Pharmacology and Pharmacotherapeutics in k k k
Advanced Nursing Practice k k k
NGR6172 k
Pharmacology and Pharmacotherapeutics in Advanced Nursing Practice NGR6172 k k k k k k k
Chapter 1: Prescriptive Authority and Role Implementation: Tradition vs Change
k k k k k k k k k
o Primary Care is provided by clinicians who address "personal health care needs, developing a sustained partnership
k k k k k k k k k k k k k k k
with patient, and practicing in the context of family and community."
k k k k k k k k k k k
• Prevention, Diagnosis, Prescription, Treatment k k k
▪ Assess health status. k k
▪ Promote healthy lifestyles. k k
▪ Identifying/diagnosing normal/abnormal conditions. k k
▪ Determining the causes of abnormal conditions, providing referral to health care specialists. k k k k k k k k k k k
▪ Selecting appropriate therapeutic measures. k k k
▪ Implementing treatment. k
▪ Supervising/monitoring the patient on an ongoing basis. k k k k k k
• Traditional Primary Care--physicians as the only providers with diagnostic and treatment authority--an intention to
k k k k k k k k k k k k k
protect the public.
k k k
▪ Prescriptive practices should not be compared to those of physicians--all providers should be held to a
k k k k k k k k k k k k k k k
standard of approved therapeutic practice.
k k k k k
• Most Prescribed by PCP--antidepressants, NSAIDs, antihistamines/bronchodilators, antihypertensives,
k k k k k k
antilipidemic.
k
• Rate of Adoption by Prescribers--innovators, early adopters, early majority, late majority, and laggards.
k k k k k k k k k k k k
o Problems in the Prescribing Practice of Physicians
k k k k k k
• Prescriptions are not the most up to date--"new research findings diffuse slowly into practice."
k k k k k k k k k k k k k
• Pharmaceutical company influence--FDA intervention and PhRMA guidelines.
k k k k k k
• Lack of time--short consultation, incorrect H&P, problem is left undefined, over-reliance on drug therapy.
k k k k k k k k k k k k k
• Consumers' pressure for prescribed medications--"Do something!"--lifetime of medications, overused antibiotics,
k k k k k k k k k
and direct-to-consumer advertising.
k k k
• Ineligible prescriptions --> Medication errors. Current federal mandate for e-prescribing. TJC Do Not Use
k k k k k k k k k k k k k
Abbreviations.
• Undetected/anticipating drug interactions--liver cytochrome P450 enzymes = drug-to-drug interactions may render k k k k k k k k k k
medication ineffective--prescription warning system alerts. Rising use of OTC and herbal products.
k k k k k k k k k k k k
Chapter 2: Historical View of Prescriptive Authority (Nurses vs. PA)
k k k k k k k k k
o Primary Care is provided by clinicians who address "personal health care needs, developing a sustained partnership
k k k k k k k k k k k k k k k
with patient, and practicing in the context of family and community."
k k k k k k k k k k k
o "Delegable authority --> "Delegable prescriptive authority" without it, an APN can only suggest OTC medications.
k k k k k k k k k k k k k k
o Nursing Legislation
k
• Dependent authority--the physician retains ultimate authority through co-signature.
k k k k k k k
• Independent authority--the APN prescribes alone--can still be restrictive.
k k k k k k k
• 1993--Definition and Registration of MLPs--can obtain DEA# beginning with M
k k k k k k k k k
▪ NPs
• DEA number and prescriptive authority differ by state. k k k k k k k
, • May dispense pharmaceutical samples in all states.
k k k k k k
• Across-state-line prescribing k
▪ CNMs
▪ CRNAs--do not "prescribe" under law.
k k k k
▪ CNSs
o Barriers to Practice for Nurses in the Diagnosing and Prescribing Role
k k k k k k k k k k
• Regulatory irregularity among states
k k k
, • Increased antagonism from organized medical groups competing with APNs for patients
k k k k k k k k k k
• Growing number of NP graduates without prior nursing experience
k k k k k k k k
• Inequity in data collection on physician prescribing patterns among pharmaceutical companies
k k k k k k k k k k
• Difficulty in obtaining prescribing data from Prescription Drug Marketing Act
k k k k k k k k k
Chapter 9: Establishing the Therapeutic Relationship
k k k k k
• "How scientific principles are introduced in the relationship with the patient has everything to do with therapeutic success."
