Pharmacology and Pharmacotherapeutics in Advanced Nursing Practice
NGR6172
Chapter 1: Prescriptive Authority and Role Implementation: Tradition vs Change
o
Primary Care is provided by clinicians who address "personal health care needs, developing a sustained
partnership with patient, and practicing in the context of family and community."
•
Prevention, Diagnosis, Prescription, Treatment
▪ Assess health status.
▪ Promote healthy lifestyles.
▪ Identifying/diagnosing normal/abnormal conditions.
▪ Determining the causes of abnormal conditions, providing referral to health care specialists.
▪ Selecting appropriate therapeutic measures.
▪ Implementing treatment.
▪ Supervising/monitoring the patient on an ongoing basis.
•
Traditional Primary Care--physicians as the only providers with diagnostic and treatment authority--an intention
to protect the public.
▪ Prescriptive practices should not be compared to those of physicians--all providers should be held to a
standard of approved therapeutic practice.
•
Most Prescribed by PCP--antidepressants, NSAIDs, antihistamines/bronchodilators,
antihypertensives, antilipidemic.
•
Rate of Adoption by Prescribers--innovators, early adopters, early majority, late majority, and laggards.
o
Problems in the Prescribing Practice of Physicians
•
Prescriptions are not the most up to date--"new research findings diffuse slowly into practice."
•
Pharmaceutical company influence--FDA intervention and PhRMA guidelines.
•
Lack of time--short consultation, incorrect H&P, problem is left undefined, over-reliance on drug therapy.
•
Consumers' pressure for prescribed medications--"Do something!"--lifetime of medications, overused
antibiotics, and direct-to-consumer advertising.
•
Ineligible prescriptions --> Medication errors. Current federal mandate for e-prescribing. TJC Do Not Use
Abbreviations.
•
Undetected/anticipating drug interactions--liver cytochrome P450 enzymes = drug-to-drug interactions may
render medication ineffective--prescription warning system alerts. Rising use of OTC and herbal products.
Chapter 2: Historical View of Prescriptive Authority (Nurses vs. PA)
o
Primary Care is provided by clinicians who address "personal health care needs, developing a sustained
partnership with patient, and practicing in the context of family and community."
o
"Delegable authority --> "Delegable prescriptive authority" without it, an APN can only suggest OTC medications.
o
Nursing Legislation
•
Dependent authority--the physician retains ultimate authority through co-signature.
•
Independent authority--the APN prescribes alone--can still be restrictive.
•
1993--Definition and Registration of MLPs--can obtain DEA# beginning with M
▪ NPs
• DEA number and prescriptive authority differ by state.
• May dispense pharmaceutical samples in all states.
• Across-state-line prescribing
▪ CNMs
▪ CRNAs--do not "prescribe" under law.
▪ CNSs
o
Barriers to Practice for Nurses in the Diagnosing and Prescribing Role
•
Regulatory irregularity among states
•
Increased antagonism from organized medical groups competing with APNs for patients
•
Growing number of NP graduates without prior nursing experience
•
Inequity in data collection on physician prescribing patterns among pharmaceutical companies
, •
Difficulty in obtaining prescribing data from Prescription Drug Marketing Act
Chapter 9: Establishing the Therapeutic Relationship
•
"How scientific principles are introduced in the relationship with the patient has everything to do with therapeutic
success." The balance of art and science in healthcare.
•
"A continuing relationship with the healthcare provider is essential in making adjustments to discover the proper therapy for
the individual."
o
Identify a problem, assess it adequately, identify various potential solutions, examine he variables needed to
judge the risk/benefit ratio of the solutions, choose the most appropriate solution, and identify the effects (beneficial
and adverse) that may result from implementation of the chosen solution.
•
Factors of a Therapeutic Relationship
o
Time--investment--particularly with the elderly--initial investment to obtain thorough H&P--cost-effective--
follow up call strengthen the relationship
o
Attitude--how time is spent and what is said--"Who owns the problem?"
o
Information--it may take several visits to obtain a full history
o
Communication--effective two-way communication between patient and provider requires consistent
commitment to respect the others' role in the relationship.
• Transference
• Focus on patient, environment, and lastly, self.
• Find a balance between creating uncontrolled and unfounded anxieties vs creating a false sense of
equally grounding security and reassurance.
• It is implicitly understood that once a problem is presented, the provider will do their utmost to provide
the best therapy.
