APRN prescriber is responsible for the final decision on which drug to use and how to use it. Degree of autonomy in

Roles and Responsibilities of APRN Prescribers APRN prescriber is responsible for the final decision on which drug to use and how to use it. Degree of autonomy in this role and the breadth of drugs that can be prescribed vary from state to state based on the nurse practice act of that state. Nurse practitioner prescriptive authority is regulated by the State Board of Nursing for each state.•Advanced KnowledgeoAdditional knowledge, critical thinking, and assumption of a higher level of legal responsibility are required to assume the prescriber role Knowledge of medicine, pharmacology, and nursing intertwine in the NP role As a prescriber, it becomes the role and responsibility of the NP to determine the diagnosis for which the drug will be ordered, prescribe the appropriate drug, monitor the expected outcome of the drug, and incorporate a holistic assessment of the impact of disease and therapy on patient lives •Benefits of an APRN as PrescriberoAlternative treatment options are also part of the armamentarium that can be used to treat a given disorder and may interact with the pharmacotherapeutic intervention oAPRN look at the big picture and consider alternative treatment options and lifestyle changes oPatients are looked at in a holistic approach and include the patient in decision making regarding their care.oNP practice may thrive under healthcare reform because of the demonstrated ability of nurse practitioners to control costs and improve patient outcomes Prescriptive authority is the legal right to prescribe drugs. Full prescriptive authority affords the legal right to prescribe independently and without limitation. Recall that there are two components of prescriptive authority: (1) the right to prescribe independently and (2) the right to prescribe without limitation. The provider who prescribes independently is not subject to rules requiring physician supervision or collaboration. The provider who prescribes without limitation may prescribe any drugs, including controlled drugs, with the exception of schedule I drugs, which have no current medical use.Full practice authority is sometimes interpreted differently for advanced practice registered nurses (APRNs) and physician assistants (PAs) because supervisory requirements vary for the two professions.APRN ROLE There are many different issues to acknowledge when writing a prescription. Important considerations include cost, current practice guidelines, medication interactions, side effects, and the need for monitoring.Prescription Components -Pt's full name and address -Prescriber's full name, address, telephone # and DEA # -Date of issuance -Prescriber signature -Drug name, dose, dosage form, amount -Directions for use -Refill instructions Refills There are a few things to consider when refilling a prescription. Questions you should ask yourself include the following: • Is this a newer medication for this patient?• Am I changing dose or frequency of the medication?• Am I adding new medications to their regimen? 1 / 4

• Is the patient having undesired side effects?• When do I expect to follow up with this patient?• If the patient is requesting a refill by telephone, when was the last time I saw this patient? Do I need to see the patient again before refill?• Is this a schedule II medication?Promoting positive drug therapy outcomes requires a thoughtful and deliberate proactive approach to medication management. In this chapter we explore ways the provider can improve patient outcomes. Emphasis is placed on monitoring therapy, promoting adherence to therapy, and educating the patient.Patient Teaching for Drug Monitoring There are three primary reasons for drug monitoring: (1) determining therapeutic dosage, (2) evaluating medication adequacy, and (3) identifying adverse effects.When testing is needed for monitoring, include the following when providing patient teaching.

What: What test is needed?

oPatients like to know what test is needed. Rather than telling them that a blood test is needed, let them know the type of blood test (e.g., a test of thyroid function or cholesterol levels).

When: When is testing required?

oTesting can disrupt normal routines. Patients need to know, in advance, how often testing is needed so they can make plans.

Where: Where will testing take place?

oIn some practices, testing takes place at locations other than the primary clinic. Patients who are unfamiliar with the area need directions to the testing site and where to go after arrival.

Why: Why is testing necessary?

oTesting is often expensive and disruptive to daily lives. These barriers are common reasons that patients miss appointments. If they understand the need for testing, they are more likely to adhere to testing schedules.

