NR565 Midterm Study Guide with Complete Solutions

NR565 Midterm Study Guide with Complete Solutions APRN prescribing role Prescriptive authority for nurse practitioners also regulates prescribing rights beyond medications and controlled substances. These rights include therapeutic devices and services and are outlined in state practice laws and regulations and include Durable Medical Equipment (DME) such as wheelchairs, power scooters, hospital beds, portable oxygen equipment, handicap placards, etc. and medical services such as Physical Therapy (PT), Occupational Therapy (OT), home health services, etc. Prescriptive authority encompasses more than writing a prescription correctly. It requires adherence to ethical guidelines to ensure that patients are safeguarded from harm. Ethical prescribing starts with being well-informed about medications. Mechanism of action, efficacy, and safety are important considerations, as are a patient's distinct needs and circumstances, including the number of medications prescribed (Mitchell & Oliphant, 2016). Most patients receiving a prescription are taking other medications, whether prescription or over-the-counter. Appropriate selection, dosing, and duration of pharmaceutical agents are key to maximizing outcomes and minimizing adverse effects benefits of full practice authority Nurse practitioners have the autonomy to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight promoting positive outcomes through prudent prescribing practices Administering medications and prescribing medications are two distinct processes. Prescription writing requires prudent and deliberate decision-making processes to maintain patient safety and reduce liability, including: *documentation of a provider-patient relationship for the recipient of the prescribed medications *documentation of a thorough history and physical examination for the recipient *documentation of discussions regarding risk factors, side effects, or therapy options *documentation of drug monitoring or titration plan, if applicable *documentation of consultations, if any avoidance of prescribing medications for self, family, or friends Rational drug selection requires a logical approach that includes the formulation of a diagnosis based on clinical reasoning and the selection and monitoring of the most appropriate pharmacological treatment Considerations include: Cost, guidelines, availability, interactions, side effects, allergies, hepatic/renal functions, need for monitoring, & special populations Beer's Criteria identifies drugs with a high likelihood of causing adverse effects in older adults. Accordingly, drugs on this list should generally be avoided in adults older than 65 years except when the benefits are significantly greater than the risks. Pharmacodynamics the study of the biochemical and physiologic effects of drugs on the body and the molecular mechanisms by which those effects are produced Pharmacokinetics the study of drug movement throughout the body Pharmacogenomics the study of how genes affect a person's response to drugs. The purpose of this is to combine the sciences of genomics and pharmacology to provide individualized, targeted, safe drug therapies to patients CYP450 inducers Inducers are xenobiotics (medications and environmental agents) that elevate CYP450 enzyme activity by increasing enzyme synthesis. This action leads to additional sites available for biotransformation. The increased number of sites enhances medication metabolism, decreasing the concentration of the "parent drug" while increasing metabolite production. Inducers = Increase medication metabolism (Carbamazepine, Rifampin, Alcohol, Phenytoin, Griseofulvin, Phenobarbital, Sulfonylureas) CYP450 inhibitors Inhibitors are medications that inhibit the metabolic activity of one or more of the CYP450 enzymes. Medications that inhibit an enzyme potentially slows that enzyme's activity or blocks the activity required for the metabolism of other medications, thereby increasing the levels of medications dependent on that particular enzyme for biotransformation. Inhibitors = decrease medication metabolism (Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol, Ketoconazole, Grapefruit Juice, Quinidine) cultural influences in prescribing The greatest concern surrounding race-based therapy has to do with genetic variability. We know there is great diversity within and among racial groups; therefore, a "one fits all" approach based on race is unwise. Still, we can use known associations to guide choices. For example, differences in metabolism between people with East Asian and European heritage are common. The provider can use this knowledge to guide initial dosing (with adjustment, as indicated based on response) if genetic testing is not feasible or warranted Polypharmacy: Definition, challenges, and outcomes treatment with multiple drugs greatly increases the risk for interactions. Some of these interactions are negligible, but some can have life-threatening consequences. It is of crucial importance to ask the patient about all current drugs, including over-the-counter (OTC) medications and other herbal preparations. Many patients do not consider OTC or alternative pharmaceuticals as "medications" and may not mention them unless you ask specifically. Acute Pain Management Chronic Pain Management Opioid Management Regulations of Controlled Substances The U.S. Department of Justice Drug Enforcement Agency (DEA) coordinates with local, state, and federal agents to