Pharmacology for the Primary Care Provider: Study Guide Solutions 2022 Rated A+
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Course
Nursing Pharmocology
Institution
Nursing Pharmocology
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 practi...
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
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