NR565 / NR 565 Midterm Exam Study Guide (Latest 2025 UPDATED): Advanced Pharmacology Fundamentals - Chamberlain

APRN prescribing role

Prescriptive authority for nurse practitioners also regulates prescribing rights beyond medications and controlled substances. These rights include therapeutic devices and services and are outlined in state practice laws and regulations and include Durable Medical Equipment (DME) such as wheelchairs, power scooters, hospital beds, portable oxygen equipment, handicap placards, etc. and medical services such as Physical Therapy (PT), Occupational Therapy (OT), home health services, etc. Prescriptive authority encompasses more than writing a prescription correctly. It requires adherence to ethical guidelines to ensure that patients are safeguarded from harm. Ethical prescribing starts with being well-informed about medications. Mechanism of action, efficacy, and safety are important considerations, as are a patient's distinct needs and circumstances, including the number of medications prescribed (Mitchell & Oliphant, 2016). Most patients receiving a prescription are taking other medications, whether prescription or over-the-counter. Appropriate selection, dosing, and duration of pharmaceutical agents are key to maximizing outcomes and minimizing adverse effects

benefits of full practice authority

Nurse practitioners have the autonomy to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight

promoting positive outcomes through prudent prescribing practices

Administering medications and prescribing medications are two distinct processes. Prescription writing requires prudent and deliberate decision-making processes to maintain patient safety and reduce liability, including:

*documentation of a provider-patient relationship for the recipient of the prescribed medications

*documentation of a thorough history and physical examination for the recipient

*documentation of discussions regarding risk factors, side effects, or therapy options

*documentation of drug monitoring or titration plan, if applicable

*documentation of consultations, if any

avoidance of prescribing medications for self, family, or friends

Rational drug selection requires a logical approach that includes the formulation of a diagnosis based on clinical reasoning and the selection and monitoring of the most appropriate pharmacological treatment

Considerations include: Cost, guidelines, availability, interactions, side effects, allergies, hepatic/renal functions, need for monitoring, & special populations

Beer's Criteria

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.

Pharmacodynamics

the study of the biochemical and physiologic effects of drugs on the body and the molecular mechanisms by which those effects are produced

Pharmacokinetics

the study of drug movement throughout the body

Pharmacogenomics

the study of how genes affect a person's response to drugs. The purpose of this is to combine the sciences of genomics and pharmacology to provide individualized, targeted, safe drug therapies to patients

CYP450 inducers

Inducers are xenobiotics (medications and environmental agents) that elevate CYP450 enzyme activity by increasing enzyme synthesis. This action leads to additional sites available for biotransformation. The increased number of sites enhances medication metabolism, decreasing the concentration of the "parent drug" while increasing metabolite production.

Inducers = Increase medication metabolism

(Carbamazepine, Rifampin, Alcohol, Phenytoin, Griseofulvin, Phenobarbital, Sulfonylureas)

CYP450 inhibitors

Inhibitors are medications that inhibit the metabolic activity of one or more of the CYP450 enzymes. Medications that inhibit an enzyme potentially slows that enzyme's activity or blocks the activity required for the metabolism of other medications, thereby increasing the levels of medications dependent on that particular enzyme for biotransformation. Inhibitors = decrease medication metabolism (Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol, Ketoconazole, Grapefruit Juice, Quinidine)

cultural influences in prescribing

The greatest concern surrounding race-based therapy has to do with genetic variability. We know there is great diversity within and among racial groups; therefore, a "one fits all" approach based on race is unwise. Still, we can use known associations to guide choices. For example, differences in metabolism between people with East Asian and European heritage are common. The provider can use this knowledge to guide initial dosing (with adjustment, as indicated based on response) if genetic testing is not feasible or warranted

Polypharmacy: Definition, challenges, and outcomes

treatment with multiple drugs

greatly increases the risk for interactions. Some of these interactions are negligible, but some can have life-threatening consequences. It is of crucial importance to ask the patient about all current drugs, including over-the-counter (OTC) medications and other herbal preparations. Many patients do not consider OTC or alternative pharmaceuticals as "medications" and may not mention them unless you ask specifically.

