Regis NU 340, Community Health NursingSpring 2021 EXAM 1 LATEST UPDATE Rated A+

Regis NU 340, Community Health NursingSpring 2021 Cassie Medeiros NU-340 Exam 1 Regis College Young School of Nursing NU 340, Community Health Nursing Spring 2021 Take-Home Exam One __________________________________________________________________________________ Directions:  Gather your textbook, PowerPoint slides, and other anticipated resources.  Organize your individual testing resources. You are free to utilize your textbook, PowerPoint slides, online sites, and other materials to complete the exam.  Please avail yourself of all course Moodle site learning materials as well.  Your submission, despite the availability of open resources, is expected to be uniquely yours.  Clearly indicate your responses to all questions (e.g., highlight in yellow the correct answer or delete all the incorrect responses). Do make your answers absolutely explicit.  Do submit your answers as a Microsoft Word or PDF document (i.e., not Pages, Notes, etc.). Submission formats other than Microsoft Word or PDF may not be accepted.  You do not need to provide reference(s) for your responses.  While written responses do not require references, appropriate spelling and grammar are expected. Absence of proper spelling and/or grammar may result in lost points.  Submit your answers to the Moodle submission box within the specified timeframe.  Be sure to include your name on the uploaded submission.  No late submissions will be accepted without prior written instructor approval.  Good luck! _____________________________________________________________________________________ Part A: QUESTIONS BY TEXTBOOK CHAPTER and ASSORTED CONTENT Number of Questions in This Section: 24 Point Value: 2.5 Points/Question Total Points Possible in Part A: 60 Chapter One: 1. A marker of Affordable Care Act enactment success is? a. A greater percentage of the population is covered by insurance b. The prevalence of hypertension remains unchanged c. Public health departments offer more nursing positions d. Americans pay closer attention to their health status 2. List and briefly define the three (3) core functions of public health. Answer: Assessment, policy development and assurance are the three core functions of public health. Assessment involves systemic data collection on the population, monitoring the populations health status and additionally making information accessible about the health of the community. Policy development is efforts to evolve policies that assist the health of the population including utilization of a scientific knowledge base to make policy decisions. Assurance is making sure that necessary community-oriented health services are obtainable. This encompasses providing essential personal health services for individuals, as well as a component PH workforce. 3. One of the core public health functions is assessment of the health status of a community. Which of the following questions would be asked in the assessment phase? a. What programs are available to reduce the risk of cardiac disease in the population? b. What educational materials are needed to inform the community about environmental risk NU 340, Spring 2021, Take-Home Exam ONE Page 1 of 17 Cassie Medeiros NU-340 Exam 1 factors? c. What is the prevalence rate of hypertension about various age, race, and gender groups in the community? d. What types of public transportation are needed in the community to ensure access to services? 4. Increase in life span of the human population can be principally attributed to which change(s)? a. Increased focus on and funding for public health b. Reform of the medical insurance system c. Improvements in sanitation, safety, nutrition, and housing d. Improvements in medical knowledge and treatment approaches 5. A public health nurse establishes a cardiac rehabilitation program for cardiac patients living in the community. Which of the following best describes establishment of this program? a. Health education b. Policy making c. Primary prevention d. Tertiary prevention 6. Joseph, a community-based registered nurse, would be most likely responsible for completing which of the following? a. Assessing the health needs of a community b. Providing care to individuals in a community c. Promoting the health of an entire community d. Investigating occupational health hazards in a community _____________________________________________________________________________________ Chapter Two: 7. The local public health department provides community health nursing services in a county population of 25,000 residents. The goal is to provide health promotion, surveillance, and disease prevention services to the residents of the county. The primary nurse at the public health department is preparing to offer an influenza vaccination clinic, which is being held at the mall. She has arranged to have several volunteer nurses assist with the effort and is expecting to treat approximately 1,000 individuals. Public health nursing emphasizes prevention of disease. What are the challenges associated with such a goal? SELECT ALL THAT APPLY. a. Increased costs and decreased funding b. Independence of problem-solving and decision-making c. It is easier to measure the effects of prevention. d. It is more difficult to measure the effects of prevention that the effects of treatment. e. Emerging communicable diseases continue to be a health threat. 