• The therapeutic objective must be clearly stated--1) must be realistic and attainable, 2) clearly related
to the problem as defined and assessed, 3) measurable.
• Be flexible, accept occasional lapses in compliance, attempt to understand the patient's point of view.
o
Therapeutic Relationship Fails
• Skepticism in the medical profession.
▪
Provider main goal is pharmacoadherence.
▪
Over or under utilization.
▪
Therapeutic failure and increase in disease severity.
▪
Gender, race, education, occupation, income, marital status--are not factors in compliance.
•
Blame the economy!
• Compliance vs adherence--both suggest patient fault
• Concordance--suggests a therapeutic alliance between prescriber and patient--a negotiated
agreement that may even be an agreement to disagree.
▪
Patient--actively participates in consultation process regarding treatment, risk, and benefit.
▪
Provider--communicates evidence to enable the patient to make informed choices, accepts
patient's choices regarding their care, continues to negotiate treatment and part of the ongoing
process.
▪
Risk Factors
•
Increases with preventive care
•
Increases with duration of therapy
•
Greatest for regimens with significant behavioral change
•
Poor understanding of instructions
•
Complex treatment regimen
•
Unpleasant side effects
•
Increases in drug costs
Chapter 10: Practical Tips on Writing Prescriptions
•
DEA--state-controlled substance license--federally issued DEA#
o
Drugs are scheduled by potential for abuse.
,•
Components of a Traditional Prescription
o
Name of prescriber--credentials, address, phone number
o
Date
o
Name of patient--address, age, and weight
o
Superscription--Rx--"take"
o
Inscription--drug ingredients, quantity, strength, and/or concentration
• Drug--full name of medication--no abbreviations
• Strength/concentration
o
Signature
o
The better the instructions, the better the medication compliance and patient understanding.
o
Refills
• No refills on Schedule II drugs
• Only 6 months/5 refills allowed
• "NO REFILLS"
o
DEA#--should not be printed on Rx or used for ID purposes
o
Generic Substitutions Okay?
• Dispense as Written
• Brand Medically Necessary
•
Electronic Signatures in Global and National Commerce Act: 2000
o
E-Sign
• No need to paper or hard copy.
• Schedule II--need to fax/present hard copy.
• Specifically, and emphatically prohibit the reimposition of tangible/paper requirements.
o
Prescription Etiquette
• Cannot prescribe narcotics to self or family--can prescribe non-narcotic Schedule IIs but it is
considered poor judgement.
▪
The DEA may start an investigation.
▪
Frequent prescribing for self/family may not be covered by HMOs.
▪
Prescriptions that are refilled without a Provider visit.
▪
Drug sampling--on the margin of legality.
▪
The prescriber is always responsible for what happens to the individual receiving the medication.
• Avoiding Mistakes
▪
Write clearly
▪
Stay up-to-date
•
Drug-drug interactions
•
Renal dosing of medications
•
Direct-to-consumer advertising--patients ask for medications PCP's may not
normally prescribe
•
Medication errors are inversely correlated to PCP's years of practice
▪
With disclosed suicidal ideation: Write for no more than a 7-day supply of a medication a
patient could overdose on if taken all at once
▪
Discuss side effects
▪
Discontinue a medication when it causes a cautioned side effect
▪
Get informed consent when a drug can cause permanent side effects and a less risky alternative
is available
▪
If prescribing “off-label”: Document the rationale for deviating from the package insert
instructions, and be prepared to prove that the standard of care supports the alternative prescribing
regimen
▪
If a drug is known to cause adverse effects after long-term use, avoid using the drug for long-
term therapy or monitor carefully for the onset of potential problems
▪
▪
Ask, Listen, and Alter the Plan
• Administrative Concerns
, ▪
Formularies--cost-saving measure that can be restrictive, are slow to integrate new and
effective drugs.
▪
Medicaid--joint Federal and State program--provider must be a Medicaid subscriber--states have
their own Medicaid formularies which omit new medications, expensive trade name medications, and
medications deemed "less than effective" by the FDA--payment is not made for non-formulary drugs
unless a waiver stating medical necessity or life-sustaining measures will be obtained from the
medication.
▪
Out-of-State Prescriptions--may or may not be filled--can also cause problems with
telehealth prescriptions--counterfeit medications purchased online.
▪
Telephone Orders--no Schedule I or II
▪
Emergency Dispensing of Medications--usually antibiotics or narcotic analgesics.
▪
Generic Substitutions--some states automatically allow--if brand name is required, write "Do
Not Substitute."