Acute Pain Management

Chronic Pain Management

Opioid Management

Regulations of Controlled Substances

The U.S. Department of Justice Drug Enforcement Agency (DEA) coordinates with local, state, and federal agents to reduce illicit drug use. The DEA enacted the Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances based on their potential for abuse and dependency. Five schedules of controlled substances were created that are updated annually. Classes of scheduled substances include narcotics, depressants, stimulants, hallucinogens, and anabolic steroids. The DEA issues eligible providers with a registration number to write prescriptions for controlled substances. Characteristics of a valid DEA number include:

-The first letter identifies the type of provider: A=before 1985; B=after 1985; F=after 2007; M=nurse practitioner or physician assistant

-The 2nd letter the 1st letter of the provider's last name at the time of initial registration

Example: Tammy Greene applies for and receives a DEA number of MG2705208

M=nurse practitioner and G=Greene

Opioid Epidemic & Responsible Prescribing

Opioid Use Disorder

a pattern of use that leads to significant impairment or distress. Typically, this disorder is marked by unsuccessful efforts to reduce or control use resulting in the inability to fulfill work, school, or home responsibilities. Opioid use disorder is different from drug tolerance and physical dependence, which may also exist. Opioid use creates high levels of positive reinforcement, increasing the likelihood of continued use. It is often a chronic lifelong disorder, leading to serious consequences such as disability and death. Although it is similar to other substance use disorders, it has distinct features that have fueled the current opioid epidemic. Opioids can lead to physical dependence in only 4-8 weeks. Abruptly stopping use in chronic users leads to severe symptoms, which motivates continued use to prevent withdrawal. The 2016 CDC guidelines for prescribing opioids recommends calculating the total daily dose of opioids to help identify patients who might benefit from the reduction or tapering of opioids, given the risk of overdose

State Prescription Drug

Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

Monitoring Programs

safeguards to address the opioid public health crisis include prescription drug monitoring programs (PDMPs). These electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances. According to the CDC (2020), PDMPs have shown promising results in changing prescribing behaviors, decreasing the use of multiple providers by patients, and decreasing substance abuse treatment admissions.

Drug Schedules

Each drug preparation regulated under the CSA has been assigned to one of five categories: schedule I, II, III, IV, or V. Drugs in schedule I have a high potential for abuse and no approved medical use in the United States. In contrast, drugs in schedules II through V all have approved applications. Assignment to schedules II through V is based on abuse potential and potential for causing physical or psychological dependence. Of the drugs that have medical applications, those in schedule II have the highest potential for abuse and dependence. Drugs in the remaining schedules have decreasing abuse and dependence liabilities.

The therapeutic window

is the amount of a medication between the amount that gives an effect (effective dose) and the amount that gives more adverse effects than desired effects. For instance, medication with a small pharmaceutical window must be administered with care and control, e.g. by frequently measuring blood concentration of the drug, since it easily loses effects or gives adverse effects

Antagonist

A drug that attenuates the effect of an agonist. Can be competitive or non-competitive, each of which can be reversible or irreversible. A competitive antagonist binds to the same site as the agonist but does not activate it, thus blocks the agonist's action. A non-competitive antagonist binds to an allosteric (non-agonist) site on the receptor to prevent activation of the receptor. A reversible antagonist binds non-covalently to the receptor, therefore can be "washed out". An irreversible antagonist binds covalently to the receptor and cannot be displaced by either competing ligands or washing.

Agonist

A drug that binds to and activates a receptor. Can be full, partial or inverse. A full agonist has high efficacy, producing a full response while occupying a relatively low proportion of receptors. A partial agonist has lower efficacy than a full agonist. It produces sub-maximal activation even when occupying the total receptor population, therefore cannot produce the maximal response, irrespective of the concentration applied. An inverse agonist produces an effect opposite to that of an agonist, yet it binds to the same receptor binding-site as an agonist

Silent Antagonist

A drug that attenuates the effects of agonists or inverse agonists, producing a functional reduction in signal transduction. Affects only ligand-dependent receptor activation and displays no intrinsic activity itself. Also known as a neutral antagonist.

The duration of action of a drug

is the length of time that particular drug is effective. Duration of action is a function of several parameters including plasma half-life, the time to equilibrate between plasma and target compartments, and the off rate of the drug from its biological target.

Schedule I Drugs

Substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse.

-heroin, LSD, marijuana, methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote

Schedule II Drugs

Substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence

All prescriptions for schedule II drugs must be typed or filled out in ink or indelible pencil and signed by the prescriber. Alternatively, prescribers may submit prescriptions using an electronic prescribing procedure. Oral prescriptions may be called in but only in emergencies, and a written prescription must follow within 72 hours. Prescriptions for schedule II drugs cannot be refilled. However, a DEA rule allows a prescriber to write multiple prescriptions on the same day—for the same patient and same drug

-combination products with less than 15 milligrams of hydrocodone per dosage unit.

-Vicoden, cocaine, methamphetamine, methadone, hydromorphone, meperidine, oxycodone, fentanyl, adderall, ritalin

Schedule III Drugs

Substances, or chemicals, are defined as drugs with a moderate to low potential for physical and psychological dependence. Less potential abuse than schedule I and II.