8. A public health nurse is determining which type of programming should be developed for the community. Which of the following is the most crucial factor that will influence program development? a. Comprehensive assessment and planning done in the community b. Documented needs of the local community c. Federal funding for priority diseases or groups d. Nursing staff’s expertise and skills NU 340, Spring 2021, Take-Home Exam ONE Page 2 of 17 Cassie Medeiros NU-340 Exam 1 9. A public health nurse is reviewing the screening guidelines for early detection of lead poisoning in pediatric patients ages 1 to 5. Which document would most likely provide useful information about this topic? a. The Future of Public Health b. Healthy People 2020 c. Patient Protection and Affordable Care Act d. Scope and Standards of Public Health Nursing Practice 10. The Elizabethan Poor Law of 1601, enacted in England and Wales and later adopted by early American settlers, provided the policy framework for which of the following medical care programs? a. Food stamps b. Welfare c. Medicaid d. Medicare 11. A graduate of the New York Training Hospital for Nurses, progressive reformer and nurse Lillian Wald is credited with which major public health contribution of 1893? a. Establishment of the Henry Street Settlement b. Creation of the Public Health Service c. Founding of the American Nurses Association d. Founding of the National Organization for Public Health Nursing 12. Between 1900 and 1955, which major health trend occurred in the United States? a. Chronic diseases became the leading causes of death. b. Deaths linked to communicable diseases increased. c. The mortality rate of Americans remained unchanged. d. The mortality rate of Americans increased. ____________________________________________________________________________________ Chapter Twenty-One: 13. A community health center offers free COVID-19 screening tests to area residents. Which level of prevention is being employed? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Quaternary prevention 14. An 80 y/o female comes to the local comprehensive primary care clinic with a large bag of medications. She tells the nurse that she can no longer afford these medications, because her only income is Social Security. Which statement is the best response by the nurse? a. “Let’s go through these medications and see which ones we can delete.” b. “You can get these medicines at this clinic for free.” c. “Let’s see if we can get some help from Medicare to help you pay for these medications.” d. “These medications are important. Do your best to pay for them.” 15. On which overarching concept was Healthy People 2020 established? a. Advance the agenda of the World Health Organization (WHO) b. Establish nursing centers for health promotion purposes c. Create partnerships among individuals, communities, and systems d. Eradicate disease in developing countries NU 340, Spring 2021, Take-Home Exam ONE Page 3 of 17 Cassie Medeiros NU-340 Exam 1 _____________________________________________________________________________________ Chapter Five: 16. Which of the following statements is true? a. The poor are more likely to receive health care through private agencies b. The poor in the United States are as healthy as persons with higher incomes. c. Millions of people in the United States are without health insurance. d. Persons with money or health insurance are less likely to seek care. 17. Which of the following individuals is most likely to be uninsured? a. A 10 year-old male with asthma whose legal guardian is his grandfather b. A 69 year-old female with end-stage renal disease c. A 48 year-old female who works full-time for a successful electronics corporation d. A 29 year-old male who works part-time as a computer programmer 18. Development of a hospice care program in the community is an example of which strategy? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Primary care 19. Which of the following payment methods for delivery of healthcare services attempts to limit uncontrolled spending and costs? Select all that apply. a. Prospective reimbursement b. Retrospective reimbursement c. Capitation d. Fee-for-service 20. Which of the following statements regarding Medicare and Medicaid is correct? a. Two federal programs that provide insurance to qualifying groups b. Available to any United States citizen who wishes to enroll c. Funded by the state government d. Are defined as private insurance providers _____________________________________________________________________________________ Assorted Related Content: 21. A visiting nurse makes a home visit to a patient. The patient’s chart reveals a recent physician order for Synthroid 75 mcg PO daily. The pharmacy filled the patient’s Synthroid prescription as 0.15 mg tab (scored). How may tablets will the nurse instruct the patient to take daily? Please show your calculations to receive credit. Answer: 75 mcg 0.075 mg _____ = 0.075 mg ________ = 0.5 tablet 1000 mg 0.15 mg NU 340, Spring 2021, Take-Home Exam ONE Page 4 of 17 Cassie Medeiros NU-340 Exam 1 22. A 48-year-old female with a history of uncontrolled asthma presents to the comprehensive primary care clinic with a heart rate of 120, respiratory rate of 48, oxygen saturation of 84%, and mild hemoptysis. The RN should give priority to: 1. Obtaining a full health history 2. Administering oxygen 3. Obtaining additional vital signs 4. Checking arterial blood gases 23. Anthony, a 13-year-old male, is newly diagnosed with type 1 diabetes mellitus. Which of the following health information points should the community health nurse include? Select all that apply. a. Type 1 diabetes mellitus can be triggered by a viral infection. b. Type 1 diabetes mellitus damages alpha cells in the pancreas. c. Type 1 diabetes mellitus is often diagnosed before age 30. d. Type 1 diabetes mellitus is treated with antiglycemic medications. e. Blood glucose levels in type 1 diabetes mellitus can be controlled by diet and exercise. 