k k k k k k k k k k k k k k k k k
The balance of art and science in healthcare.
k k k k k k k k
• "A continuing relationship with the healthcare provider is essential in making adjustments to discover the proper therapy for
k k k k k k k k k k k k k k k k k
the individual."
k k
o Identify a problem, assess it adequately, identify various potential solutions, examine he variables needed to judge
k k k k k k k k k k k k k k k
the risk/benefit ratio of the solutions, choose the most appropriate solution, and identify the effects (beneficial and
k k k k k k k k k k k k k k k k k
adverse) that may result from implementation of the chosen solution.
k k k k k k k k k k
• Factors of a Therapeutic Relationship
k k k k
o Time--investment--particularly with the elderly--initial investment to obtain thorough H&P--cost-effective--follow k k k k k k k k
up call strengthen the relationship
k k k k k
o Attitude--how time is spent and what is said--"Who owns the problem?" k k k k k k k k k k
o Information--it may take several visits to obtain a full history k k k k k k k k k
o Communication--effective two-way communication between patient and provider requires consistent commitment k k k k k k k k k
to respect the others' role in the relationship.
k k k k k k k k
• Transference
• Focus on patient, environment, and lastly, self. k k k k k k
• Find a balance between creating uncontrolled and unfounded anxieties vs creating a false sense of equally
k k k k k k k k k k k k k k k
grounding security and reassurance. k k k k
• It is implicitly understood that once a problem is presented, the provider will do their utmost to provide
k k k k k k k k k k k k k k k k k
the best therapy. k k k
• The therapeutic objective must be clearly stated--1) must be realistic and attainable, 2) clearly related to
k k k k k k k k k k k k k k k
the problem as defined and assessed, 3) measurable. k k k k k k k
• Be flexible, accept occasional lapses in compliance, attempt to understand the patient's point of view.
k k k k k k k k k k k k k k
o Therapeutic Relationship Fails k k
• Skepticism in the medical profession. k k k k
▪ Provider main goal is pharmacoadherence. k k k k
▪ Over or under utilization. k k k
▪ Therapeutic failure and increase in disease severity. k k k k k k
▪ Gender, race, education, occupation, income, marital status--are not factors in compliance. k k k k k k k k k k
• Blame the economy! k k
• Compliance vs adherence--both suggest patient fault k k k k k
• Concordance--suggests a therapeutic alliance between prescriber and patient--a negotiated agreement k k k k k k k k k
that may even be an agreement to disagree.
k k k k k k k k
▪ Patient--actively participates in consultation process regarding treatment, risk, and benefit. k k k k k k k k k
▪ Provider--communicates evidence to enable the patient to make informed choices, accepts k k k k k k k k k k
patient's choices regarding their care, continues to negotiate treatment and part of the ongoing process.
k k k k k k k k k k k k k k k
▪ Risk Factors k
• Increases with preventive care k k k
• Increases with duration of therapy k k k k
• Greatest for regimens with significant behavioral changek k k k k k
• Poor understanding of instructions
k k k
• Complex treatment regimen k k
• Unpleasant side effects k k
• Increases in drug costs k k k
, Chapter 10: Practical Tips on Writing Prescriptions
k k k k k k
• DEA--state-controlled substance license--federally issued DEA#
k k k k
o Drugs are scheduled by potential for abuse.
k k k k k k
• Components of a Traditional Prescription
k k k k
o Name of prescriber--credentials, address, phone number
k k k k k
o Date
o Name of patient--address, age, and weight
k k k k k
o Superscription--Rx--"take"
o Inscription--drug ingredients, quantity, strength, and/or concentration k k k k k
• Drug--full name of medication--no abbreviations k k k k
• Strength/concentration
o Signature
o The better the instructions, the better the medication compliance and patient understanding.
