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NR565 Midterm Study Guide
Be familiar with the interactive activities throughout course modules. You could see variations of those same questions on your exams. Week 1
- Which schedule drugs can APRNs prescribe? o Schedule II-V with a prescriber/prescriptive authority o APRNs are educated to practice and prescribe independently without supervision; however, some state laws require that they practice in collaboration with or under the supervision of a physician
- Who determines and regulates prescriptive authority? o State law o Affects providers who serve in locum tenens staffing positions or who have practices in two contingous states o Regulation of prescriptive authority is under the jurisdiction of the
health professional board ▪ State Board of Nursing or Medicine or state board of pharmacy depending on the state
- How does limited prescriptive authority impact patients within the healthcare system? o Numerous barriers to quality, affordable, and accessible pt care o Restrictions on the distance of APRN or PA from the physician providing supervision or collaboration may prevent outreach to areas of greatest need o Requirement: to obtain physician’s co-signature on prescriptions can increase pt waits o Even through collaborative arrangements- one partner holds the power o APRN’s are blamed more commonly blamed than the physician
- What are the key responsibilities of prescribing? o Having a documented provider-patient relationship for whom the APRN is prescribing to o Do not prescribe medications for family/friends/self o Document a thorough H&P exam
can change over time ▪ Drugs may not be available in your pharmacy or at a specific pharmacy and can affect choice of medications o Interactions ▪ Pay attention to polypharmacy ▪ Ask about all meds, including OTC and herbal preparations o Side effects ▪ Can affect one and not affect another ▪ Assessing risk-to-benefit ratio of medication → severity of side effects o Allergies ▪ Determine type of reaction and document in pt’s chart o Hepatic and renal fxn ▪ If ↑are impaired, it can lead to increased adverse effects & possible med overdose ▪ Hepatic/renal dosing → decreasing dose o Needs for monitoring ▪ Warfarin
▪ Lithium ▪ Opioids ▪ Immunosuppressive therapies (tacrolimus, sirolimus) ▪ Frequent lab apt’s o Special populations ▪ Pregnant/nursing mothers ▪ Older adults
- Be familiar with pharmacokinetic and pharmacodynamic changes of older adults and how that would translate to baseline information needed to prescribe. o Pharmacokinetics → study of drug absorption, distribution, metabolism, and excretion in the body o Pharmacodynamics → study of biochemical and physiological effect and the molecular mechanisms
- Beer’s Criteria o What is it? ▪ Addressing appropriate prescribing practices for 65 YO and older ▪ Guidelines for safety components to protect older adults and
o Increased hospital readmissions o Increased mortality
- CYP450 inhibitors o Examples ▪ Valporate ▪ Isoniazid ▪ Sulfonamides ▪ Amiodarone ▪ Chloramphenicol ▪ Ketoconazole ▪ Grapefruit Juice ▪ Quinidine ▪ When giving medications that are metabolized by the CYP450 systems it can either inhibit (↓ the inactive form → supratherapeutic) ▪ Decreases medication metabolism (decreases inactive form → supratherapeutic) ▪ Act on liver by slowing rate of metabolism ↑ drug accumulation leading to adverse effect and toxicity
▪ Act on one or more of the CYP450 enzyme ▪ Blocks enzyme activity required for metabolism of other meds o What do they cause if not used correctly? (aka: What would the patient experience?) ▪ Toxicity where the medications is circulating around bloodstream for longer periods of time (free radicals?) ▪ Drug interactions
- Examples of CYP450 inducers o Examples ▪ Carbamazepine ▪ Rifampin ▪ Alcohol ▪ Phenytoin ▪ Griseofulvin ▪ Phenobarbital ▪ Sulfonylureas ▪ St Johns Worth o What do they do?