-Products containing less than 90 milligrams of codeine per dosage unit (tylenol with codeine), ketamine, anabolic steroids, testosterone.

Prescriptions for drugs in schedules III may be oral, written, or electronic. If authorized by the prescriber, these prescriptions may be refilled up to 5 times. Refills must be made within 6 months of the original order. If additional medication is needed beyond the amount provided for in the original prescription, a new prescription must be written

Schedule IV Drugs

Substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence.

-Xanax, soma, darvon, darvocet, valium, ativan, ambien, tramadol

Prescriptions for drugs in schedules IV may be oral, written, or electronic. If authorized by the prescriber, these prescriptions may be refilled up to 5 times. Refills must be made within 6 months of the original order. If additional medication is needed beyond the amount provided for in the original prescription, a new prescription must be written

Schedule V Drugs

preparations containing limited quantities of certain narcotics. Used mainly for antidiarrheal, antitussives, and analegesic purposes.

-cough preparations with less than 200 milligrams of codeine or per 100 mililiters (robitussion AC), lomotil, motofen, lyrica, parepectolin

Effects of certain pain medications on the heart

How to assess patient's overdose risk

Use of benzodiazepines with opioids

Assessing and Addressing OUD

Determining whether to initiate opioids for chronic pain

Using PDMP to promote patient safety

Reducing the risks of opioids

Treating chronic pain without opioids

Nitrates

Nitroglycerin has been used to treat angina

Nitroglycerin decreases the pain of exertional angina primarily by decreasing cardiac oxygen demand. Oxygen demand is decreased as follows: by dilating veins, nitroglycerin decreases venous return to the heart and thereby decreases ventricular filling; the resultant decrease in wall tension (preload) decreases oxygen demand

Therapeutic Goal: Reduction of the frequency and intensity of anginal attacks.

Baseline Data: Frequency and intensity of anginal attacks and the factors that precipitate anginal attacks. Blood pressure and heart rate should be noted.

Monitoring: No routine blood monitoring necessary.

Identifying High-Risk Patients: Use with caution in hypotensive patients and in patients taking drugs that can lower blood pressure.

Evaluating Therapeutic Effects: Instruct patients to keep a record of the frequency and intensity of anginal attacks and the factors that precipitate these attacks.

Minimizing Adverse Effects: Use with phosphodiesterase type 5 inhibitors (sildenafil) is contraindicated.

Adverse effect-> headache

Beta-blockers

β blockers (e.g., propranolol, metoprolol) are first-line drugs for angina of effort, but are not effective against vasospastic angina

β blockers should not be used by patients with sick sinus syndrome, heart failure, or second-degree or third-degree AV block.

β blockers reduce anginal pain primarily by decreasing cardiac oxygen demand, principally through blockade of β1 receptors in the heart, which decreases heart rate and contractility.

β blockers should be used with caution by patients with asthma. If an asthmatic individual absolutely must use a β blocker, a β1-selective agent (e.g., metoprolol) should be chosen. β blockers can mask signs of hypoglycemia and therefore must be used with caution in patients with diabetes.

When starting or restarting sotalol, patients should be in a facility that can provide continuous electrocardiogram monitoring and cardiopulmonary resuscitation for a minimum of 3 days to minimize problems associated with induced arrhythmia.

Creatinine clearance should be established before initiating this drug.

Betapace cannot be substituted for Betapace AF when treating atrial fibrillation.

Therapeutic Goal: Principal indications are hypertension, angina pectoris, heart failure, and cardiac dysrhythmias. Indications for individual agents are shown in Table 16.5.

Baseline Data: Heart rate, blood pressure (supine, sitting, and standing depending on patient status), ECG (if indicated by patient age and status), and general cardiovascular status

Monitoring: Heart rate, blood pressure, evaluation for adverse effects (with symptom-focused assessment if indicated). Advise patients to record the incidence, circumstances, and severity of any symptoms that may indicate inadequate control of symptoms for which the drug is given (e.g., angina) or a new onset of adverse effects.

Identifying High-Risk Pat

Calcium Channel Blockers

The CCBs used most frequently are verapamil, diltiazem, and nifedipine (a dihydropyridine-type calcium channel blocker). Accordingly, our discussion focuses on these three drugs. All three can block calcium channels in VSM, primarily in arterioles.

Verapamil and Diltiazem

Therapeutic Goal: Verapamil and diltiazem are indicated for hypertension, angina, and cardiac dysrhythmias.