24. Click the following short video link to meet and learn about Dr. Dinee Simpson, the first Black female transplant surgeon in the State of Illinois: addressing that relate to community/public/population health. Please be specific. a. Establishing educational programs for patients Health literacy is very low for not only African American communities but others as well. Dr. Simpson wants to offer education about diagnosis and treatment in language that is easy to understand. By taking time to answer questions patients and families will allow them to feel comfortable with their treatment/diagnosis. b. Black people disproportionately face health inequity Many black communities don’t have the same health care resources available to them compared to a community that is mostly white. Either they can’t afford the health care services or they don’t have the knowledge about that to go receive that care. Dr. Simpson wants to put a team in place to help connect patients and families with the resources they need from insurance assistance to support groups. c. Providers not being culturally competent A culturally competent provider can help improve health outcomes and quality of care and can contribute to the elimination of racial and ethnic health disparities. Dr. Simpson wants providers to understand the differences in opportunities and resources that African Americans face so that they can get the health care that they need ------------------------------------------------------------------------------------------------------------------------------- Part B: EXPLORING THE COMMUNITY ASSESSMENT PROCESS Number of Questions in This Section: 4 Point Value: 2.5 Points/Question Total Points Possible in Part B: 10 DIRECTIONS:  Watch the following Alaska public health nurse (PHN) recruitment video:  Answer the questions related to the Alaska PHN recruitment video. NU 340, Spring 2021, Take-Home Exam ONE Page 5 of 17 Cassie Medeiros NU-340 Exam 1 RELATED VIDEO QUESTIONS: 25. Identify the specific community that Colleen and her fellow PHNs are assessing. The specific community that Colleen and her fellow PHNs are assessing is Russian mission, which is a small village that doesn’t really have public services available to them. 26. Identify three (3) key findings of the windshield (or walking) survey that Colleen and her fellow PHNs conduct and the significance of each finding. a. Russian Mission was a close-knit community and wants to do better In order to improve a community’s issues, you need a community that has strong leadership and community participation. Having the leaders of the community support the PHN, then fellow residents will do the same almost like a domino effect. Furthermore, the residents need to want to improve otherwise there won’t be strong participation and improvements can only happen if there is such. These qualities are seen within close-knit communities and that makes it easier for the PHNs to provide these services. This is a significant finding as it an important quality for a community to have for a PHN to successful help the community. b. High percentage of alcohol and substance abuse A big concern the village council had was the percentage of alcohol and substance abuse. As a PHN, knowing this is a big issue shows there is no support or treatment available to those who struggle with this disease. Also, it makes you wonder what is leading all these residents to turn to alcohol or substance abuse. Furthermore, cases of TB and STD’s are high and these are preventable diseases when given the correct health services. Overall, this is a significant finding as these are all issues that could be prevented or avoided with proper health care. c. High prices of all items within stores Groceries and day to day living supplies are very expensive within the village. For instance, orange juice was $19 dollars and that is just crazy. For a community that doesn’t have many opportunities for residents to establish an income this is concerning for a PHN. Are families or even children being well-nourished and having proper hygiene. Malnourishment and lack of good hygiene can lead to so many health problems and that is actually a problem the community already has, bad health. This is a significant finding as it could be the root of many other concerns within the village. 27. Identify two (2) individuals highlighted in the video whom you think should serve as key informants for the community assessment. a. Colleen Osterhaus PHN b. Yvette Barrows PHN 28. Briefly explain your rationale for selecting your chosen two individuals to serve as key informants. For example, what insight or perspective could your chosen two individuals provide? Please be specific. I chose Colleen Osterhaus (PHN) because she is someone who has never done itinerant travel before so this will be here first trip. Colleen will bring the perspective of an actual outsider who has never seen Russian Mission so her community assessment can result with finding that were never thought of before. Also, as a younger generation PHN, she can take the information she collected from the community assessment and handle them in a “newer” method compared to older generation PHN. Lastly, she can NU 340, Spring 2021, Take-Home Exam ONE Page 6 of 17 Cassie Medeiros NU-340 Exam 1 relate and collaborate with to the younger residents, whom will be the upcoming leaders of the community. I chose Yvette Barrows PHN as she is someone who is an experienced and has traveled to this community countless times. Her community assessment will be one that contains more understanding behind the collected data when analyzing the information. For example, the data could show that many women don’t bring their children to the clinic when its open. From experience she knows that the reason behind it, is that younger mothers in the community will feel judged if they don’t know everything so bringing their children in would relate a message that they don’t. Yvette also has built relationships with the residents due to many visits, which allows her to bring the insight of the residents themselves. She also knows the history of the communities and can determine what collected data has changed over the years or stayed the same. Overall her assessment will contain data that may be overlooked or misunderstood by someone with no experience in this community. ____________________________________________________________________________________ Part C: CONTINUING EDUCATION ARTICLE Number of Questions in This Section: 12 Point Value: 2.5 Points/Question Total Points Possible in Part C: 30 DIRECTIONS:  Read the 2018 continuing education unit (CEU) article entitled “Medication Nonadherence: America’s Other Drug Problem” below and answer the related questions. All answers can be found in the article, as the activity is designed to be completed by practicing RNs looking to complete CEU credits for continued RN licensure.  