• Preventing Problems in Drug Use
▪
The Abusing Patient--asks for narcotics by name, carries proof of pain, calls requesting
refills early due to lost or stolen medications, altering prescriptions, using multiple providers.
•
Providers who feel they cannot continue to meet the needs of the patient have a
responsibility to help that patient find another provider.
▪
The Abusing Provider
▪
The Financially Needy Patient
Chapter 11: Evidence-Based Decision Making and Treatment Guidelines
•
Quality of healthcare relies upon 1) decisions that determine what actions are taken, 2) the quality of the actions executed.
•
Critical Thinking in Nursing
o
Made up of knowledge and an attitude of inquiry--a critical appraisal of knowledge
• Collecting and analyzing whatever evidence exists regarding the benefits, harms, and costs of each option.
• Clarify personal values or preferences of the patient.
▪
Joint decision making.
Knowledge --> Judgements --> Estimate --> Patient/provider preferences --> Decision
Evidence Critical analyses. Outcomes Critical thinking
Benefits vs Harm Judgements
Costs Important patient outcomes
Marginal benefits Estimated patient
outcomes Patient
preferences
•
Evidence-based medicine is the science--no single correct answer and no obligation that everyone must agree--is the art.
•
Brenner 1984--described the process of skill acquisition by nurses.
o
Begins with decision-making analysis, then hypothetical deductive reasoning, and the eventual emergence of
the expert that functions at an intuitive level.
• The effects of intuition on an expert nurse's ability to make clinical decisions…
▪
Pattern recognition--recognizing relationships
▪
Similarity recognition--recognizing relationships despite obvious differences
▪
Commonsense understanding--having a deep understanding of a given entity
▪
Skilled know-how--ability to visualize a situation
▪
Sense a salience--ability to recognize what is important
▪
Deliberative rationality-ability to anticipate events
o
Diagnostic errors can be classified into:
• Faulty hypothesis triggering
▪
Failure to pick right hypothesis or revise hypothesis
• Faulty context formulation
▪
Occurs when clinician and patient have different goals
• Faulty information gathering process
▪
Failure to order appropriate tests or misinterprets information
• Faulty verification of diagnoses
▪
Failure to collect enough data to confirm a diagnosis or to completely rule out others
NGR6172
Chapter 1: Prescriptive Authority and Role Implementation: Tradition vs Change
o
Primary Care is provided by clinicians who address "personal health care needs, developing a sustained
partnership with patient, and practicing in the context of family and community."
•
Prevention, Diagnosis, Prescription, Treatment
▪ Assess health status.
▪ Promote healthy lifestyles.
▪ Identifying/diagnosing normal/abnormal conditions.
▪ Determining the causes of abnormal conditions, providing referral to health care specialists.
▪ Selecting appropriate therapeutic measures.
▪ Implementing treatment.
▪ Supervising/monitoring the patient on an ongoing basis.
•
Traditional Primary Care--physicians as the only providers with diagnostic and treatment authority--an intention
to protect the public.
▪ Prescriptive practices should not be compared to those of physicians--all providers should be held to a
standard of approved therapeutic practice.
•
Most Prescribed by PCP--antidepressants, NSAIDs, antihistamines/bronchodilators,
antihypertensives, antilipidemic.
•
Rate of Adoption by Prescribers--innovators, early adopters, early majority, late majority, and laggards.
o
Problems in the Prescribing Practice of Physicians
•
Prescriptions are not the most up to date--"new research findings diffuse slowly into practice."
•
Pharmaceutical company influence--FDA intervention and PhRMA guidelines.
•
Lack of time--short consultation, incorrect H&P, problem is left undefined, over-reliance on drug therapy.
•
Consumers' pressure for prescribed medications--"Do something!"--lifetime of medications, overused
antibiotics, and direct-to-consumer advertising.
•
Ineligible prescriptions --> Medication errors. Current federal mandate for e-prescribing. TJC Do Not Use
Abbreviations.
•
Undetected/anticipating drug interactions--liver cytochrome P450 enzymes = drug-to-drug interactions may
render medication ineffective--prescription warning system alerts. Rising use of OTC and herbal products.
Chapter 2: Historical View of Prescriptive Authority (Nurses vs. PA)
o
Primary Care is provided by clinicians who address "personal health care needs, developing a sustained
partnership with patient, and practicing in the context of family and community."
o
"Delegable authority --> "Delegable prescriptive authority" without it, an APN can only suggest OTC medications.
o
Nursing Legislation
•
Dependent authority--the physician retains ultimate authority through co-signature.