o 1: patient adherence to directions for drug use is essential for efficacy or o 2: patients need to know about potentially serious effects when deciding to use a drug
- Black Box Warnings o What are they? ▪ Boxed warning ▪ This feature draws the reader’s attention to important safety concerns r/t to contraindications and adverse effects ▪ Alert for serious/life-threatening events ▪ Ways to prevent or reduce harm o Why are they issued? ▪ To warn for o life-threatening dysrhythmias o Suicidality o Major fetal harm - Reasons for medication non- adherence o Cost o Guidelines o Availability o (^) Interactio o (^) Side effects o (^) Allergies o Hepatic/renal fxn o Special populations o Need for monitoring
- Neonate and infant drug absorption o Be familiar with general development and when absorption would reach adult levels ▪ Oral administration: delayed gastric emptying → adult values reached by 6-8 mo ▪ Low gastric acidity for 24 hours after birth → adult values reached around 24 months
- Common fears with genetic testing o Fear of discrimination
- Written Prescription: o Prescriber name, license #, contact info o Prescriber U.S. DEA (drug enforcement administration) # o Pt name and DOB o Pt allergies o Name of medication o Indication of medication o Medication strength o Dose of medication and frequency o # of tablets or capsules to dispense
other effects o Subdivided into two groups ▪ (^) Strong opioid agonists (a substance that initiates a physiological response when combined with a receptor) ▪ Moderate opioid agonists o (^) Morphine is the prototype (First, typical or preliminary model of something → to which forms are copied/developed) (^) of the strong agonists o Codeine is the prototype of moderate to strong agonists Drugs (^) Recept or Type μ Receptor Type (^) κ Pure Opioid Agonists Morphine, codeine, meperidine and Agonist Agonist
others Agonist- Antagonist Opioids Pentazocine, nalbuphine, butophanol Antago nist Agonist Buprenorphine Patrial agonist Antagon ist Pure Opioid Antagonists Naloxone, naltrexone, others Antago nist Antagon ist
- What is used to calculate a patient’s overdose risk? (An actual calculation won’t be done on the exam) o MME (morphine milligram equivalents) is an opioid dosage’s equivalency to morphine
o What is it? ▪ Utilized by providers, state health departments, and pharmacists ▪ Can help identify high-risk pt’s and send proactive reports to providers
- Helps identify if pt is currently receiving controlled substance from another provider ▪ PDMP helps decrease the use of multiple providers by patient ▪ Helps decrease substance abuse treatment admission ▪ Electronic database that tracks controlled substance prescriptions ▪ Helpful when pt med hx is unavailable and when care transitions to a new clinician o Why is it important? ▪ Allows providers to log in and see the controlled substances the patient is currently on
- How renal and hepatic function impact medication levels in the body o Can experience greater peak effect and longer duration of action
for meds thereby reducing the dose at which respiratory depression and overdose may occur o 65+ reduced renal fxn and medication clearance d/t age can result in smaller therapeutic window between safe dosages and dosages associated with respiratory deperssion and overdose o Renal failure may influence drug metabolism by either inducing or inhibiting hepatic enzymes or its effects on other variables such as protein binding, hepatic blood flow, and accumulation of metabolites o Renal failure decreases drug absorption o Kidneys are responsible for filtering blood and removing waste products ▪ Antibiotics and antiviral meds ▪ Medications eliminated by kidneys can accumulate in pt’s leading to higher-than-intended blood levels and increased risk of side effects o Liver is responsible for metabolizing drugs breaking them down into inactive compounds that can be eliminated from the body ▪ Antidepressants and antipsychotics
When should naloxone be prescribed for a patient? ▪ Multiple prescriptions → scripts from different HCP for the same meds and request prescriptions for multiple meds ▪ Missing meds → reporting to HCP meds are lost/stolen frequently ▪ Selling/sharing meds → excessive amts of meds or may share meds w/others ▪ Unexplained absences → request time off from work or miss apt’s frequently without valid reason ▪ Behavioral changes → person may appear anxious, agitated, or preoccupied with obtaining meds o Other S/S: ▪ Selling prescription drugs ▪ Doctor selling ▪ Illegal internet pharmacies ▪ Drug theft ▪ Prescription pad theft and forgery o Given when person is chronically dependent on opioids ( 50 MME/day) → risk for opioid overdose
o Classic triad of symptoms: ▪ Respiratory depression ▪ Coma ▪ Pinpoint pupils o Prescribed opioids for chronic pain → taking opioids for chronic pain and are at risk of overdose if take too much meds/mix it with other substances that can increase effects ▪ High doses of opioids or hx of opioid overdose o Using opioids for recreational purposes ▪ Heroin, fentanyl o Recovery from opioid addiction ▪ Risk of relapse and opioid overdose o Meds that can interact with opioids ▪ Benzodiazepines or ETOH can increase risk of overdose
- Behaviors that predict controlled substance addiction o Frequent requests for early refills or dosage increases o Using multiple HCP/pharmacies o Self-medicating for emotional/psychological problems o Engaging in risky behaviors
