NR 565 Midterm Exam Study Guide
i i i i i
Roles iand iResponsibilities iof iAPRN iPrescribers
APRN iprescriber iis iresponsible ifor ithe ifinal idecision ion iwhich idrug ito iuse iand ihow ito iuse iit. iDegree iof iautonomy iin
ithis irole iand ithe ibreadth iof idrugs ithat ican ibe iprescribed ivary ifrom istate ito istate ibased ion ithe inurse ipractice iact iof
ithat istate. iNurse ipractitioner iprescriptive iauthority iis iregulated iby ithe iState iBoard iof iNursing ifor ieach istate.
• Advanced iKnowledgeoAdditional iknowledge, icritical ithinking, iand iassumption iof ia ihigher ilevel iof ilegal iresponsibility
are irequired ito iassume ithe iprescriber irole
i
Knowledge iof imedicine, ipharmacology, iand inursing iintertwine iin ithe iNP irole
As ia iprescriber, iit ibecomes ithe irole iand iresponsibility iof ithe iNP ito idetermine ithe idiagnosis ifor iwhich ithe idrug iwill ibe
iordered, iprescribe ithe iappropriate idrug, imonitor ithe iexpected ioutcome iof ithe idrug, iand iincorporate ia iholistic
iassessment iof ithe iimpact iof idisease iand itherapy ion ipatient ilives
• Benefits iof ian iAPRN ias iPrescriberoAlternative itreatment ioptions iare ialso ipart iof ithe iarmamentarium ithat ican ibe
used ito itreat ia igiven idisorder iand imay iinteract iwith ithe ipharmacotherapeutic iintervention
i
oAPRN ilook iat ithe ibig ipicture iand iconsider ialternative itreatment ioptions iand ilifestyle ichanges
oPatients iare ilooked iat iin ia iholistic iapproach iand iinclude ithe ipatient iin idecision imaking iregarding itheir icare.
oNP ipractice imay ithrive iunder ihealthcare ireform ibecause iof ithe idemonstrated iability iof inurse ipractitioners ito
icontrol icosts iand iimprove ipatient ioutcomes
Prescriptive iauthority iis ithe ilegal iright ito iprescribe idrugs. iFull iprescriptive iauthority iaffords ithe ilegal iright ito iprescribe
iindependently iand iwithout ilimitation. iRecall ithat ithere iare itwo icomponents iof iprescriptive iauthority: i(1) ithe iright ito
iprescribe iindependently iand i(2) ithe iright ito iprescribe iwithout ilimitation. iThe iprovider iwho iprescribes iindependently iis
inot isubject ito irules irequiring iphysician isupervision ior icollaboration. iThe iprovider iwho iprescribes iwithout ilimitation imay
iprescribe iany idrugs, iincluding icontrolled idrugs, iwith ithe iexception iof ischedule iI idrugs, iwhich ihave ino icurrent imedical
iuse.
Full ipractice iauthority iis isometimes iinterpreted idifferently ifor iadvanced ipractice iregistered inurses i(APRNs) iand iphysicianiassistan
i(PAs) ibecause isupervisory irequirements ivary ifor ithe itwo iprofessions.
APRN iROLE iThere iare imany idifferent iissues ito iacknowledge iwhen iwriting ia iprescription. iImportant iconsiderationsiinclude
icost, icurrent ipractice iguidelines, imedication iinteractions, iside ieffects, iand ithe ineed ifor imonitoring.
Prescription iComponents
-Pt's ifull iname iand iaddress
-Prescriber's ifull iname, iaddress, itelephone i# iand iDEA i#
-Date iof iissuance
-Prescriber isignature
-Drug iname, idose, idosage iform, iamount
-Directions ifor iuse
-Refill iinstructions
Refills
There iare ia ifew ithings ito iconsider iwhen irefilling ia iprescription. iQuestions iyou ishould iask iyourself iinclude ithe ifollowing:
• • iIs ithis ia inewer imedication ifor ithis ipatient?
, • • iAm iI ichanging idose ior ifrequency iof ithe imedication?
• • iAm iI iadding inew imedications ito itheir iregimen?
• • iIs ithe ipatient ihaving iundesired iside ieffects?
• • iWhen ido iI iexpect ito ifollow iup iwith ithis ipatient?
