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Roles and responsibilities of Non NP APNs CORRECT ANSWERS✅ very useful for collaboration. For example, Certified Wound Therapy specialists, Certified Nurse Midwives, Certified Registered Nurse Anesthetists, and Clinical Nurse Specialists. They have MSN degrees but do not function same as an FNP, ANP Roles and responsibility of aprns CORRECT ANSWERS✅ whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, play a pivotal role in the future of health care. APRNs are often primary care providers and are at the forefront of providing preventative care to the public (ANA, 2016). *As of 2014, both NPs and CNSs must obtain at least a Master's degree in nursing to be able to practice. After obtaining this level of education, the different responsibilities that are expected of the two types of nurses is still different. For instance, Nurse Practitioners are able to prescribe medications in most states, while Clinical Nurse Specialists are generally not allowed this opportunity. One of the most significant differences between the two roles appears in the most common work environments. Many more Nurse Practitioners work in a private practice, office setting while Clinical Nurse Specialists are more likely to be found working in an acute care facility, such as a hospital. Obviously, these are very different nursing experiences. An NP who is well-suited to work with a variety of patients in a family practice setting might be unhappy specializing in a certain population, or working in a bustling hospital. Both NPs and CNSs work hard to provide exceptional patient care, but the right role for any individual nurse will depend largely on what type of work and work environment most interests them and best provides an outlet for their skills. How many states have title protection for NPs CORRECT ANSWERS✅ All Who regulates nursing practice? CORRECT ANSWERS✅ The Board of Nursing regulates practice. Five states have joint oversight with the Medical Board
How is scope of practice determined for NPs? CORRECT ANSWERS✅ determined by NP license. How many states are totally autonomous? CORRECT ANSWERS✅ 26 21- have independent prescribing Not Texas What is the role of the NP in canada? CORRECT ANSWERS✅ Scope of Practice varies from province to province. Educational preparation varies. Most providences have independent practice and prescribing. NP title is newly protected. Specialties Pediatric nurse practitioner, family nurse practitioner, advanced nurse practitioner, anesthesia NP Mental health NPs working on prescriptive authority, but must be a prescribing NP in family, pediatric or primary care Describe advanced knowledge of the NP CORRECT ANSWERS✅ NPs blend medicine and nursing knowledge. Understanding of disease process, pharmacology, and nursing Knowledge required to be a safe prescriber -Pathophysiology and disease process -Pharmacology -Rational drug selection
Duplications in medications patient is taking? Over-the-counter vs. prescription drugs Cost? Sources of information What is the level of population's resistance to a particular antibiotic? Is a prescription the right treatment? Would TLC have been as effective? We MUST stay current-need to read, read, read after you complete the program to remain abreast of new treatment guidelines, etc. Describe NP collaboration with other providers CORRECT ANSWERS✅ Collaboration is critical for quality patient care. Physicians Historical issues in NP-medical doctor relationships Different perspective on prescribing Pharmacist PharmD is a clinical practice doctorate. Expert in pharmacokinetics and pharmacotherapeutics Describe NP prescriptive authority CORRECT ANSWERS✅ Federal and state statutes and administrative law define control of medications which includes prescribing drugs. In the 1950s the Durham-Humphrey amendment discussed 'legend drugs' which could only be obtained with a prescription. Then came the Comprehensive Drug Abuse Prevention and Control Act (1970) which limited prescribing, dispensing and distribution to individuals who were registered with the Drug Enforcement Administration (DEA). This is when certain drugs were classified-like narcotics, stimulants and depressants. The term controlled substances developed. So, DEA registers providers who prescribe narcotics and
other controlled substances (Edmunds, Mayhew, 2014). Nurses are licensed by the state where they practice. Currently, 21 states have fully independent prescribing by nurse practitioners. In 17 states and the District of Columbia, NPs have independent scope-of-practice and prescriptive authority-do not require attestation for MD collaboration, consultation, delegation, or supervision. Some states have full or limited prescribing by CNSs. Every year, the January issue of Nurse Practitioner Journal & American Journal for Nurse Practitioners provide an article regarding each state's practice acts as they relate to titling, roles and prescriptive authority. Please go to the following Texas BNE website and particularly watch & listen to the audio information provided on slides 22-30: https://www.bon.texas.gov/APRNpresentation/index.asp How should prescriptions be written? CORRECT ANSWERS✅ It is important to write an unambiguous, clear, precise, legible, dated and clearly signed. Use only accepted abbreviations. AVOID "Prohibited abbreviations" You can no longer write IU (international unit), U (Unit), QD or QOD, MS or MSO4, HS, S.C or S.Q., cc, or D/C. If using a decimal in a dosage, you cannot use a trailing zero (2.0) and never forget to place a leading zero (example: 0.25 mg). What are current issues and trends in health care? CORRECT ANSWERS✅ Autonomy and prescriptive authority Interdisciplinary teams The Institute of Medicine goals "Medical Home" model of care Level of education Reimbursement
Cure the disease? Relieve symptoms of disease? Replacing deficiencies (e.g., insulin)? Long-term prevention? What is the treatment goal? You must know the expected outcomes when you prescribe. Are you looking to cure the illness (as w/ UTI or pneumonia) or relieve symptoms (pain, rash, anxiety). If long-term therapy, you need to look at the med cost (ex. Humira) Describe patient collaboration CORRECT ANSWERS✅ The World Health Organization recommends including patient in developing therapeutic objective of drug therapy. Your patient is more likely to be compliant if they are involved in developing a plan of care How does the NP choose the treatment? CORRECT ANSWERS✅ Use evidence- based guidelines. Individualize for each patient. Novice providers use analytic, step-by-step decision making. Experienced providers use experience and pattern recognition. Use more systematic approach with complex patients. 2 step process: 1. Determine appropriate treatment per recommended guidelines (ex. From American Diabetes Association). 2. individualize plan to the patient.
