NR565 Midterm Study Guide 2022 2023
Week 1
• Which schedule drugs can APRNs prescribe?
• DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as noted
in collaborative agreement. May be facility/state dependent.
• Who determines and regulates prescriptive authority?
• Determines: Also known as independent prescribing. APRNS can prescribe without
limitation and is state dependent. Includes "legend" (prescription) and controlled drugs,
health/medical services, DME, etc.
Regulates: regulated by health professional board, state board of nursing or the State
Board of Medicine, or the State Board of Pharmacy, as determined by each state. Federal
government controls drug regulations but has no control over prescriptive authority.
• Prescriptive authority is the legal right to prescribe drugs.
• How does limited prescriptive authority impact patients within the
healthcare system?
• Limited prescriptive authority creates numerous barriers to quality, affordable, and
accessible patient care. For example, restrictions on the distance of the APRN or PA from
the physician providing supervision or collaboration may prevent outreach to area of
greatest need. An increase in patient waits.
• What are the key responsibilities of prescribing?
The ability to prescribe medications is both a privilege and a burden. Have a documented
provider-patient relationship, do not prescribe medications to family or friends or yourself,
Document a thorough history and physical examination, include any discussions you have
with the patient about risk factors, side effects, or therapy options, have documented plan
regarding drug monitoring or titration, if you consult additional providers not that you did
so. Use the references provided in the following boxes to assist in safely and rationally
choosing one medication over another.
Be sensible, accept responsibility, do not fear it, know constraints and limitations, always
learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with
patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off
label use), Provide use and rationale.
• What should be used to make prescribing decisions?
• The best way to keep your patients (and yourself) safe is to be prudent and deliberate in
your decision-making process. Cost, availability, current practice guidelines, medication
interactions including interactions with food, side effects, need for monitoring, how drug
is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)
Cost: It is of critical importance that providers ask patients if they have difficulty
obtaining their medication because it is cost-prohibitive.
, Guidelines: It is the provider's responsibility to keep abreast of new
recommendations or changes in guidelines and to incorporate these into their
prescribing practices.
Availability: The drug you want may not be available in your facility or at a specific
pharmacy. This can affect your choice of medications.
Interactions: There are very few medications that do not interact with either another
medication or food. Polypharmacy greatly increases the risk of interactions. Some of
these interactions are negligible, but some can have life-threatening consequences.
Side Effects: All drugs have side effects. Some are adverse, and some may be
beneficial.
Allergies: Unfortunately, your patient may have an allergy to that medication or class
of drug. It is of critical importance to determine the type of reaction and to
document it in the patient's chart. Then, the selection of an appropriate drug may
begin.
Hepatic and Renal Function: Many drugs are metabolized and eliminated by the liver
and kidneys. If these systems are impaired, this can lead to increased adverse effects
and possible medication overdose.
Need for monitoring: Some drugs require frequent monitoring at initiation or
throughout the duration of treatment.
Special Populations: Populations that deserve special mention when thinking about
medications include pregnant or nursing mothers and older adults.
• Be familiar with pharmacokinetic and pharmacodynamic changes of older
adults and how that would translate to baseline information needed to
prescribe.
• Pharmacokinetic is the study of drug absorption, distribution, metabolism, and excretion
in the body; what the body does to the drug. Pharmacodynamic is what the drug does to
the body.
• The ability of older adults to metabolize drugs is commonly decreased. Drug dosages
may need to be reduced to prevent drug toxicity.