• • iIf ithe ipatient iis irequesting ia irefill iby itelephone, iwhen iwas ithe ilast itime iI isaw ithis ipatient? iDo iI ineed ito isee ithe
ipatient iagain ibefore irefill?
• • iIs ithis ia ischedule iII imedication?
Promoting ipositive idrug itherapy ioutcomes irequires ia ithoughtful iand ideliberate iproactive iapproach ito imedication
imanagement. iIn ithis ichapter iwe iexplore iways ithe iprovider ican iimprove ipatient ioutcomes. iEmphasis iis iplaced ion
imonitoring itherapy, ipromoting iadherence ito itherapy, iand ieducating ithe ipatient.
Patient iTeaching ifor iDrug iMonitoring
There iare ithree iprimary ireasons ifor idrug imonitoring: i(1) idetermining itherapeutic idosage, i(2) ievaluating imedication
iadequacy, iand i(3) iidentifying iadverse ieffects.
When itesting iis ineeded ifor imonitoring, iinclude ithe ifollowing iwhen iproviding ipatient iteaching.
• What: iWhat itest iis ineeded?
o Patients ilike ito iknow iwhat itest iis ineeded. iRather ithan itelling ithem ithat ia iblood itest iis ineeded, ilet ithem
iknow ithe itype iof iblood itest i(e.g., ia itest iof ithyroid ifunction ior icholesterol ilevels).
• When: iWhen iis itesting irequired?
o Testing ican idisrupt inormal iroutines. iPatients ineed ito iknow, iin iadvance, ihow ioften itesting iis ineeded iso
ithey ican imake iplans.
• Where: iWhere iwill itesting itake iplace?
o In isome ipractices, itesting itakes iplace iat ilocations iother ithan ithe iprimary iclinic. iPatients iwho iare
iunfamiliar iwith ithe iarea ineed idirections ito ithe itesting isite iand iwhere ito igo iafter iarrival.
• Why: iWhy iis itesting inecessary?
o Testing iis ioften iexpensive iand idisruptive ito idaily ilives. iThese ibarriers iare icommon ireasons ithat ipatients
imiss iappointments. iIf ithey iunderstand ithe ineed ifor itesting, ithey iare imore ilikely ito iadhere ito itesting
ischedules.
• How: iHow idoes ithe ipatient iprepare ifor itesting?
o Some itests irequire ispecial ipreparation. iFor iexample, imany iblood itests irequire ifasting. iIf iexercise itestingiis
ineeded, ipatients ishould ibe itold ito ibring icomfortable ishoes. iIt iis iimportant ito ilet ipatients iknow iof
ianything ithey ineed ito ido iprior ito iarrival.
Best iPractices iin iDeveloping iWritten iPatient iEducation iMaterials
Practice Rationale
Limit icontent Focus ion imain ipoints. iInclude ionly ithe imost iimportant-to-
iknow icontent.
Place iimportant iinformation ifirst People itend ito iremember ithe ifirst ithings ithey iread iand imay
,Best iPractices iin iDeveloping iWritten iPatient iEducation iMaterials
Practice Rationale
become idistracted itoward ithe iend.
Write iin iactive ivoice Active ivoice iis imore idirect. iPassive ivoice iis iless idynamic iand
imay ibe iconfusing.
Include iadequate iwhite ispace White ispace idoes inot icontain itext ior iimages. iWhite ispace
imakes ithe ipage ifeel iless icluttered iand iless ioverwhelming.
Use imeaningful iillustrations Illustrations iare ia iuseful iway ito ibreak iup itext. iSelect iimages
ior idrawings ithat ihave ia ipurpose ior ithat ireinforce ia ipoint iin
ithe ihandout.
Avoid iprofessional iterminology Use icommon iterms iin ishort, isimple isentences ithat ipatients
ican ieasily iunderstand.
Check ifor ireadability Materials ishould ibe iwritten iat ia ilower ieducation ilevel ithatican
ibe iunderstood iby imost ipatients. iInformation ifor iincreasing
ireadability iis iavailable
at ihttp://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
In iexamining ithese, ifive iprimary ipatterns iemerge. iThese iare: i(1) iforgetfulness, i(2) ilack iof iplanning, i(3) icost, i(4)
idissatisfaction, iand i(5) ialtered idosing. iAn ihonest iand iopen idiscussion ithat irespects iboth ithe ipatient iand iprovider
iperspectives ican ibe ian iimportant ifacilitator ito ipromoting ipositive ioutcomes. iIndividualized isolutions ithat iaddress ithe
ispecific ipatient's iconcerns iare ithose imost ilikely ito ibe isuccessful.