Just a reminder: Once you have secured RN licensure, you will be responsible for completing CEU credits regularly in order to maintain licensure (much like the IHI certification that you are completing for the course). As such, I try to select recent and relevant CEU articles that will not only acquaint you with the CEU process (if you are not familiar already) but also inform you on current nursing topics in community/public/population health. ------------------------------------------------------------------------------------------------------------------------------- Medication Nonadherence America’s Other Drug Problem by Dana Bartlett, MSN, MA, RN, CSPI CE679 | 1.00 contact hour Course Objectives The purpose of this program is to inform healthcare professionals about the importance of medication adherence, the factors that prevent it, and the methods to facilitate it. After studying the information presented here, you will be able to:  Discuss the importance of medication adherence and the significance of failure to adhere to medication regimens  Describe four factors that prevent medication adherence in the community  Name four methods to improve medication adherence ______________________________________________________________________________ NU 340, Spring 2021, Take-Home Exam ONE Page 7 of 17 Cassie Medeiros NU-340 Exam 1 “Drugs don’t work in patients who don’t take them.” C. Everett Koop, MD U.S. Surgeon General, Sixty-eight-year-old Mr. Riley has a new diagnosis of hypertension and hyperlipidemia. His blood pressure has been in the range of 155-165/85-90 mmHg over several months, and his total cholesterol is 280 mg/dL. Mr. Riley’s healthcare provider prescribes lisinopril (Zestril), an ACE inhibitor, for hypertension; lovastatin (Mevacor) for hyperlipidemia; and low-dose aspirin. The provider advises Mr. Riley to return monthly for blood pressure checks and to see how the lisinopril is working. Eight months later, Mr. Riley presents to the ED with chest pain. When Mr. Riley’s healthcare provider asks why he never followed up in the office, Mr. Riley says he takes only the aspirin. The lovastatin didn’t seem to be doing anything, and the lisinopril made him cough. “I’m not going to take a medicine that doesn’t make me feel better, and I’m sure not going to take one that makes me feel worse,” he said. Mr. Riley is not alone in failing to take his medications as prescribed. Poor medication adherence has been called “America’s other drug problem.” Nonadherence to a prescribed medication regimen is very common.1,2 (Level B) It has been estimated that about 50% of all patients do not take their medication as prescribed,3 and nonadherence is directly responsible for millions of hospitalizations and re-admissions; it causes or can cause increased morbidity and mortality, decreased quality of life, decreased occupational and social functioning, and the healthcare costs associated with nonadherence have been estimated to be billions of dollars.1-7 Medication nonadherence is an especially serious problem for patients who have chronic conditions, such as cardiovascular disease and diabetes. Behavioral, emotional, social, economic, medical, and public policy factors all contribute to the problem of medication nonadherence and affect virtually every aspect of the healthcare system.8,9 (Level B) This urgent issue has attracted significant attention over the past few years, resulting in major reports and action plans, such as the World Health Organization’s Adherence to Long-Term Therapies, the National Council on Patient Information and Education’s Enhancing Prescription Medication Adherence, and the U.S. National Medication Adherence Campaign’s Script Your Future. Healthcare professionals as a team can help identify issues that affect medication adherence and work together to improve it. _____________________________________________________________________________ What Is Medication Adherence? The terms concordance, compliance, and adherence have been used to describe taking medication as prescribed.10 These terms represent different concepts to patients and providers and reflect a differing relationship between them. For example, “concordance” (often used in Europe) conveys an active partnership between clinician and patient in which they collaborate to improve outcomes based on shared beliefs about health.10,11 “Compliance” indicates a passive role for the patient that may appear to blame and stigmatize the patient’s independent judgment and may reflect a paternalistic role on the part of the provider.10-12 The term “adherence” implies a more cooperative relationship between patient and provider and is more respectful of a patient’s treatment decisions.3 “Medication adherence” is the term most often used in the U.S. Medication adherence appears simple. But in reality it is a set of behaviors that includes making and NU 340, Spring 2021, Take-Home Exam ONE Page 8 of 17 Cassie Medeiros NU-340 Exam 1 keeping appointments with healthcare providers, delivering prescriptions to pharmacies, taking medications in the manner and frequency prescribed, monitoring supplies of medications to avoid running out, returning to the pharmacy for refills in time to keep from missing doses, securing new prescriptions from providers when they expire, and making and keeping appointments with providers to evaluate the effectiveness of treatment.13 Failure to take medications as prescribed falls into one of three categories:13  Primary nonadherence (or nonfulfillment) is the failure to fill a new prescription.  Medication non-persistence is the filling of a new prescription but discontinuing it during the first year.  