•
Independent authority--the APN prescribes alone--can still be restrictive.
•
1993--Definition and Registration of MLPs--can obtain DEA# beginning with M
▪ NPs
• DEA number and prescriptive authority differ by state.
• May dispense pharmaceutical samples in all states.
• Across-state-line prescribing
▪ CNMs
▪ CRNAs--do not "prescribe" under law.
▪ CNSs
o
Barriers to Practice for Nurses in the Diagnosing and Prescribing Role
•
Regulatory irregularity among states
•
Increased antagonism from organized medical groups competing with APNs for patients
•
Growing number of NP graduates without prior nursing experience
•
Inequity in data collection on physician prescribing patterns among pharmaceutical companies
, •
Difficulty in obtaining prescribing data from Prescription Drug Marketing Act
Chapter 9: Establishing the Therapeutic Relationship
•
"How scientific principles are introduced in the relationship with the patient has everything to do with therapeutic
success." The balance of art and science in healthcare.
•
"A continuing relationship with the healthcare provider is essential in making adjustments to discover the proper therapy for
the individual."
o
Identify a problem, assess it adequately, identify various potential solutions, examine he variables needed to
judge the risk/benefit ratio of the solutions, choose the most appropriate solution, and identify the effects (beneficial
and adverse) that may result from implementation of the chosen solution.
•
Factors of a Therapeutic Relationship
o
Time--investment--particularly with the elderly--initial investment to obtain thorough H&P--cost-effective--
follow up call strengthen the relationship
o
Attitude--how time is spent and what is said--"Who owns the problem?"
o
Information--it may take several visits to obtain a full history
o
Communication--effective two-way communication between patient and provider requires consistent
commitment to respect the others' role in the relationship.
• Transference
• Focus on patient, environment, and lastly, self.
• Find a balance between creating uncontrolled and unfounded anxieties vs creating a false sense of
equally grounding security and reassurance.
• It is implicitly understood that once a problem is presented, the provider will do their utmost to provide
the best therapy.
• The therapeutic objective must be clearly stated--1) must be realistic and attainable, 2) clearly related
to the problem as defined and assessed, 3) measurable.
• Be flexible, accept occasional lapses in compliance, attempt to understand the patient's point of view.
o
Therapeutic Relationship Fails
• Skepticism in the medical profession.
▪
Provider main goal is pharmacoadherence.
▪
Over or under utilization.
▪
Therapeutic failure and increase in disease severity.
▪
Gender, race, education, occupation, income, marital status--are not factors in compliance.
•
Blame the economy!
• Compliance vs adherence--both suggest patient fault
• Concordance--suggests a therapeutic alliance between prescriber and patient--a negotiated
agreement that may even be an agreement to disagree.
▪
Patient--actively participates in consultation process regarding treatment, risk, and benefit.
▪
Provider--communicates evidence to enable the patient to make informed choices, accepts
patient's choices regarding their care, continues to negotiate treatment and part of the ongoing
process.
▪
Risk Factors
•
Increases with preventive care
•
Increases with duration of therapy
•
Greatest for regimens with significant behavioral change
•
Poor understanding of instructions
•
Complex treatment regimen
•
Unpleasant side effects
•
Increases in drug costs
Chapter 10: Practical Tips on Writing Prescriptions
•
DEA--state-controlled substance license--federally issued DEA#
o
Drugs are scheduled by potential for abuse.
,•
Components of a Traditional Prescription
o
Name of prescriber--credentials, address, phone number
o
Date
o
Name of patient--address, age, and weight
o
Superscription--Rx--"take"
o
Inscription--drug ingredients, quantity, strength, and/or concentration
• Drug--full name of medication--no abbreviations
• Strength/concentration
o
Signature
o
The better the instructions, the better the medication compliance and patient understanding.
o
Refills
• No refills on Schedule II drugs
• Only 6 months/5 refills allowed
• "NO REFILLS"
o
DEA#--should not be printed on Rx or used for ID purposes
o
Generic Substitutions Okay?
• Dispense as Written
• Brand Medically Necessary
•
Electronic Signatures in Global and National Commerce Act: 2000
o
E-Sign
• No need to paper or hard copy.
• Schedule II--need to fax/present hard copy.