Managing iMedication iTherapy
In iaddition ito ithe imedication ireview iundertaken iat ieach ipatient iencounter, ia imore icomprehensive iand ideliberate
ireview iis ineeded iperiodically i(at ileast iannually). iThis ireview ishould ibe iapproached iwith ithe iintent ipurpose iof
idetermining iwhether ithere iare ibetter ioptions ifor imedication itherapy. iInherent iquestions ithat imust ibe iasked iabout ieach
idrug iinclude ithe ifollowing:
• • iIs ieach imedication iaccomplishing iits iintended ipurpose?
• • iIs ieach imedication istill inecessary?
o • iHas ithe ipatient's icondition ichanged?
o • iDo iadverse ieffects ior irisks ioutweigh ithe ibenefits ithat isome idrugs iprovide?
o • iWhat iwould ihappen iif isome imedications iwere ino ilonger iprescribed?
• • iWhat iproblems idoes ieach imedication icreate ifor ithe ipatient?
o • iIs ia imedication iproblem iamplified iby iother idrugs ithe ipatient iis itaking?
o • iIf ia imedication iis inecessary ibut iproblematic, iare idrugs iwith ifewer iadverse ieffects iavailable?
, • • iIf ipolypharmacy iis ian iissue, iare ithere iways ito idecrease ithe inumber iof imedications?
o • iWill ia icombination idrug isimplify imanagement?
o • iIs ia isingle idrug iavailable i(and idesirable) ifor imanagement iof itwo idifferent iconditions?
The iBeers iList iidentifies idrugs iwith ia ihigh ilikelihood iof icausing iadverse ieffects iin iolder iadults. iAccordingly, idrugs ion ithis
ilist ishould igenerally ibe iavoided iin iadults iolder ithan i65 iyears iexcept iwhen ithe ibenefits iare isignificantly igreater ithan ithe
irisks. iA ipartial ilisting iof ithese idrugs iappears iin i Table i10.2. iThe ifull ilist, iupdated iin i2019, iis iavailable ionline
at ihttps://onlinelibrary.wiley.com/doi/pdf/10.1111/jgs.15767.
TABLE i10.2
Some iDrugs ito iGenerally iAvoid iin iOlder iAdults
Drugs Reason ifor iConcern Alternative iTreatments
Analgesics
Indomethacin Risk iof iGI ibleeding iand iacute irenal Mild ipain: iacetaminophen, icodeine, iCOX-2–
i(Indocin) ifailure. iIndomethacin iis imore iprone iselective iinhibitors iif ino iheart ifailure irisk, ishort-
ito iaffect ithe iCNS ithan iother iNSAIDs. iterm iuse iof ilow-dose i NSAIDs
Ketorolac
i(Toradol)
Chronic iuse iof
inon- i–COX-2
iselective
iNSAIDsi(e.g.,
iibuprofen,
iaspirin
>325 img/day)
Meperidine Not ieffective iat iusual idoses, irisk ifor Moderate ito isevere ipain: imorphine, ioxycodone,
i(Demerol) ineurotoxicity, iconfusion, idelirium ihydrocodone
Tricyclic iAntidepressants, iFirst iGeneration
Amitriptyline Anticholinergic ieffects i(constipation, SSRIs iwith ishorter ihalf-life, i(e.g., iparoxetine,
iurinary iretention, iblurred ivision), isertraline, ifluvoxamine), iSNRIs, ior iother
Clomipramine
irisk ifor icognitive iimpairment, iantidepressants
i(Anafranil)
idelirium, isyncope
Doxepin
(>6 img/day)
Imipramine
i(Tofranil)
Antihistamines, iFirst iGeneration
Chlorpheniramine Anticholinergic ieffects i(constipation, Second-generation iantihistamines, isuch ias
i(Chlor-Trimeton, iurinary iretention, iblurred ivision), icetirizine i(Zyrtec), ifexofenadine i(Allegra), ior
i i i i i
Roles iand iResponsibilities iof iAPRN iPrescribers
APRN iprescriber iis iresponsible ifor ithe ifinal idecision ion iwhich idrug ito iuse iand ihow ito iuse iit. iDegree iof iautonomy iin
ithis irole iand ithe ibreadth iof idrugs ithat ican ibe iprescribed ivary ifrom istate ito istate ibased ion ithe inurse ipractice iact iof
ithat istate. iNurse ipractitioner iprescriptive iauthority iis iregulated iby ithe iState iBoard iof iNursing ifor ieach istate.