• Physiologic Changes That Can Affect Pharmacokinetics in Older Adults
• Absorption of Drugs
• Increased gastric pH
• Decreased absorptive surface area
• Decreased splanchnic blood flow
, • Decreased lgastrointestinal lmotility
• Delayed lgastric lemptying
• Distribution lof lDrugs
• Increased lbody lfat
• Decreased llean lbody lmass
• Decreased ltotal lbody lwater
• Decreased lserum lalbumin
• Decreased lcardiac loutput
• Metabolism lof lDrugs
• Decreased lhepatic lblood lflow
• Decreased lhepatic lmass
• Decreased lactivity lof lhepatic lenzymes
• Excretion lof lDrugs
• Decreased lrenal lblood lflow
• Decreased lglomerular lfiltration lrate
• Decreased ltubular lsecretion
• Decreased lnumber lof lnephrons
• Measures lto lReduce lAdverse lDrug lReactions lin lOlder lAdults
• Take la lthorough ldrug lhistory, lincluding lover-the-counter lmedications, lherbal
lremedies, land ldietary lsupplements
• Account lfor lthe lpharmacokinetic land lpharmacodynamic lchanges lthat loccur lwith
laging
• Initiate ltherapy lwith llow ldoses land ltitrating lupward lgradually l(“start llow land lgo
lslow”)
• Monitor lclinical lresponses land lplasma ldrug llevels lto lprovide la lrational lbasis lfor
ldosage ladjustment
• Employ lthe lsimplest lmedication lregimen lpossible
• Monitor lfor ldrug–drug linteractions land liatrogenic lillness
• Periodically lreview lthe lneed lfor lcontinued ldrug ltherapy, land ldiscontinue
lmedications las lappropriate
• Encourage lthe lpatient lto ldispose lof lold lmedications
• Take lsteps lto lpromote ladherence
• Avoid ldrugs lincluded lin lBeers lCriteria lfor lPotentially lInappropriate lMedication lUse
lin lOlder lAdults l(the lBeers llist) lunless lbenefits loutweigh lrisks.
•
• Beer’s lCriteria
lo l l What lis lit?
• Guidelines lfor lprescribing lmedications lto lpatients l65 l& lolder. lDrugs lon lthe llist lshould
lbe lavoided lin lpatients lover l65 lexpect lwhen lthe lbenefits lsignificantly loutweigh lthe lrisks.
The lBeers lCriteria lincludes lfive llists lthat ldescribe lcertain lmedications land lsituations land
linclude: lpotentially linappropriate lmedication l(PIM) luse lin lolder ladults, lPIM luse lin
lolder ladults ldue lto lmedication-disease lor lmedication-syndrome linteractions lthat lmay
, exacerbate lthe ldisease lor lsyndrome, lmedications lto lbe lused lcautiously lin lolder ladults,
lclinically lsignificant ldrug linteractions lthat lshould lbe lavoided lin lolder ladults, lmedications
lto lbe lavoided lor ldosage ldecreased lin lthe lpresence lof limpaired lkidney lfunction lin
lolder ladults.
o l l l Why lis lit limportant?
• It lprovides la llist lof lmedications lthat lare lpotentially lharmful lin lelderly. lList lthat lidentifies
ldrugs lwith la lhigh llikelihood lof lcausing ladverse leffects lin lolder ladults. lBeers lCriteria
lare lrecommendations; lultimately lprescribers lmust ldetermine lwhether la lmedication lis
lappropriate lfor luse lor lnot. lThese lguidelines lare lnot lintended lto llimit lthe luse lof
lmedications lor lapply lto lall lolder ladults. lSafe land ljudicious lprescribing lis lcrucial lin lthe
lolder ladult lto loptimize lpharmacotherapy.
• Impacts/outcomes lof lpolypharmacy
• polypharmacy l(the luse lof lfive lor lmore lmedications ldaily)
• Polypharmacy lgreatly lincreases lthe lrisk lfor linteractions. lDrug linteractions lwith lmild lside
leffects lto llife-threatening lconsequences. lElderly lis lat la lhigher lrisk lof lpolypharmacy
ldue lto ltaking lfive lor lmore lmedications ldaily.
• CYP450 linhibitors
• CYP450 l are lpart lof lthe lmetabolic lpathway, linvolved lin lmetabolism lof ldrugs lin lthe lliver.
lMetabolism lcan lbe linhibited lor linduced lby ldrugs land lonce lthis lhappens ldrug-drug
linteraction lcan loccur.
o Examples
• Valproate, l Isoniazid, lSulfonamides, lAmiodarone, lChloramphenicol,
lKetoconazole, lGrapefruit ljuice, lQuinidine
Week 1
• Which schedule drugs can APRNs prescribe?
• DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as noted
in collaborative agreement. May be facility/state dependent.
• Who determines and regulates prescriptive authority?
• Determines: Also known as independent prescribing. APRNS can prescribe without
limitation and is state dependent. Includes "legend" (prescription) and controlled drugs,
health/medical services, DME, etc.
Regulates: regulated by health professional board, state board of nursing or the State
Board of Medicine, or the State Board of Pharmacy, as determined by each state. Federal
government controls drug regulations but has no control over prescriptive authority.
• Prescriptive authority is the legal right to prescribe drugs.
• How does limited prescriptive authority impact patients within the
healthcare system?
• Limited prescriptive authority creates numerous barriers to quality, affordable, and
accessible patient care. For example, restrictions on the distance of the APRN or PA from
the physician providing supervision or collaboration may prevent outreach to area of
greatest need. An increase in patient waits.
• What are the key responsibilities of prescribing?
The ability to prescribe medications is both a privilege and a burden. Have a documented
provider-patient relationship, do not prescribe medications to family or friends or yourself,
Document a thorough history and physical examination, include any discussions you have
with the patient about risk factors, side effects, or therapy options, have documented plan
regarding drug monitoring or titration, if you consult additional providers not that you did
so. Use the references provided in the following boxes to assist in safely and rationally
choosing one medication over another.
Be sensible, accept responsibility, do not fear it, know constraints and limitations, always
learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with
patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off
label use), Provide use and rationale.
• What should be used to make prescribing decisions?
• The best way to keep your patients (and yourself) safe is to be prudent and deliberate in
your decision-making process. Cost, availability, current practice guidelines, medication
interactions including interactions with food, side effects, need for monitoring, how drug
is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)
Cost: It is of critical importance that providers ask patients if they have difficulty
obtaining their medication because it is cost-prohibitive.
, Guidelines: It is the provider's responsibility to keep abreast of new
recommendations or changes in guidelines and to incorporate these into their
prescribing practices.
Availability: The drug you want may not be available in your facility or at a specific
pharmacy. This can affect your choice of medications.
Interactions: There are very few medications that do not interact with either another
medication or food. Polypharmacy greatly increases the risk of interactions. Some of
these interactions are negligible, but some can have life-threatening consequences.
Side Effects: All drugs have side effects. Some are adverse, and some may be
beneficial.
Allergies: Unfortunately, your patient may have an allergy to that medication or class
of drug. It is of critical importance to determine the type of reaction and to
document it in the patient's chart. Then, the selection of an appropriate drug may
begin.
Hepatic and Renal Function: Many drugs are metabolized and eliminated by the liver
and kidneys. If these systems are impaired, this can lead to increased adverse effects
and possible medication overdose.
Need for monitoring: Some drugs require frequent monitoring at initiation or
throughout the duration of treatment.
Special Populations: Populations that deserve special mention when thinking about
medications include pregnant or nursing mothers and older adults.
• Be familiar with pharmacokinetic and pharmacodynamic changes of older
adults and how that would translate to baseline information needed to
prescribe.
• Pharmacokinetic is the study of drug absorption, distribution, metabolism, and excretion
in the body; what the body does to the drug. Pharmacodynamic is what the drug does to
the body.
• The ability of older adults to metabolize drugs is commonly decreased. Drug dosages
may need to be reduced to prevent drug toxicity.