• Specifically, and emphatically prohibit the reimposition of tangible/paper requirements.
o
Prescription Etiquette
• Cannot prescribe narcotics to self or family--can prescribe non-narcotic Schedule IIs but it is
considered poor judgement.
▪
The DEA may start an investigation.
▪
Frequent prescribing for self/family may not be covered by HMOs.
▪
Prescriptions that are refilled without a Provider visit.
▪
Drug sampling--on the margin of legality.
▪
The prescriber is always responsible for what happens to the individual receiving the medication.
• Avoiding Mistakes
▪
Write clearly
▪
Stay up-to-date
•
Drug-drug interactions
•
Renal dosing of medications
•
Direct-to-consumer advertising--patients ask for medications PCP's may not
normally prescribe
•
Medication errors are inversely correlated to PCP's years of practice
▪
With disclosed suicidal ideation: Write for no more than a 7-day supply of a medication a
patient could overdose on if taken all at once
▪
Discuss side effects
▪
Discontinue a medication when it causes a cautioned side effect
▪
Get informed consent when a drug can cause permanent side effects and a less risky alternative
is available
▪
If prescribing “off-label”: Document the rationale for deviating from the package insert
instructions, and be prepared to prove that the standard of care supports the alternative prescribing
regimen
▪
If a drug is known to cause adverse effects after long-term use, avoid using the drug for long-
term therapy or monitor carefully for the onset of potential problems
▪
▪
Ask, Listen, and Alter the Plan
• Administrative Concerns
, ▪
Formularies--cost-saving measure that can be restrictive, are slow to integrate new and
effective drugs.
▪
Medicaid--joint Federal and State program--provider must be a Medicaid subscriber--states have
their own Medicaid formularies which omit new medications, expensive trade name medications, and
medications deemed "less than effective" by the FDA--payment is not made for non-formulary drugs
unless a waiver stating medical necessity or life-sustaining measures will be obtained from the
medication.
▪
Out-of-State Prescriptions--may or may not be filled--can also cause problems with
telehealth prescriptions--counterfeit medications purchased online.
▪
Telephone Orders--no Schedule I or II
▪
Emergency Dispensing of Medications--usually antibiotics or narcotic analgesics.
▪
Generic Substitutions--some states automatically allow--if brand name is required, write "Do
Not Substitute."
• Preventing Problems in Drug Use
▪
The Abusing Patient--asks for narcotics by name, carries proof of pain, calls requesting
refills early due to lost or stolen medications, altering prescriptions, using multiple providers.
•
Providers who feel they cannot continue to meet the needs of the patient have a
responsibility to help that patient find another provider.
▪
The Abusing Provider
▪
The Financially Needy Patient
Chapter 11: Evidence-Based Decision Making and Treatment Guidelines
•
Quality of healthcare relies upon 1) decisions that determine what actions are taken, 2) the quality of the actions executed.
•
Critical Thinking in Nursing
o
Made up of knowledge and an attitude of inquiry--a critical appraisal of knowledge
• Collecting and analyzing whatever evidence exists regarding the benefits, harms, and costs of each option.
• Clarify personal values or preferences of the patient.
▪
Joint decision making.
Knowledge --> Judgements --> Estimate --> Patient/provider preferences --> Decision
Evidence Critical analyses. Outcomes Critical thinking
Benefits vs Harm Judgements
Costs Important patient outcomes
Marginal benefits Estimated patient
outcomes Patient
preferences
•
Evidence-based medicine is the science--no single correct answer and no obligation that everyone must agree--is the art.
•
Brenner 1984--described the process of skill acquisition by nurses.
o
Begins with decision-making analysis, then hypothetical deductive reasoning, and the eventual emergence of
the expert that functions at an intuitive level.
• The effects of intuition on an expert nurse's ability to make clinical decisions…
▪
Pattern recognition--recognizing relationships
▪
Similarity recognition--recognizing relationships despite obvious differences
▪
Commonsense understanding--having a deep understanding of a given entity
▪
Skilled know-how--ability to visualize a situation
▪
Sense a salience--ability to recognize what is important
▪
Deliberative rationality-ability to anticipate events
o
Diagnostic errors can be classified into:
• Faulty hypothesis triggering
▪
Failure to pick right hypothesis or revise hypothesis
• Faulty context formulation
▪
Occurs when clinician and patient have different goals
• Faulty information gathering process
▪
Failure to order appropriate tests or misinterprets information
• Faulty verification of diagnoses
▪
Failure to collect enough data to confirm a diagnosis or to completely rule out others