Medication nonadherence includes all other behaviors associated with not taking medications as prescribed: taking them less frequently or in smaller doses than prescribed, taking more than is prescribed, skipping doses on purpose or accidentally, or taking them at the wrong time of day. Medication adherence, as previously mentioned, is very common and the consequences of this phenomenon can be significant. Nonadherence to a prescribed medication regimen in patients who have cardiovascular disease has been estimated to be as high as 80%, and nonadherence can almost double the risk for cardiovascular mortality, hospitalization, and myocardial infarction.5 The same is true for two other common chronic diseases, diabetes and hypertension. Adherence to prescribed drug regimens for the treatment of diabetes and hypertension has been estimated to be less than 50% and 14% respectively; complete or partial nonadherence can cause amputation, blindness, congestive heart failure, and renal failure for a patient with diabetes, and cardiovascular, cerebrovascular, and renal complications, such as stroke and kidney failure, for a patient with hypertension.2,14-16 Factors Influencing Adherence Medication nonadherence in the United States affects people of all ages and both sexes, and involves higher-income, well-educated people just as often as lower-income people with less education.17 Factors affecting patient adherence to prescribed medications in the community represent a complex interaction of medical, personal, and economic factors, as well as factors related to the medication itself. NU 340, Spring 2021, Take-Home Exam ONE Page 9 of 17 Cassie Medeiros NU-340 Exam 1 Medication-related factors: Many patients, especially older patients, take multiple medications several times a day, and the complexity of the medication regimen may be a primary reason for nonadherence.18 For example, patients on once-daily medications are much more likely to adhere than those required to take multiple medications several times each day. About 54% of people 65 and older take three or four prescriptions daily, and about one-third take eight or more.17 Compounding the problem is the fact that many patients see more than one provider, each of whom may prescribe medications for different conditions. Adherence also falls when patients must master new techniques to take their medications correctly, such as injecting, using inhalers, or testing blood.13,17 Patients may stop or decrease medications when experiencing adverse effects, as Mr. Riley did when the ACE inhibitor caused him to cough. Patients stop medications in the belief they are not working, as with antidepressants and other medications that take time to produce results. Patients also may stop medications for hyperlipidemia and hypertension because they don’t necessarily make people feel better even though the medications are working as intended. Some patients elect to take “drug holidays,” during which they cease taking some or all of their medications for a time because of perceived adverse effects or lack of benefit. Patient-related factors: Patients ultimately control whether they take their medications. People may simply forget a dose or two. Others do not understand what their providers tell them. For example, 60% of patients in one study could not correctly report what their providers told them about their medications 10 to 80 minutes later.17 Many patients are poor readers with a limited capacity to understand medical instructions; these patients have poor health literacy, a measurement of their capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.19 A U.S. Department of Education study found U.S. health literacy to be about 12% proficient, 53% intermediate, 22% basic, and 14% below basic, and these findings have been confirmed by more recent research.19,20 Put another way, nearly nine out of 10 patients may be unable to fully comprehend oral or written information about how and when to take medication.19 Other patients decide not to fill a new prescription or not to refill it the second time. A large cohort study found that 22% of patients had no dispensing of or only one dispensing of a new prescription.21 (Level B) An analysis of 423,616 electronically submitted prescriptions showed that even then, 24% were not filled.22 (Level B) Cost is also a factor in whether patients take medications. In a study of Medicare patients (who are insured), 29% of people with a disability and 13% of seniors failed to fill prescriptions or skipped doses because of cost.17 Factors related to patients’ willingness to take medications as prescribed include a denial of illness and the need for medication; worry about the social stigma of taking medications; media influences regarding safety of medications; beliefs about the effectiveness of treatment; a lack of acceptance of taking medications for preventive purposes and for symptomless conditions (e.g., statins and anti-hypertensives); a lack of positive motivation to make necessary behavioral changes; and the assumption that once symptoms have improved or the person feels better, it is all right to stop a medication.17 Prescriber-related factors. The U.S. Food and Drug Administration found that only 66% of patients polled in a survey reported receiving instructions from their providers about how often to take new medications.17 Providers may overestimate patients’ ability and willingness to adhere to a regimen by as much as 50%.3 Providers point to a lack of time for medication counseling and a lack of reimbursement for such education.13,17 Patients may be left without understanding exactly what the prescribed medication is for, what its potential adverse effects are and what to do about them, and when to return for follow-up care.17 A lack of trust between patient and provider leads to less adherence, as does poor communication between the two; this is exacerbated if the patient-physician interaction is in the U.S. NU 340, Spring 2021, Take-Home Exam ONE Page 10 of 17 Cassie Medeiros NU-340 Exam 1 