• Physiologic Changes That Can Affect Pharmacokinetics in Older Adults
• Absorption of Drugs
• Increased gastric pH
• Decreased absorptive surface area
• Decreased splanchnic blood flow
, • Decreased lgastrointestinal lmotility
• Delayed lgastric lemptying
• Distribution lof lDrugs
• Increased lbody lfat
• Decreased llean lbody lmass
• Decreased ltotal lbody lwater
• Decreased lserum lalbumin
• Decreased lcardiac loutput
• Metabolism lof lDrugs
• Decreased lhepatic lblood lflow
• Decreased lhepatic lmass
• Decreased lactivity lof lhepatic lenzymes
• Excretion lof lDrugs
• Decreased lrenal lblood lflow
• Decreased lglomerular lfiltration lrate
• Decreased ltubular lsecretion
• Decreased lnumber lof lnephrons
• Measures lto lReduce lAdverse lDrug lReactions lin lOlder lAdults
• Take la lthorough ldrug lhistory, lincluding lover-the-counter lmedications, lherbal
lremedies, land ldietary lsupplements
• Account lfor lthe lpharmacokinetic land lpharmacodynamic lchanges lthat loccur lwith
laging
• Initiate ltherapy lwith llow ldoses land ltitrating lupward lgradually l(“start llow land lgo
lslow”)
• Monitor lclinical lresponses land lplasma ldrug llevels lto lprovide la lrational lbasis lfor
ldosage ladjustment
• Employ lthe lsimplest lmedication lregimen lpossible
• Monitor lfor ldrug–drug linteractions land liatrogenic lillness
• Periodically lreview lthe lneed lfor lcontinued ldrug ltherapy, land ldiscontinue
lmedications las lappropriate
• Encourage lthe lpatient lto ldispose lof lold lmedications
• Take lsteps lto lpromote ladherence
• Avoid ldrugs lincluded lin lBeers lCriteria lfor lPotentially lInappropriate lMedication lUse
lin lOlder lAdults l(the lBeers llist) lunless lbenefits loutweigh lrisks.
•
• Beer’s lCriteria
lo l l What lis lit?
• Guidelines lfor lprescribing lmedications lto lpatients l65 l& lolder. lDrugs lon lthe llist lshould
lbe lavoided lin lpatients lover l65 lexpect lwhen lthe lbenefits lsignificantly loutweigh lthe lrisks.
The lBeers lCriteria lincludes lfive llists lthat ldescribe lcertain lmedications land lsituations land
linclude: lpotentially linappropriate lmedication l(PIM) luse lin lolder ladults, lPIM luse lin
lolder ladults ldue lto lmedication-disease lor lmedication-syndrome linteractions lthat lmay
, exacerbate lthe ldisease lor lsyndrome, lmedications lto lbe lused lcautiously lin lolder ladults,
lclinically lsignificant ldrug linteractions lthat lshould lbe lavoided lin lolder ladults, lmedications
lto lbe lavoided lor ldosage ldecreased lin lthe lpresence lof limpaired lkidney lfunction lin
lolder ladults.
o l l l Why lis lit limportant?
• It lprovides la llist lof lmedications lthat lare lpotentially lharmful lin lelderly. lList lthat lidentifies
ldrugs lwith la lhigh llikelihood lof lcausing ladverse leffects lin lolder ladults. lBeers lCriteria
lare lrecommendations; lultimately lprescribers lmust ldetermine lwhether la lmedication lis
lappropriate lfor luse lor lnot. lThese lguidelines lare lnot lintended lto llimit lthe luse lof
lmedications lor lapply lto lall lolder ladults. lSafe land ljudicious lprescribing lis lcrucial lin lthe
lolder ladult lto loptimize lpharmacotherapy.
• Impacts/outcomes lof lpolypharmacy
• polypharmacy l(the luse lof lfive lor lmore lmedications ldaily)
• Polypharmacy lgreatly lincreases lthe lrisk lfor linteractions. lDrug linteractions lwith lmild lside
leffects lto llife-threatening lconsequences. lElderly lis lat la lhigher lrisk lof lpolypharmacy
ldue lto ltaking lfive lor lmore lmedications ldaily.
• CYP450 linhibitors
• CYP450 l are lpart lof lthe lmetabolic lpathway, linvolved lin lmetabolism lof ldrugs lin lthe lliver.
lMetabolism lcan lbe linhibited lor linduced lby ldrugs land lonce lthis lhappens ldrug-drug
linteraction lcan loccur.
o Examples
• Valproate, l Isoniazid, lSulfonamides, lAmiodarone, lChloramphenicol,
lKetoconazole, lGrapefruit ljuice, lQuinidine