k k k k k k k k k k k
o Refills
• No refills on Schedule II drugs k k k k k
• Only 6 months/5 refills allowed k k k k
• "NO REFILLS" k
o DEA#--should not be printed on Rx or used for ID purposes
k k k k k k k k k k
o Generic Substitutions Okay?k k
• Dispense as Written k k
• Brand Medically Necessary k k
• Electronic Signatures in Global and National Commerce Act: 2000
k k k k k k k k
o E-Sign
• No need to paper or hard copy. k k k k k k
• Schedule II--need to fax/present hard copy. k k k k k
• Specifically, and emphatically prohibit the reimposition of tangible/paper requirements. k k k k k k k k
o Prescription Etiquette k
• Cannot prescribe narcotics to self or family--can prescribe non-narcotic Schedule IIs but it is considered
k k k k k k k k k k k k k k
poor judgement.
k k
▪ The DEA may start an investigation. k k k k k
▪ Frequent prescribing for self/family may not be covered by HMOs. k k k k k k k k k
▪ Prescriptions that are refilled without a Provider visit. k k k k k k k
▪ Drug sampling--on the margin of legality. k k k k k
▪ The prescriber is always responsible for what happens to the individual receiving the medication.
k k k k k k k k k k k k k
• Avoiding Mistakes k
▪ Write clearly k
▪ Stay up-to-date k
• Drug-drug interactions k
• Renal dosing of medications k k k
• Direct-to-consumer advertising--patients ask for medications PCP's may not normally k k k k k k k k
prescribe k
• Medication errors are inversely correlated to PCP's years of practice k k k k k k k k k
▪ With disclosed suicidal ideation: Write for no more than a 7-day supply of a medication a patient
k k k k k k k k k k k k k k k k
could overdose on if taken all at once
k k k k k k k k
▪ Discuss side effects k k
▪ Discontinue a medication when it causes a cautioned side effect k k k k k k k k k
▪ Get informed consent when a drug can cause permanent side effects and a less risky alternative is
k k k k k k k k k k k k k k k k
available k
▪ If prescribing “off-label”: Document the rationale for deviating from the package insert
k k k k k k k k k k k
instructions, and be prepared to prove that the standard of care supports the alternative prescribing regimen
k k k k k k k k k k k k k k k
▪ If a drug is known to cause adverse effects after long-term use, avoid using the drug for long-term
k k k k k k k k k k k k k k k k k
therapy or monitor carefully for the onset of potential problems
k k k k k k k k k k
Advanced Nursing Practice k k k
NGR6172 k
Pharmacology and Pharmacotherapeutics in Advanced Nursing Practice NGR6172 k k k k k k k
Chapter 1: Prescriptive Authority and Role Implementation: Tradition vs Change
k k k k k k k k k
o Primary Care is provided by clinicians who address "personal health care needs, developing a sustained partnership
k k k k k k k k k k k k k k k
with patient, and practicing in the context of family and community."
k k k k k k k k k k k
• Prevention, Diagnosis, Prescription, Treatment k k k
▪ Assess health status. k k
▪ Promote healthy lifestyles. k k
▪ Identifying/diagnosing normal/abnormal conditions. k k
▪ Determining the causes of abnormal conditions, providing referral to health care specialists. k k k k k k k k k k k
▪ Selecting appropriate therapeutic measures. k k k
▪ Implementing treatment. k
▪ Supervising/monitoring the patient on an ongoing basis. k k k k k k
• Traditional Primary Care--physicians as the only providers with diagnostic and treatment authority--an intention to
k k k k k k k k k k k k k
protect the public.
k k k
▪ Prescriptive practices should not be compared to those of physicians--all providers should be held to a
k k k k k k k k k k k k k k k
standard of approved therapeutic practice.
k k k k k
• Most Prescribed by PCP--antidepressants, NSAIDs, antihistamines/bronchodilators, antihypertensives,
k k k k k k
antilipidemic.
k
• Rate of Adoption by Prescribers--innovators, early adopters, early majority, late majority, and laggards.
k k k k k k k k k k k k
o Problems in the Prescribing Practice of Physicians
k k k k k k
• Prescriptions are not the most up to date--"new research findings diffuse slowly into practice."
k k k k k k k k k k k k k
• Pharmaceutical company influence--FDA intervention and PhRMA guidelines.
k k k k k k
• Lack of time--short consultation, incorrect H&P, problem is left undefined, over-reliance on drug therapy.
k k k k k k k k k k k k k
• Consumers' pressure for prescribed medications--"Do something!"--lifetime of medications, overused antibiotics,
k k k k k k k k k
and direct-to-consumer advertising.
k k k
• Ineligible prescriptions --> Medication errors. Current federal mandate for e-prescribing. TJC Do Not Use
k k k k k k k k k k k k k
Abbreviations.