• Advanced iKnowledgeoAdditional iknowledge, icritical ithinking, iand iassumption iof ia ihigher ilevel iof ilegal iresponsibility
are irequired ito iassume ithe iprescriber irole
i
Knowledge iof imedicine, ipharmacology, iand inursing iintertwine iin ithe iNP irole
As ia iprescriber, iit ibecomes ithe irole iand iresponsibility iof ithe iNP ito idetermine ithe idiagnosis ifor iwhich ithe idrug iwill ibe
iordered, iprescribe ithe iappropriate idrug, imonitor ithe iexpected ioutcome iof ithe idrug, iand iincorporate ia iholistic
iassessment iof ithe iimpact iof idisease iand itherapy ion ipatient ilives
• Benefits iof ian iAPRN ias iPrescriberoAlternative itreatment ioptions iare ialso ipart iof ithe iarmamentarium ithat ican ibe
used ito itreat ia igiven idisorder iand imay iinteract iwith ithe ipharmacotherapeutic iintervention
i
oAPRN ilook iat ithe ibig ipicture iand iconsider ialternative itreatment ioptions iand ilifestyle ichanges
oPatients iare ilooked iat iin ia iholistic iapproach iand iinclude ithe ipatient iin idecision imaking iregarding itheir icare.
oNP ipractice imay ithrive iunder ihealthcare ireform ibecause iof ithe idemonstrated iability iof inurse ipractitioners ito
icontrol icosts iand iimprove ipatient ioutcomes
Prescriptive iauthority iis ithe ilegal iright ito iprescribe idrugs. iFull iprescriptive iauthority iaffords ithe ilegal iright ito iprescribe
iindependently iand iwithout ilimitation. iRecall ithat ithere iare itwo icomponents iof iprescriptive iauthority: i(1) ithe iright ito
iprescribe iindependently iand i(2) ithe iright ito iprescribe iwithout ilimitation. iThe iprovider iwho iprescribes iindependently iis
inot isubject ito irules irequiring iphysician isupervision ior icollaboration. iThe iprovider iwho iprescribes iwithout ilimitation imay
iprescribe iany idrugs, iincluding icontrolled idrugs, iwith ithe iexception iof ischedule iI idrugs, iwhich ihave ino icurrent imedical
iuse.
Full ipractice iauthority iis isometimes iinterpreted idifferently ifor iadvanced ipractice iregistered inurses i(APRNs) iand iphysicianiassistan
i(PAs) ibecause isupervisory irequirements ivary ifor ithe itwo iprofessions.
APRN iROLE iThere iare imany idifferent iissues ito iacknowledge iwhen iwriting ia iprescription. iImportant iconsiderationsiinclude
icost, icurrent ipractice iguidelines, imedication iinteractions, iside ieffects, iand ithe ineed ifor imonitoring.
Prescription iComponents
-Pt's ifull iname iand iaddress
-Prescriber's ifull iname, iaddress, itelephone i# iand iDEA i#
-Date iof iissuance
-Prescriber isignature
-Drug iname, idose, idosage iform, iamount
-Directions ifor iuse
-Refill iinstructions
Refills
There iare ia ifew ithings ito iconsider iwhen irefilling ia iprescription. iQuestions iyou ishould iask iyourself iinclude ithe ifollowing:
• • iIs ithis ia inewer imedication ifor ithis ipatient?
, • • iAm iI ichanging idose ior ifrequency iof ithe imedication?
• • iAm iI iadding inew imedications ito itheir iregimen?
• • iIs ithe ipatient ihaving iundesired iside ieffects?
• • iWhen ido iI iexpect ito ifollow iup iwith ithis ipatient?