and English is not the patient’s first language.13,17 Poor coordination between multiple providers may lead to problems with medication adherence as well.13,17 Pharmacy-related factors. Because pharmacists have direct and frequent contact with both providers and patients, they are well positioned to promote medication adherence and to help identify and prevent drug-related problems. Pharmacists, however, face many of the same issues as providers do, i.e., a lack of time and reimbursement for counseling.17 Adequate space and privacy may not exist for counseling.17 Patients and providers may not perceive pharmacists as the valuable resource they can be. Finally, pharmacists themselves do not all agree about their roles in healthcare delivery.17 Other factors that may influence medication adherence include the timing of new prescriptions. The immediate post-discharge period is a period of high risk for nonadherence; four of 10 patients are nonadherent in filling prescriptions after hospital discharge.23 Patients often improve their medicationtaking behavior shortly before and after outpatient appointments with healthcare providers, termed “white-coat adherence.”24 Populations at risk for low adherence include older patients with chronic conditions who take multiple medications.13 Adherence rates for acute conditions are higher.17 Children and teens are another at-risk group, especially when it comes to asthma treatments; adherence may be as low as 30% in adolescents, which can result in poor symptom control.17 Improving Adherence Despite the many factors contributing to medication nonadherence, it can be improved through directed interventions. Improving medication adherence is complex and requires patients and everyone involved in their care work to identify and overcome barriers and sustain long-term adherence. The Network for Excellence in Health Innovation examined 40 clinical studies relevant to medication adherence and categorized suggestions for improvement:25 (Level C) Simplify drug regimens: The complexity of a medication regimen has been inversely associated with nonadherence. Medication regimen complexity has many factors, including but not limited to the number of medications taken, the frequency of dosing, the number of doses per day, the medication forms, and the need to use special equipment to administer the drugs. When possible, modifying patients’ drug regimens to simplify the medication regimen, e.g., reducing the number of pills taken at dosing intervals or the number taken each day, will help improve adherence. One study found 11% better adherence among patients with hypertension who took medication once a day compared with those taking it twice a day.25 In another study, researchers found that for patients with HIV infection, a single-tablet regimen produced an almost 20% higher rate of adherence than a multi-tablet regimen.26 Other interventions include eliminating unnecessary medications by using combination products (e.g., an antihypertensive with a diuretic rather than two pills) and simplifying administration by using oral or transdermal medications rather than parenteral or inhaled ones when possible.25,27 Improve patient education: Patient education is consistently mentioned in the literature as a valuable tool for increasing medication adherence. The phrase patient education, of course, is very broad, and evaluating the effectiveness of education for increasing medication adherence can be difficult because patient populations and needs and educational interventions are all different.27 (Level B),28 There are many methods that can be used, and the role of the educator and the needs of the patients are varied and complex.25 Successful patient education and increasing medication adherence can be accomplished by:25,28-30  Effective communication and fostering of patient trust, both of which are closely linked with NU 340, Spring 2021, Take-Home Exam ONE Page 11 of 17 Cassie Medeiros NU-340 Exam 1 improved medication adherence  Education combined with patient monitoring and feedback  Using complex interventions that have multiple components  Combining education with other interventions, such as simplifying the medication regimens and using reminders like automated voice calls  Increasing patient understanding of the specific disease process and the mechanism(s) of action of the medications they take  Using written material, videos, and educational sessions  Evaluating and understanding patients’ beliefs and preferences about their medications Enroll patients in case management/disease management programs: Many healthcare organizations and health insurers offer case management or disease management programs providing specialized programs to people with chronic conditions, such as asthma, diabetes, hypertension, and heart failure. In these programs, healthcare professionals — most often nurses but sometimes dietitians, pharmacists, and respiratory therapists — regularly contact patients to discuss elements of their disease and the medications to treat it. One study showed that patients with diabetes receiving assessment calls and selfcare coaching by nurses had 21% better medication adherence than patients who did not participate in such programs.25 And a chronic disease management program featuring multiple interventions was shown over a three-year period to improve medication regimen adherence in patients who had type 2 diabetes and/or hypertension.31 Use the pharmacist: Pharmacists may be the most underused healthcare professionals, yet pharmacists have frequent interaction with patients in the community and can favorably affect medication adherence. Studies of patients with heart failure who received counseling by pharmacists showed nonadherence that was less than half of that in usual-care patients.25 When counseling is combined with dose simplification, adherence increased by 46%.25 Another study in which pharmacists provided adherence counseling to patients with hyperlipidemia improved medication adherence