• Undetected/anticipating drug interactions--liver cytochrome P450 enzymes = drug-to-drug interactions may render k k k k k k k k k k
medication ineffective--prescription warning system alerts. Rising use of OTC and herbal products.
k k k k k k k k k k k k
Chapter 2: Historical View of Prescriptive Authority (Nurses vs. PA)
k k k k k k k k k
o Primary Care is provided by clinicians who address "personal health care needs, developing a sustained partnership
k k k k k k k k k k k k k k k
with patient, and practicing in the context of family and community."
k k k k k k k k k k k
o "Delegable authority --> "Delegable prescriptive authority" without it, an APN can only suggest OTC medications.
k k k k k k k k k k k k k k
o Nursing Legislation
k
• Dependent authority--the physician retains ultimate authority through co-signature.
k k k k k k k
• Independent authority--the APN prescribes alone--can still be restrictive.
k k k k k k k
• 1993--Definition and Registration of MLPs--can obtain DEA# beginning with M
k k k k k k k k k
▪ NPs
• DEA number and prescriptive authority differ by state. k k k k k k k
, • May dispense pharmaceutical samples in all states.
k k k k k k
• Across-state-line prescribing k
▪ CNMs
▪ CRNAs--do not "prescribe" under law.
k k k k
▪ CNSs
o Barriers to Practice for Nurses in the Diagnosing and Prescribing Role
k k k k k k k k k k
• Regulatory irregularity among states
k k k
, • Increased antagonism from organized medical groups competing with APNs for patients
k k k k k k k k k k
• Growing number of NP graduates without prior nursing experience
k k k k k k k k
• Inequity in data collection on physician prescribing patterns among pharmaceutical companies
k k k k k k k k k k
• Difficulty in obtaining prescribing data from Prescription Drug Marketing Act
k k k k k k k k k
Chapter 9: Establishing the Therapeutic Relationship
k k k k k
• "How scientific principles are introduced in the relationship with the patient has everything to do with therapeutic success."
k k k k k k k k k k k k k k k k k
The balance of art and science in healthcare.
k k k k k k k k
• "A continuing relationship with the healthcare provider is essential in making adjustments to discover the proper therapy for
k k k k k k k k k k k k k k k k k
the individual."
k k
o Identify a problem, assess it adequately, identify various potential solutions, examine he variables needed to judge
k k k k k k k k k k k k k k k
the risk/benefit ratio of the solutions, choose the most appropriate solution, and identify the effects (beneficial and
k k k k k k k k k k k k k k k k k
adverse) that may result from implementation of the chosen solution.
k k k k k k k k k k
• Factors of a Therapeutic Relationship
k k k k
o Time--investment--particularly with the elderly--initial investment to obtain thorough H&P--cost-effective--follow k k k k k k k k
up call strengthen the relationship
k k k k k
o Attitude--how time is spent and what is said--"Who owns the problem?" k k k k k k k k k k
o Information--it may take several visits to obtain a full history k k k k k k k k k
o Communication--effective two-way communication between patient and provider requires consistent commitment k k k k k k k k k
to respect the others' role in the relationship.
k k k k k k k k
• Transference
• Focus on patient, environment, and lastly, self. k k k k k k
• Find a balance between creating uncontrolled and unfounded anxieties vs creating a false sense of equally
k k k k k k k k k k k k k k k
grounding security and reassurance. k k k k
• It is implicitly understood that once a problem is presented, the provider will do their utmost to provide
k k k k k k k k k k k k k k k k k
the best therapy. k k k
• The therapeutic objective must be clearly stated--1) must be realistic and attainable, 2) clearly related to
k k k k k k k k k k k k k k k
the problem as defined and assessed, 3) measurable. k k k k k k k
• Be flexible, accept occasional lapses in compliance, attempt to understand the patient's point of view.
