Pharmacology for the Primary Care Provider: Study Guide Solutions 2022 Rated A+

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