• • iIf ithe ipatient iis irequesting ia irefill iby itelephone, iwhen iwas ithe ilast itime iI isaw ithis ipatient? iDo iI ineed ito isee ithe
ipatient iagain ibefore irefill?
• • iIs ithis ia ischedule iII imedication?
Promoting ipositive idrug itherapy ioutcomes irequires ia ithoughtful iand ideliberate iproactive iapproach ito imedication
imanagement. iIn ithis ichapter iwe iexplore iways ithe iprovider ican iimprove ipatient ioutcomes. iEmphasis iis iplaced ion
imonitoring itherapy, ipromoting iadherence ito itherapy, iand ieducating ithe ipatient.
Patient iTeaching ifor iDrug iMonitoring
There iare ithree iprimary ireasons ifor idrug imonitoring: i(1) idetermining itherapeutic idosage, i(2) ievaluating imedication
iadequacy, iand i(3) iidentifying iadverse ieffects.
When itesting iis ineeded ifor imonitoring, iinclude ithe ifollowing iwhen iproviding ipatient iteaching.
• What: iWhat itest iis ineeded?
o Patients ilike ito iknow iwhat itest iis ineeded. iRather ithan itelling ithem ithat ia iblood itest iis ineeded, ilet ithem
iknow ithe itype iof iblood itest i(e.g., ia itest iof ithyroid ifunction ior icholesterol ilevels).
• When: iWhen iis itesting irequired?
o Testing ican idisrupt inormal iroutines. iPatients ineed ito iknow, iin iadvance, ihow ioften itesting iis ineeded iso
ithey ican imake iplans.
• Where: iWhere iwill itesting itake iplace?
o In isome ipractices, itesting itakes iplace iat ilocations iother ithan ithe iprimary iclinic. iPatients iwho iare
iunfamiliar iwith ithe iarea ineed idirections ito ithe itesting isite iand iwhere ito igo iafter iarrival.
• Why: iWhy iis itesting inecessary?
o Testing iis ioften iexpensive iand idisruptive ito idaily ilives. iThese ibarriers iare icommon ireasons ithat ipatients
imiss iappointments. iIf ithey iunderstand ithe ineed ifor itesting, ithey iare imore ilikely ito iadhere ito itesting
ischedules.
• How: iHow idoes ithe ipatient iprepare ifor itesting?
o Some itests irequire ispecial ipreparation. iFor iexample, imany iblood itests irequire ifasting. iIf iexercise itestingiis
ineeded, ipatients ishould ibe itold ito ibring icomfortable ishoes. iIt iis iimportant ito ilet ipatients iknow iof
ianything ithey ineed ito ido iprior ito iarrival.
Best iPractices iin iDeveloping iWritten iPatient iEducation iMaterials
Practice Rationale
Limit icontent Focus ion imain ipoints. iInclude ionly ithe imost iimportant-to-
iknow icontent.
Place iimportant iinformation ifirst People itend ito iremember ithe ifirst ithings ithey iread iand imay
,Best iPractices iin iDeveloping iWritten iPatient iEducation iMaterials
Practice Rationale
become idistracted itoward ithe iend.
Write iin iactive ivoice Active ivoice iis imore idirect. iPassive ivoice iis iless idynamic iand
imay ibe iconfusing.
Include iadequate iwhite ispace White ispace idoes inot icontain itext ior iimages. iWhite ispace
imakes ithe ipage ifeel iless icluttered iand iless ioverwhelming.
Use imeaningful iillustrations Illustrations iare ia iuseful iway ito ibreak iup itext. iSelect iimages
ior idrawings ithat ihave ia ipurpose ior ithat ireinforce ia ipoint iin
ithe ihandout.
Avoid iprofessional iterminology Use icommon iterms iin ishort, isimple isentences ithat ipatients
ican ieasily iunderstand.
Check ifor ireadability Materials ishould ibe iwritten iat ia ilower ieducation ilevel ithatican
ibe iunderstood iby imost ipatients. iInformation ifor iincreasing
ireadability iis iavailable
at ihttp://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
In iexamining ithese, ifive iprimary ipatterns iemerge. iThese iare: i(1) iforgetfulness, i(2) ilack iof iplanning, i(3) icost, i(4)
idissatisfaction, iand i(5) ialtered idosing. iAn ihonest iand iopen idiscussion ithat irespects iboth ithe ipatient iand iprovider
iperspectives ican ibe ian iimportant ifacilitator ito ipromoting ipositive ioutcomes. iIndividualized isolutions ithat iaddress ithe
ispecific ipatient's iconcerns iare ithose imost ilikely ito ibe isuccessful.
