI and low-dose aspirin.High-intensity warfarin(INR 3)should
19、not be considered as an alternative to aspirin in first-line treatment.For patients unable to take aspirin or clopidogrel,consider moderate-intensity warfarin(INR 23)for up to 4 years and possibly longer.The combination of warfarin and clopidogrel is not routinely recommended.Monitor renal function
20、and serum potassium before and during treatment.If hyperkalaemia is a problem,halve the dose or stop the treatment.For patients intolerant of statins,other lipid lowering agents should be considered.Reduce or stop the dose of statins if there are issues surrounding the metabolic pathway,food and/or
21、drug interactions and/or concomitant illness.Discontinue the statin and seek specialist advice if patients develop peripheral neuropathy that may be attributable to the statin treatment.Measure baseline liver enzymes before initiation.Do not routinely exclude patients who have raised liver enzymes f
22、rom treatment.Routine monitoring of creatine kinase in asymptomatic patients is not recommended,but should be measured in patients who develop muscle symptoms.Patient Education Education and stress management programmes reduce cardiac mortality and MI recurrence in post MI patients to notice?How lon
23、g will it take to notice any effect?药学监护计划药学监护计划（日期日期Date监护点监护点/期望结果期望结果Care Issues/Desired output 措施措施 Action 结果结果OutputDay1(09/01)Drug history-ensure the drug history accurately and correctly Check DH-discuss with patient-medical notes-GP/community pharmacistPatient didnt take any drugs on admissi
24、on Acute treatment on acute myocardial infarctionensure appropriate acute treatment Check to ensure-aspirin-streptokinase-metoclopramide-b blockerNo contraindication,all drug prescribed and given appropriately DateCare Issues/Desired output Action OutputSecondary prevention on MI-ensure appropriate
25、secondary preventionCheck to ensure-aspirin-ACE inhibitor-B-blocker-statin Aspirin 75mg,ramipril 2.5mg,metoprolol 25mg,simvastatin 40mg were prescribed Prevention of DVTensure appropriate treatment Check to ensure-low molecule weight heparinEnoxaparin 40mg was prescribedstopAware side effect of ACE
26、inhibitor-ensure no hypotension-aware the renal function Check BPCheck U&Es BP108-145/55-91mmHgU&Es stable DateCare Issues/Desired output Action Outputday2Metoprolol due to BPDizziness,cant tolerate-ensure patient tolerate-patient dizziness-alternative drugsMonitor BPMonitor U&EsObserve patient BP73
27、-97mmHg systolic on metoprololChange to atenolol,BP123/69mmHg Aware SE of b-blocker-ensure no hypotension-aware the renal functionMonitor BPMonitor U&EsBP123/69mmHgU&Es stableAware SE of Simvastatin-ensure no hepatotoxicity-ensure no myopathyMonitor LFTsD/W patientLFTs normalNo muscle pain,no tender
28、ness,no weakness DateCare Issues/Desired output Action Outputday5GTN spray-ensure correct use of sprays-ensure the correct dosageD/W patient-how to use it-not more than three times in 15 minutes-take spray when sitting down if possibleGood comprehensionSmoke cessation-ensure correct use of patch-ens
29、ure correct frequencyD/W patient-maximum frequency 1patch/24 hoursPatient good comprehensionDateCare Issues/Desired output Action Output patient discharge-ensure correct use of drugs at homeAspirin Atenolol Ramipril Simvastatin GTN spray Nicotine PatchD/W patient about the drugs at discharge patient good comprehensionThanks