from a national average of 40% to 90%, and individual studies and overviews of systematic reviews have shown that interventions by pharmacists can significantly decrease nonadherence.17,32,33 Nurses should encourage patients to say “yes” when a pharmacist asks if they would like medication counseling. Use technology, media, and enhanced medication containers: New tools are available to encourage medication adherence. Patients may receive automated phone calls to remind them to fill prescriptions. Some case management programs allow patients to enter blood pressure, weight, or blood glucose readings into online systems that alert providers of abnormal values. Patients can “visit” their providers via Skype or live chats, or they may elect to receive text messages, tweets, and emails reminding them to take their medications and to refill them. Smart phone apps are available that list medications, schedule dosing reminders, and help patients obtain refills. Text messaging has used as a method for increasing medication adherence, and with some success,34 but a comprehensive review of studies (albeit of a specific medical condition) concluded that although text messaging showed promise as a way of increasing adherence, more research is needed.35 Packaging can greatly affect medication adherence. Medications may be blister packed at the pharmacy with an entire day’s worth sorted and sealed so the patient knows which pills to take at what times. One systematic review showed that calendar packaging (similar to oral contraceptives) in combination with education and reminder strategies produced higher adherence in 60% of trials.36 (Level A) There are dozens of varieties of containers that can improve adherence and patient convenience. Patients can organize pills for a day, a week, or a month. Some boxes have locks; only the current day’s medication is accessible. Others have ringing or buzzing alarms or voice instructions to let people know when to take their medications. NU 340, Spring 2021, Take-Home Exam ONE Page 12 of 17 Cassie Medeiros NU-340 Exam 1 There are internet-connected pill caps that light up, play music, and ring phones to help patients remember their medications. Electronic multi-compartment medication devices (automatic medication dispensing devices with many features, e.g., they can hold weeks’ worth of medications, dispense the right medication at the right time, and give auditory and visual reminders) have shown some promise. Some studies have found that they can increase adherence, but research has also shown that as with any intervention designed to improve medication adherence, the method must be adapted to the individual, and interventions will help some patients but not all.37,38 Combine interventions: Studies suggest that medication adherence programs that combine interventions, e.g., written materials, education, patient self-monitoring, and technical assistance (alarms, media messages, internet-connected pill caps, user-friendly medication packaging, etc.) may produce higher levels of adherence.28,29 (Level A) Address the issue of costs: Out-of-pocket costs for medications can, for some patients, be a considerable financial burden, and these costs have been noted to contribute to medication nonadherence.39 This aspect of nonadherence can be easily overlooked by healthcare providers, but if the patient is not adhering to the prescribed medication regimen, the provider should bring up the issue of costs. Strategies for Improving Medication Adherence17  Identify poor adherence by looking for markers of nonadherence (missed appointments, lack of response to medication, and lack of refills)  Ask patients about barriers  Emphasize the value of medications and the importance of adherence  Elicit the feelings of patients about the medication regimen and their ability to follow it  Provide simple instructions and simplify the regimen when possible  Encourage use of a medication-taking system (interactive pillboxes, etc.)  Obtain help from family, friends, and community support services  Reinforce desirable behavior and results  Consider “more forgiving” medications, such as those with longer half-lives, extended-release formulas, or transdermal application, when adherence seems unlikely A National Action Plan The National Council on Patient Information and Education convened a panel of experts to set national priorities that may have a great impact on improving medication adherence in the United States. The recommendations are designed to serve as a catalyst for action across the continuum of care by involving stakeholders, such as federal, state, and local governments; professional societies; healthcare providers; health educators; and patient advocates. Recommendations include:17  Elevate patient adherence to a critical healthcare issue  Agree on a common adherence terminology that will unite all stakeholders  Create a public/private partnership to mount a unified national education campaign to make patient adherence a national health priority  Establish an interprofessional approach to adherence education and management  Immediately start professional training and increase funding for professional education on patient NU 340, Spring 2021, Take-Home Exam ONE Page 13 of 17 Cassie Medeiros NU-340 Exam 1 medication adherence  Address barriers to patient adherence for patients with low health literacy  Create the means to share information about best practices in adherence education and management  Develop a curriculum on medication adherence for medical, nursing, and allied healthcare schools  Seek regulatory changes to remove roadblocks for adherence assistance programs  Increase the federal budget and stimulate rigorous research on medication adherence Nonadherence is a complex problem, and it involves more than patients who simply stop taking their medications. Nonadherence includes failing to fill or refill prescriptions, missing doses, stopping the medication before the appropriate time, taking someone else’s medications, taking