How: How does the patient prepare for testing?

oSome tests require special preparation. For example, many blood tests require fasting. If exercise testing is needed, patients should be told to bring comfortable shoes. It is important to let patients know of anything they need to do prior to arrival.Best Practices in Developing Written Patient Education Materials PracticeRationale Limit contentFocus on main points. Include only the most important-to- know content.Place important information firstPeople tend to remember the first things they read and may 2 / 4

Best Practices in Developing Written Patient Education Materials PracticeRationale become distracted toward the end.Write in active voiceActive voice is more direct. Passive voice is less dynamic and may be confusing.Include adequate white spaceWhite space does not contain text or images. White space makes the page feel less cluttered and less overwhelming.Use meaningful illustrationsIllustrations are a useful way to break up text. Select images or drawings that have a purpose or that reinforce a point in the handout.Avoid professional terminologyUse common terms in short, simple sentences that patients can easily understand.Check for readabilityMaterials should be written at a lower education level that can be understood by most patients. Information for increasing readability is available

at http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf

In examining these, five primary patterns emerge. These are: (1) forgetfulness, (2) lack of planning, (3) cost, (4) dissatisfaction, and (5) altered dosing. An honest and open discussion that respects both the patient and provider perspectives can be an important facilitator to promoting positive outcomes. Individualized solutions that address the specific patient's concerns are those most likely to be successful.Managing Medication Therapy In addition to the medication review undertaken at each patient encounter, a more comprehensive and deliberate review is needed periodically (at least annually). This review should be approached with the intent purpose of determining whether there are better options for medication therapy. Inherent questions that must be asked about each

drug include the following:

• Is each medication accomplishing its intended purpose?• Is each medication still necessary?o• Has the patient's condition changed?o• Do adverse effects or risks outweigh the benefits that some drugs provide?o• What would happen if some medications were no longer prescribed?• What problems does each medication create for the patient?o• Is a medication problem amplified by other drugs the patient is taking?o• If a medication is necessary but problematic, are drugs with fewer adverse effects available? 3 / 4

• If polypharmacy is an issue, are there ways to decrease the number of medications?o• Will a combination drug simplify management?o• Is a single drug available (and desirable) for management of two different conditions?The Beers List identifies drugs with a high likelihood of causing adverse effects in older adults. Accordingly, drugs on this list should generally be avoided in adults older than 65 years except when the benefits are significantly greater than the risks. A partial listing of these drugs appears in Table 10.2. The full list, updated in 2019, is available online

at https://onlinelibrary.wiley.com/doi/pdf/10.1111/jgs.15767.

TABLE 10.2

Some Drugs to Generally Avoid in Older Adults DrugsReason for ConcernAlternative Treatments Analgesics Indomethacin (Indocin) Ketorolac (Toradol) Chronic use of non- –COX-2 selective NSAIDs (e.g., ibuprofen, aspirin >325 mg/day) Risk of GI bleeding and acute renal failure. Indomethacin is more prone to affect the CNS than other NSAIDs.

Mild pain: acetaminophen, codeine, COX-2–

selective inhibitors if no heart failure risk, short- term use of low-dose NSAIDs Meperidine (Demerol) Not effective at usual doses, risk for neurotoxicity, confusion, delirium

Moderate to severe pain: morphine, oxycodone,

hydrocodone Tricyclic Antidepressants, First Generation Amitriptyline Clomipramine (Anafranil) Doxepin (>6 mg/day) Imipramine (Tofranil) Anticholinergic effects (constipation, urinary retention, blurred vision), risk for cognitive impairment, delirium, syncope SSRIs with shorter half-life, (e.g., paroxetine, sertraline, fluvoxamine), SNRIs, or other antidepressants Antihistamines, First Generation Chlorpheniramine (Chlor-Trimeton, Anticholinergic effects (constipation, urinary retention, blurred vision), Second-generation antihistamines, such as cetirizine (Zyrtec), fexofenadine (Allegra), or

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