reduce illicit drug use. The DEA enacted the Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances based on their potential for abuse and dependency. Five schedules of controlled substances were created that are updated annually. Classes of scheduled substances include narcotics, depressants, stimulants, hallucinogens, and anabolic steroids. The DEA issues eligible providers with a registration number to write prescriptions for controlled substances. Characteristics of a valid DEA number include: -The first letter identifies the type of provider: A=before 1985; B=after 1985; F=after 2007; M=nurse practitioner or physician assistant -The 2nd letter the 1st letter of the provider's last name at the time of initial registration Example: Tammy Greene applies for and receives a DEA number of MG2705208 M=nurse practitioner and G=Greene Opioid Epidemic & Responsible Prescribing Opioid Use Disorder a pattern of use that leads to significant impairment or distress. Typically, this disorder is marked by unsuccessful efforts to reduce or control use resulting in the inability to fulfill work, school, or home responsibilities. Opioid use disorder is different from drug tolerance and physical dependence, which may also exist. Opioid use creates high levels of positive reinforcement, increasing the likelihood of continued use. It is often a chronic lifelong disorder, leading to serious consequences such as disability and death. Although it is similar to other substance use disorders, it has distinct features that have fueled the current opioid epidemic. Opioids can lead to physical dependence in only 4-8 weeks. Abruptly stopping use in chronic users leads to severe symptoms, which motivates continued use to prevent withdrawal. The 2016 CDC guidelines for prescribing opioids recommends calculating the total daily dose of opioids to help identify patients who might benefit from the reduction or tapering of opioids, given the risk of overdose State Prescription Drug Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. Monitoring Programs safeguards to address the opioid public health crisis include prescription drug monitoring programs (PDMPs). These electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances. According to the CDC (2020), PDMPs have shown promising results in changing prescribing behaviors, decreasing the use of multiple providers by patients, and decreasing substance abuse treatment admissions. Drug Schedules Each drug preparation regulated under the CSA has been assigned to one of five categories: schedule I, II, III, IV, or V. Drugs in schedule I have a high potential for abuse and no approved medical use in the United States. In contrast, drugs in schedules II through V all have approved applications. Assignment to schedules II through V is based on abuse potential and potential for causing physical or psychological dependence. Of the drugs that have medical applications, those in schedule II have the highest potential for abuse and dependence. Drugs in the remaining schedules have decreasing abuse and dependence liabilities. The therapeutic window is the amount of a medication between the amount that gives an effect (effective dose) and the amount that gives more adverse effects than desired effects. For instance, medication with a small pharmaceutical window must be administered with care and control, e.g. by frequently measuring blood concentration of the drug, since it easily loses effects or gives adverse effects Antagonist A drug that attenuates the effect of an agonist. Can be competitive or non- competitive, each of which can be reversible or irreversible. A competitive antagonist binds to the same site as the agonist but does not activate it, thus blocks the agonist's action. A non- competitive antagonist binds to an allosteric (non-agonist) site on the receptor to prevent activation of the receptor. A reversible antagonist binds non-covalently to the receptor, therefore can be "washed out". An irreversible antagonist binds covalently to the receptor and cannot be displaced by either competing ligands or washing. Agonist A drug that binds to and activates a receptor. Can be full, partial or inverse. A full agonist has high efficacy, producing a full response while occupying a relatively low proportion of receptors. A partial agonist has lower efficacy than a full agonist. It produces sub-maximal activation even when occupying the total receptor population, therefore cannot produce the maximal response, irrespective of the concentration applied. An inverse agonist produces an effect opposite to that of an agonist, yet it binds to the same receptor binding-site as an agonist Silent Antagonist A drug that attenuates the effects of agonists or inverse agonists, producing a functional reduction in signal transduction. Affects only ligand-dependent receptor activation and displays no intrinsic activity itself. Also known as a neutral antagonist. The duration of action of a drug is the length of time that particular drug is effective. Duration of action is a function of several parameters including plasma half-life, the time to equilibrate between plasma and target compartments, and the off rate of the drug from its biological target. Schedule I Drugs Substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. -heroin, LSD, marijuana, methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote Schedule II Drugs Substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence All prescriptions for schedule II drugs must be