k k k k k k k k k k k k k k
o Therapeutic Relationship Fails k k
• Skepticism in the medical profession. k k k k
▪ Provider main goal is pharmacoadherence. k k k k
▪ Over or under utilization. k k k
▪ Therapeutic failure and increase in disease severity. k k k k k k
▪ Gender, race, education, occupation, income, marital status--are not factors in compliance. k k k k k k k k k k
• Blame the economy! k k
• Compliance vs adherence--both suggest patient fault k k k k k
• Concordance--suggests a therapeutic alliance between prescriber and patient--a negotiated agreement k k k k k k k k k
that may even be an agreement to disagree.
k k k k k k k k
▪ Patient--actively participates in consultation process regarding treatment, risk, and benefit. k k k k k k k k k
▪ Provider--communicates evidence to enable the patient to make informed choices, accepts k k k k k k k k k k
patient's choices regarding their care, continues to negotiate treatment and part of the ongoing process.
k k k k k k k k k k k k k k k
▪ Risk Factors k
• Increases with preventive care k k k
• Increases with duration of therapy k k k k
• Greatest for regimens with significant behavioral changek k k k k k
• Poor understanding of instructions
k k k
• Complex treatment regimen k k
• Unpleasant side effects k k
• Increases in drug costs k k k
, Chapter 10: Practical Tips on Writing Prescriptions
k k k k k k
• DEA--state-controlled substance license--federally issued DEA#
k k k k
o Drugs are scheduled by potential for abuse.
k k k k k k
• Components of a Traditional Prescription
k k k k
o Name of prescriber--credentials, address, phone number
k k k k k
o Date
o Name of patient--address, age, and weight
k k k k k
o Superscription--Rx--"take"
o Inscription--drug ingredients, quantity, strength, and/or concentration k k k k k
• Drug--full name of medication--no abbreviations k k k k
• Strength/concentration
o Signature
o The better the instructions, the better the medication compliance and patient understanding.
k k k k k k k k k k k
o Refills
• No refills on Schedule II drugs k k k k k
• Only 6 months/5 refills allowed k k k k
• "NO REFILLS" k
o DEA#--should not be printed on Rx or used for ID purposes
k k k k k k k k k k
o Generic Substitutions Okay?k k
• Dispense as Written k k
• Brand Medically Necessary k k
• Electronic Signatures in Global and National Commerce Act: 2000
k k k k k k k k
o E-Sign
• No need to paper or hard copy. k k k k k k
• Schedule II--need to fax/present hard copy. k k k k k
• Specifically, and emphatically prohibit the reimposition of tangible/paper requirements. k k k k k k k k
o Prescription Etiquette k
• Cannot prescribe narcotics to self or family--can prescribe non-narcotic Schedule IIs but it is considered
k k k k k k k k k k k k k k
poor judgement.
k k
▪ The DEA may start an investigation. k k k k k
▪ Frequent prescribing for self/family may not be covered by HMOs. k k k k k k k k k
▪ Prescriptions that are refilled without a Provider visit. k k k k k k k
▪ Drug sampling--on the margin of legality. k k k k k
▪ The prescriber is always responsible for what happens to the individual receiving the medication.
k k k k k k k k k k k k k
• Avoiding Mistakes k
▪ Write clearly k
▪ Stay up-to-date k
• Drug-drug interactions k
• Renal dosing of medications k k k
• Direct-to-consumer advertising--patients ask for medications PCP's may not normally k k k k k k k k
prescribe k
• Medication errors are inversely correlated to PCP's years of practice k k k k k k k k k
▪ With disclosed suicidal ideation: Write for no more than a 7-day supply of a medication a patient
k k k k k k k k k k k k k k k k
could overdose on if taken all at once
k k k k k k k k
▪ Discuss side effects k k
▪ Discontinue a medication when it causes a cautioned side effect k k k k k k k k k
▪ Get informed consent when a drug can cause permanent side effects and a less risky alternative is
k k k k k k k k k k k k k k k k
available k
▪ If prescribing “off-label”: Document the rationale for deviating from the package insert
k k k k k k k k k k k
instructions, and be prepared to prove that the standard of care supports the alternative prescribing regimen
k k k k k k k k k k k k k k k
▪ If a drug is known to cause adverse effects after long-term use, avoid using the drug for long-term
k k k k k k k k k k k k k k k k k
therapy or monitor carefully for the onset of potential problems
k k k k k k k k k k
