1
PHARM MIDTERM
CHAPTER 1 THE ROLE OF THE NP AS THE PRESCRIBER
Roles and responsibilities of APRN prescribers
APRN- includes CNM, CRNA, NPs and APRNs
The degree of autonomy and breadth of drugs that can be prescribed vary from state to state
based on the Nurse practice act of the state.
Nurse Practitioner Journal and American Journal for Nurse Practitioners present a legislative
update once a year (January issue) providing a summary of each states practice as they relate
to titling, roles, and prescriptive authority.
The following were true of NP regulation of practice and prescribing authority as of 2015-
*All states have title protection for NPs
*Only Oregon has mandated third party reimbursement parity for NP services
*In all but 5 states, the control of practice and licensure is within the sole authority of the states
board of nursing. this 5 states have joint control in the board of nursing and the board of
medicine
*Scope of practice is determined by the individual NPs license under the nurse practice act of
the licensing jurisdiction p
*In 17 states and the District of Columbia, NPs have independent SOP and prescriptive authority
without a requirement for physician collaboration, consultation, delegation, or supervision
*6 states have full autonomous practice and prescriptive authority following a Period of post
licensure/ post certification supervision and collaboration.
IOM-called for removing scope of practice barriers and allowing NPs to practice to the full
extent of their education and training.
Clinical judgement in Prescribing
Prescribing a drug results from clinical judgement based on a thorough assessment of the
patient and the patients environment, the determination of medical and nursing diagnosis, a
review of potential alternative therapies, and specific knowledge about the drug chosen and the
disease process it is designed to treat.
Best therapy- least expensive, least invasive, and least likely to cause adverse reaction.
,2
Best choice- to have lifestyle, non pharmacological and pharmacological therapies working
together.
Questions arises when the choice of treatment option is a drug
Is there a clear indication for drug therapy?
1. Before drug therapy is chosen an indication and necessity of using a drug should be
carefully considered. Example: In treating Otitis media, guidelines regarding the use of
antibiotics have been evolving due to high percentage of OM infections resolves without
intervention. Of concern is organism's resistance to antibiotics, with atbx over
treatment.
What drugs are effective in treating this disorder?
1. Consider the best and most effective class of drug
2. The agency for healthcare quality (AHCQ), National Institute of Health(NIH) and many
specialty organizations publish disease specific treatment guidelines that include both
pharmacological and non pharmacological therapy.
What is the goal of therapy with this drug?
1. If cure is the goal (short term therapy ), troublesome adverse effects maybe better
tolerated and cost maybe less of an issue
2. If the goal is long term treatment for chronic condition, adverse effects and cost take on
a different level of importance, and how well the drug fits into the lifestyle of the
patient.
Under what conditions is it determined that a drug is not meeting the goal and a
different therapy or drug should be tried?
1. The provider and patient should have a clear understanding of what outcome or goal is
expected
2. Follow up and monitoring to see how well treatment with the drug is meeting the goal
3. Include questions when to consult with or refer to a specialist
Are there unnecessary duplication with other drugs that the patient is already taking
1. Review patient medication history at each encounter to detect duplications or
medications that maybe discontinued
2. Use of an integrated EHR can assist the provider in discovering the duplication of therapy
and collaborating wi5 other providers to develop a simplified regimen.
Would an OTC drug be just as useful as a prescription drug?
, 3
1. Increasing numbers of drugs are being moved from prescription to OTC, May lead to
reduction in cost or increase patients cost due to insurance no longer paying for the
medication.
2. Patient may not consider OTC as drugs because they are not prescribed therefore a
careful history of medications would specifically ask about OTC medications.
What about the cost?
1. Can the patient afford the drug?
2. Will the cost of medication affect adherence to the treatment regimen
3. Consideration of cost is a major factor in choosing between the newer drugs and ones
that has been around long enough to be available in generic form
Where is the information to answer this questions?
1. Sources of drug information includes the wide array of professional literature that ranges
from journals to literatures from specialty and professional organizations and drug
databases such as lexicomp and Epocrates
2. Reliable drug information - Current, unbiased information, relevant to specific patient
for whom the drug will be prescribed, reliable and valid research, national and
international guidelines were used
Collaboration with other providers
1. Physicians- expertise related to pharmacology is based on understanding biochemistry
and prescribing for a given pathophysiology- emphasis is on the disease and the drug
with less emphasis on the impact on the patient.
2. Pharmacist- extensive knowledge about pathophysiology and best drug to prescribe. Can
assist APRNs and physicians by offering expertise on the clinical management of the
patients including available dosage forms, potential adverse reactions and drug
interactions.
3. other APRNs- one to one basis dealing with individual patient issues. Share knowledge
base and collaborate to improve the care of the patient. Collaboration on issues related
to SOP and prescriptive privilege at the state and national level is critical to obtaining
and maintaining the autonomy of practice needed to provide optimal patient care.
4. PA-practice is similar to that of a physician so both APRN and PA can benefit from
interaction with each other
5. Nurses not in advance practice roles such as certified Diabetic Educator- carry out APRNs
order. APRNs must know the Nurse practice act in the state where they practice because
nurses preparation and responsibility are defined by the Nurse practice act in each state.