Managing iMedication iTherapy
In iaddition ito ithe imedication ireview iundertaken iat ieach ipatient iencounter, ia imore icomprehensive iand ideliberate
ireview iis ineeded iperiodically i(at ileast iannually). iThis ireview ishould ibe iapproached iwith ithe iintent ipurpose iof
idetermining iwhether ithere iare ibetter ioptions ifor imedication itherapy. iInherent iquestions ithat imust ibe iasked iabout ieach
idrug iinclude ithe ifollowing:
• • iIs ieach imedication iaccomplishing iits iintended ipurpose?
• • iIs ieach imedication istill inecessary?
o • iHas ithe ipatient's icondition ichanged?
o • iDo iadverse ieffects ior irisks ioutweigh ithe ibenefits ithat isome idrugs iprovide?
o • iWhat iwould ihappen iif isome imedications iwere ino ilonger iprescribed?
• • iWhat iproblems idoes ieach imedication icreate ifor ithe ipatient?
o • iIs ia imedication iproblem iamplified iby iother idrugs ithe ipatient iis itaking?
o • iIf ia imedication iis inecessary ibut iproblematic, iare idrugs iwith ifewer iadverse ieffects iavailable?
, • • iIf ipolypharmacy iis ian iissue, iare ithere iways ito idecrease ithe inumber iof imedications?
o • iWill ia icombination idrug isimplify imanagement?
o • iIs ia isingle idrug iavailable i(and idesirable) ifor imanagement iof itwo idifferent iconditions?
The iBeers iList iidentifies idrugs iwith ia ihigh ilikelihood iof icausing iadverse ieffects iin iolder iadults. iAccordingly, idrugs ion ithis
ilist ishould igenerally ibe iavoided iin iadults iolder ithan i65 iyears iexcept iwhen ithe ibenefits iare isignificantly igreater ithan ithe
irisks. iA ipartial ilisting iof ithese idrugs iappears iin i Table i10.2. iThe ifull ilist, iupdated iin i2019, iis iavailable ionline
at ihttps://onlinelibrary.wiley.com/doi/pdf/10.1111/jgs.15767.
TABLE i10.2
Some iDrugs ito iGenerally iAvoid iin iOlder iAdults
Drugs Reason ifor iConcern Alternative iTreatments
Analgesics
Indomethacin Risk iof iGI ibleeding iand iacute irenal Mild ipain: iacetaminophen, icodeine, iCOX-2–
i(Indocin) ifailure. iIndomethacin iis imore iprone iselective iinhibitors iif ino iheart ifailure irisk, ishort-
ito iaffect ithe iCNS ithan iother iNSAIDs. iterm iuse iof ilow-dose i NSAIDs
Ketorolac
i(Toradol)
Chronic iuse iof
inon- i–COX-2
iselective
iNSAIDsi(e.g.,
iibuprofen,
iaspirin
>325 img/day)
Meperidine Not ieffective iat iusual idoses, irisk ifor Moderate ito isevere ipain: imorphine, ioxycodone,
i(Demerol) ineurotoxicity, iconfusion, idelirium ihydrocodone
Tricyclic iAntidepressants, iFirst iGeneration
Amitriptyline Anticholinergic ieffects i(constipation, SSRIs iwith ishorter ihalf-life, i(e.g., iparoxetine,
iurinary iretention, iblurred ivision), isertraline, ifluvoxamine), iSNRIs, ior iother
Clomipramine
irisk ifor icognitive iimpairment, iantidepressants
i(Anafranil)
idelirium, isyncope
Doxepin
(>6 img/day)
Imipramine
i(Tofranil)
Antihistamines, iFirst iGeneration
Chlorpheniramine Anticholinergic ieffects i(constipation, Second-generation iantihistamines, isuch ias
i(Chlor-Trimeton, iurinary iretention, iblurred ivision), icetirizine i(Zyrtec), ifexofenadine i(Allegra), ior