more or less than what was prescribed, or taking a previously used medication that is no longer prescribed.40 Medication nonadherence has serious health consequences for patients, and it also imposes a huge financial burden on the healthcare system. Researchers examined data about medication nonadherence in patients who have diabetes, and they found that nonadherence for this patient population increased hospitalizations and ED visits by 15%.41 Using the same data, the authors projected that improved adherence in patients with diabetes would save $5 billion annually in the United States. The consequences and costs of nonadherence for the total U.S. population are considerably higher. One study noted that medication nonadherence is the cause of 33% to 69% of all hospitalizations in the U.S. and increases healthcare costs by $100 billion a year.4 (Level B) Nurses and other healthcare professionals can improve medication adherence during hospitalization, following discharge, in clinics, in provider offices, and in the community. EDITOR’S NOTE: Connie Goldsmith, MPA, RN, and Meaghan O’Keeffe, BSN, RN, past authors of this educational activity, have not had an opportunity to influence the content of this version. ________________________________________________________________________________ Medication Nonadherence: America’s Other Drug Problem Case Study: Please refer to the article for answers. Utilize your own nursing critical thinking skills as well. Mrs. Michaels, age 62, has a new diagnosis of hypertension. Her primary care physician gives her a prescription for quinapril (Accupril) and advises her to measure her blood pressure daily with a home blood pressure monitor, to call if she has any problems, and to return in six weeks for follow-up. When the provider asks if she has any questions, she says no. Six months later, Mrs. Michaels comes in to get her annual flu shot. The newly hired registered nurse (RN) administers the immunization and discovers that Mrs. Michael’s blood pressure is 188/92. On questioning, Mrs. Michaels admits that she never filled the prescription for quinapril, because her high blood pressure doesn’t make her feel sick. 1. The RN might initially: a. Scold Mrs. Michaels for not following the physician’s orders. b. Explain that hypertension is dangerous even when it does not cause symptoms. c. Hand Mrs. Michaels a brochure about hypertension and tell her to return in a month. d. Call the physician on the intercom about Mrs. Michaels’ primary nonadherence. NU 340, Spring 2021, Take-Home Exam ONE Page 14 of 17 Cassie Medeiros NU-340 Exam 1 2. The RN spends 20 minutes discussing how and when to take the quinapril, what the adverse effects are, and when to call the office. Mrs. Michaels says she understands and promises to adhere to her medication regimen. What else can the RN do? a. Schedule a reminder call before the next appointment b. Encourage Mrs. Michaels to enroll in her health plan’s hypertension case management program c. Recommend a medication-taking system d. Combine all of the above interventions 3. The nurse practitioner submits a new prescription to Mrs. Michaels’ pharmacy and notifies them that the patient needs help. How can the pharmacist help improve adherence to the quinapril? a. Phoning Mrs. Michaels every day b. Handing her a brochure about hypertension c. Using calendar packaging and counseling with each refill d. Automatically refilling the prescription each month and sending it to her _______________________________________________________________________________ Medication Nonadherence: America’s Other Drug Problem Additional Article Questions: Please refer to the article for answers. 4. How many patients fail to take their medications as prescribed? a. Very few b. About half c. About one-fourth d. At least three-fourths 5. Poor medication adherence has been called: a. America’s other drug problem b. A national disaster NU 340, Spring 2021, Take-Home Exam ONE Page 15 of 17 Cassie Medeiros NU-340 Exam 1 c. A problem for elderly patients d. Something to think about as baby boomers age 6. A person who does not fill an initial prescription is demonstrating: a. Nonpersistence b. Secondary nonadherence c. Failure to understand physician orders d. Primary nonadherence 7. Medication nonadherence is very common and includes all behaviors associated with not taking medications as prescribed. Those behaviors include which of the following? Select all that apply. a. Taking prescribed medication less frequently b. Taking prescribed medication in smaller doses than prescribed c. Skipping doses of prescribed medication on purpose or accidentally d. Taking doses of prescribed medication at the wrong time of day 8. Adherence to prescribed drug regimens for the treatment of diabetes is estimated to be less than 50%. For patients with diabetes, complete or partial nonadherence can cause which of the following? Select all that apply. a. Amputation b. Blindness c. Congestive heart failure d. Renal failure 9. Adherence is likely to be poor for which of these medications? a. Oral contraceptives b. Antibiotics c. Immunosuppressives d. Antihypertensives 10. Factors leading to poorer adherence include which of the following? Select all that apply. a. Medication cost b. Poor health literacy c. Complexity of a medication regimen d. Lack of trust between patient and provider 11. Which patients commonly demonstrate better medication adherence? a. Patients in the post-hospital discharge period b. Patients with acute conditions c. Older people on multiple medications NU 340, Spring 2021, Take-Home Exam ONE Page 16 of 17 Cassie Medeiros NU-340 Exam 1 d. Adolescents with asthma 12. What is the annual estimated cost of medication nonadherence in the United States? a. It cannot be estimated. b. $1 trillion dollars c. $100 billion dollars d. $1 million dollars _____________________________________________________________________________________ Conclusion of Exam One NU 340, Spring 2021, Take-Home Exam ONE Page 17 of 17