Analytical versus nonanalytic approach. Novices use analytical approach which is slow, systematic, time-consuming, and evidence-based. Non-analytical used by experienced clinicians who use experience & pattern recognition. It is faster, subconscious method What is the I Can PresCribE A Drug mnemonic? CORRECT ANSWERS✅ Indication Contraindications Precautions Cost/Compliance Efficacy Adverse effects Dose/Duration/Direction Describe starting treatment CORRECT ANSWERS✅ Patient usually fills prescription at pharmacy. When writing prescription, discuss whether patient has ability to pay for prescription. Insurance copays Generics often less expensive $4 retail lists Write the Rx-make sure drug, dose, and schedule are accurate. Ordering an affordable drug helps ensure the drug will be taken. Clear instructions help adherence to therapy. How should the pt be education? CORRECT ANSWERS✅ Poor adherence contributes to worsening disease, hospital admissions, and death.
Safety Cost (to patient and to society) Patient factors Provider factors Evidence-based guidelines are gold standard for drug ordering. What are pharmacokinetic factors? CORRECT ANSWERS✅ Bioavailability CYP 450 metabolism Renal elimination Dose-concentration curve Half-life Drugs excreted essentially by kidney would not be the DOC for a patient with renal failure. Right? Dose-concentration curve will determine dosing schedule. It has been shown that patients taking a pill once a day are more compliant than those dosing more frequently- like every 4 hours What are pharmacodynamic factors? CORRECT ANSWERS✅ Ease of titration Therapeutic index A narrow therapeutic index is more difficult to manage. A wider therapeutic index is safer and requires less monitoring. Narrow index-meds like digoxin, lithium. Wide index in drugs like propranolol-drug fairly safe from 20-320 mg. requires less monitoring
What are therapeutic factors? CORRECT ANSWERS✅ Evidence for therapeutic impact Clinical trials Clinical practice guidelines Systematic reviews Randomized controlled trials Extrapolate with caution Randomized controlled trials Extrapolate with caution because RCTs usually recruit patients who are fairly healthy w/ few comorbidities while patients frequently are more complex Describe safety considerations with drug factors CORRECT ANSWERS✅ Safety profile is taken into consideration. Safety profile varies by population. Teratogens Liver or renal disease Drug allergy MedWatch report U.S. Food and Drug Administration advisories Drug alert-Black Box Warning. As providers, we MUST remain current regarding BBW Describe cost associated factors when prescribing CORRECT ANSWERS✅ Cost to patient
Describe influences on rational prescribing CORRECT ANSWERS✅ Pharmaceutical promotion May influence prescribing When prescribing recommendations change When guidelines change, providers may need to be coached or reeducated regarding appropriate prescribing. Describe history of FDA mishaps CORRECT ANSWERS✅ Federal Food and Drug Act of 1906 Due to children dying from tainted food products The 1938 Amendment to the Federal Food and Drug Act After more than 100 children died after taking sulfanilamide 1962: Harris-Kefauver Amendment Mandated preclinical animal trials before testing drugs in children Federal Food and Drug Act of 1906 stated drugs must meet designated standards re: strength of drug & purity, It outlawed making adulterated, poisonous or deleterious foods, drugs, liquors. It focused on labeling & branding. The 1938 Amendment to the Federal Food and Drug Act came about because of the solvent used while making sulfonamide. The makers did not realize the solvent used to make the drug would cause toxicity. 100 people died from the med. 3 principles of the 1938 drug law restricted altering a drug, misbranding, and made unapproved transit of drugs unlawful.