Autonomy and Prescriptive authority
PHARM MIDTERM
CHAPTER 1 THE ROLE OF THE NP AS THE PRESCRIBER
Roles and responsibilities of APRN prescribers
APRN- includes CNM, CRNA, NPs and APRNs
The degree of autonomy and breadth of drugs that can be prescribed vary from state to state
based on the Nurse practice act of the state.
Nurse Practitioner Journal and American Journal for Nurse Practitioners present a legislative
update once a year (January issue) providing a summary of each states practice as they relate
to titling, roles, and prescriptive authority.
The following were true of NP regulation of practice and prescribing authority as of 2015-
*All states have title protection for NPs
*Only Oregon has mandated third party reimbursement parity for NP services
*In all but 5 states, the control of practice and licensure is within the sole authority of the states
board of nursing. this 5 states have joint control in the board of nursing and the board of
medicine
*Scope of practice is determined by the individual NPs license under the nurse practice act of
the licensing jurisdiction p
*In 17 states and the District of Columbia, NPs have independent SOP and prescriptive authority
without a requirement for physician collaboration, consultation, delegation, or supervision
*6 states have full autonomous practice and prescriptive authority following a Period of post
licensure/ post certification supervision and collaboration.
IOM-called for removing scope of practice barriers and allowing NPs to practice to the full
extent of their education and training.
Clinical judgement in Prescribing
Prescribing a drug results from clinical judgement based on a thorough assessment of the
patient and the patients environment, the determination of medical and nursing diagnosis, a
review of potential alternative therapies, and specific knowledge about the drug chosen and the
disease process it is designed to treat.
Best therapy- least expensive, least invasive, and least likely to cause adverse reaction.
,2
Best choice- to have lifestyle, non pharmacological and pharmacological therapies working
together.
Questions arises when the choice of treatment option is a drug
Is there a clear indication for drug therapy?
1. Before drug therapy is chosen an indication and necessity of using a drug should be
carefully considered. Example: In treating Otitis media, guidelines regarding the use of
antibiotics have been evolving due to high percentage of OM infections resolves without
intervention. Of concern is organism's resistance to antibiotics, with atbx over
treatment.
What drugs are effective in treating this disorder?
1. Consider the best and most effective class of drug
2. The agency for healthcare quality (AHCQ), National Institute of Health(NIH) and many
specialty organizations publish disease specific treatment guidelines that include both
pharmacological and non pharmacological therapy.
What is the goal of therapy with this drug?
1. If cure is the goal (short term therapy ), troublesome adverse effects maybe better
tolerated and cost maybe less of an issue
2. If the goal is long term treatment for chronic condition, adverse effects and cost take on
a different level of importance, and how well the drug fits into the lifestyle of the
patient.
Under what conditions is it determined that a drug is not meeting the goal and a
different therapy or drug should be tried?
1. The provider and patient should have a clear understanding of what outcome or goal is
expected
2. Follow up and monitoring to see how well treatment with the drug is meeting the goal
3. Include questions when to consult with or refer to a specialist
Are there unnecessary duplication with other drugs that the patient is already taking
1. Review patient medication history at each encounter to detect duplications or
medications that maybe discontinued
2. Use of an integrated EHR can assist the provider in discovering the duplication of therapy
and collaborating wi5 other providers to develop a simplified regimen.
Would an OTC drug be just as useful as a prescription drug?
, 3
1. Increasing numbers of drugs are being moved from prescription to OTC, May lead to
reduction in cost or increase patients cost due to insurance no longer paying for the
medication.
2. Patient may not consider OTC as drugs because they are not prescribed therefore a
careful history of medications would specifically ask about OTC medications.
What about the cost?
1. Can the patient afford the drug?
2. Will the cost of medication affect adherence to the treatment regimen
3. Consideration of cost is a major factor in choosing between the newer drugs and ones
that has been around long enough to be available in generic form
Where is the information to answer this questions?
1. Sources of drug information includes the wide array of professional literature that ranges
from journals to literatures from specialty and professional organizations and drug
databases such as lexicomp and Epocrates
2. Reliable drug information - Current, unbiased information, relevant to specific patient
for whom the drug will be prescribed, reliable and valid research, national and
international guidelines were used
Collaboration with other providers
1. Physicians- expertise related to pharmacology is based on understanding biochemistry
and prescribing for a given pathophysiology- emphasis is on the disease and the drug
with less emphasis on the impact on the patient.
2. Pharmacist- extensive knowledge about pathophysiology and best drug to prescribe. Can
assist APRNs and physicians by offering expertise on the clinical management of the
patients including available dosage forms, potential adverse reactions and drug
interactions.
3. other APRNs- one to one basis dealing with individual patient issues. Share knowledge
base and collaborate to improve the care of the patient. Collaboration on issues related
to SOP and prescriptive privilege at the state and national level is critical to obtaining
and maintaining the autonomy of practice needed to provide optimal patient care.
4. PA-practice is similar to that of a physician so both APRN and PA can benefit from
interaction with each other
5. Nurses not in advance practice roles such as certified Diabetic Educator- carry out APRNs
order. APRNs must know the Nurse practice act in the state where they practice because
nurses preparation and responsibility are defined by the Nurse practice act in each state.
Autonomy and Prescriptive authority