Describe the FDA Modernization Act of 1997 CORRECT ANSWERS✅ The U.S. Food and Drug Administration (FDA) can make a request for pediatric data on drugs that may be used in children. Provides a 6-month extension of the patent of medications that are studied in children Implications for pediatric practice More drugs studied for effectiveness in children The U.S. Food and Drug Administration (FDA) can make a request for pediatric data on drugs that may be used in children. Many say our country's FDA approval takes too long but the US avoided multiple birth defects from thalidomide which was developed in Europe and used on pregnant women. Sched I Drugs: Control required and examples CORRECT ANSWERS✅ No accepted medical use No legal use permitted For registered research facilities only Heroin, LSD, mescaline, peyote, marijuana Sched II Drugs: Control required and examples CORRECT ANSWERS✅ No refills permitted Written prescriptions only (no telephone orders) Prescription expires in 72 h if not filled Narcotics (morphine, codeine, meperidine, opium, hydromorphone, oxycodone, oxymorphone, methadone)
Tamper-proof paper Name, national provider identifier (NPI), address, and telephone number on pad DEA number if controlled substance Date Refills Spell out quantity. Fax or electronically transmit any prescription except for schedule II drugs. Be aware that patients can sometimes obtain large amounts of opioids and benzodiazepines by seeing two different providers- One provider is not aware the other prescriber has ordered opioids for the Pt. There are drugs which have the potential for abuse-an example is Soma (carisprodol) or Ultram (tramadol). Some offices have specific hardware which allows e-scribing of controlled substances. Can fax or electronically transmit any prescription except for schedule II drugs. Rx for Schedule II substances can be telephoned in emergency situations only AND it must be followed-up with a written Rx within 7 days. Describe Controlled Substance Prescribing Precautions: Opioid Prescribing CORRECT ANSWERS✅ Legitimate for pain control Accurate assessment and diagnosis Pain is subjective. Use a valid tool. The Screener and Opioid Assessment for Patients in Pain Pain treatment plan
Referral to pain specialist Pain contract Alcohol, tobacco & elicit drug abuse has become a growing problem-in US drug abuse costs $700 billion/year. Between 2002-2016, there has been a 2.8 fold increase in deaths secondary to opioid overdose per NIH (2016). The current prescription opioid abuse epidemic has led to an increased use of heroin. The # of benzodiazepine abuse deaths have also increase 4.3-fold over the past 13 years. Describe prescription drug misuse CORRECT ANSWERS✅ Principles for prescribers
- Use of chemical dependence screening skills
- Limit-setting regarding controlled drug prescribing
- Documentation of a confirmed diagnosis and the ruling out of chemical dependence before initiating a controlled prescription
- Practice "just saying no." Controlled substance misuse is becoming a HUGE problem. As providers, we should follow the principles listed above. Avoid getting into an argument with your patient. Describe drug scams CORRECT ANSWERS✅ Dealing with scams consists of the following steps
- Learning to recognize the common ones
- Refusing to give in to them
- Practicing the skill of turning the tables on the scammer Be aware of forging and altering of prescriptions
Use the 4 A's to guide initial & on-going assessment: 1. analgesia, 2. ADLs-pain's impact on ADLs(measure physical & psychologic function) 3. Adverse Effects 4. Abuse issues Describe state law pertaining to prescription drugs CORRECT ANSWERS✅ Federal government decides what is a prescription drug. States decide who can prescribe. Prescriptive authority varies from state to state. States determine how independent an NP is in prescribing. DEA number is obtained from the DEA, but states determine scope of controlled substance prescribing Federal government decides what is a whether a drug requires a prescription. States decides who can write an Rx. Prescriptive authority exists as dependent (MD delegates the authority to an NP or PA) & independent authority. Writing a prescription CORRECT ANSWERS✅ 1. Use preprinted prescription pads that contain the name, address, telephone number, and NPI number of the prescriber.
- Write the complete drug name, strength, dosage, and form.
- Write the date of the prescription.
- Use metric units of measure, such as milligrams and milliliters; avoid apothecary units of measure.
- Avoid abbreviations.
- Avoid the use of "as directed" or "as needed."
- Include the general indication, such as "for infection."
- Write "Dispense as Written" if generic substitution is not desired.
- Include the patient weight, especially if pediatric or elderly.
- Indicate if a safety cap is not required, as medications will be dispensed with them by default. Please review the error-prone abbreviation list in the Resources section on Canvas. You are liable if you use one of the unacceptable abbreviations. What are some issues in writing prescriptions CORRECT ANSWERS✅ What may be prescribed Legend drugs Controlled drugs Medical devices Home health Home testing equipment, needles, syringes OTC meds State-specific Each state can regulate prescribing details. Electronic health record Describe legend drugs CORRECT ANSWERS✅ Legend drug is a drug that, by law, can be obtained only by prescription and bears the label, "Caution: Federal law