Baseline Data: Determine blood pressure and pulse rate and obtain laboratory evaluations of liver and kidney function.

Monitoring: No routine blood monitoring required.

Identifying High-Risk Patients: These drugs are contraindicated in patients with hypotension, sick sinus syndrome, and second- or third-degree atrioventricular block.

Evaluating Therapeutic Effects: Monitor blood pressure periodically. For angina, the patient should keep ongoing records of time and intensity of anginal attacks.

Minimizing Adverse Effects: Initiate therapy with low doses, adjust doses carefully, monitor weight loss daily, and use an intermittent dosing schedule.

Thiazide diuretics

thiazides increase renal excretion of sodium, chloride, potassium, and water

ACEI

ARB

Labetalol

Protype drug for heart failure

Statins

Statin Intensity

When to use each intensity statin

-cardiac case study

Non-statin therapy

Non-statin add-on drugs to statin therapy

antiplatelet agents

Anticoagulants

Colchincine

Allopurinol

Febuxostat

Indomethacin

Alendronate

Ibandronate

NSAIDs

DMARDs

Methotrexate

Lefluonomide

During what trimester is a pregnant woman most at risk for adverse drug reactions with potential long term consequences?

1st trimester (fetus most at risk d/t rapid growth)

What is BEERS criteria?

Recommendations of medications inappropriate for elderly (65 and older), prescriber ultimately decides

What is the CYP450 (cytochrome P450)

liver enzyme system where medications are metabolized, can either be inducers or inhibitors and create drug-drug interactions

CYP450 inducers

Speed up metabolism of drugs (drug is cleared faster), drug has lesser effect (decrease blood levels of drug), elevate CYP450 enzymes

CYP450 inducers pneumonic

"Bullshit Crap GPS INDUCES rage"

CYP450 inducer drug names

Barbituates, St John wort, Carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas

CYP450 inhibitors

inhibit metabolism, increase blood levels of medications

CYP450 pneumonic

"VISA credit card debt INHIBITS spending on designers like CK to look GQ"

CYP450 inhibitors drug names

Valproate, isoniazid, sulfonamides, amiodarone, chloramphenicol, ketoconazole, grapefruit juice, quinidine

Physiological changes during pregnancy that impact pharmacodynamics and pharmacokinetic properties of drugs?

increase glomerular filtration rate leads to increase durg excretion

increase hepatic metabolism

decrease tone and motility of bowel

increase drug absorption

Examples of medications that can be teratogenic

Antiepileptic drugs, antimicrobials such as tetracyclines and fluoroquinolones, vitamin A in large doses, some anticoagulants, and hormonal medications such as diethylstilbestrol (DES).

How is absorption of intramuscular medications different in neonates?

slow and erratic due to low blood flow in muscles first few days of life

Why is absorption of medication in the stomach increased in infancy?

delayed gastric emptying

Some medications that should be avoided in the pediatric patient?

glucocorticoids, discoloration of developing teeth with tetracyclines, and kernicterus with sulfonamides, levofloxacin (antibiotics)

aspirin (Severe intoxication from acute overdose)

what should be included in medication administration patient education?

dosage size and timing

route and technique of administration

duration of treatment

drug storage

nature and time course of desired responses

nature and time course of adverse responses

finish taking antibiotic

What are some things that put the elderly patient at higher risk for adverse drug reactions?

reduced renal function

polypharmacy (the use of five or more medications daily)

greater severity of illness

presence of comorbidities

use of drugs that have a low therapeutic index (e.g., digoxin)

increased individual variation secondary to altered pharmacokinetics

inadequate supervision of long-term therapy

poor patient adherence

How can healthcare providers decrease likelihood of an elderly patient experiencing an adverse drug reaction?

obtaining a thorough drug history that includes over-the-counter medications

considering pharmacokinetic and pharmacodynamics changes due to age

monitoring the patient's clinical response and plasma drug levels

using the simplest regimen possible

monitoring for drug-drug interactions and iatrogenic illness

periodically reviewing the need for continued drug therapy

encouraging the patient to dispose of old medications

taking steps to promote adherence and to avoid drugs on the Beers list

How can we promote medication adherence with elderly patients?

simplifying drug regimens

providing clear and concise verbal and written instructions

using an appropriate dosage form

clearly labeling and dispensing easy-to-open containers

developing daily reminders

monitoring frequently

affordability of drugs

support systems

Why do nitrates need to be taken no later than 4 PM?

Need nitrate free interval so tolerance doesn't develop

Nine factors that impact outcome of medication?

Gender and race

Genetics and pharmacogenomics

Variability in absorption

placebo effect

Tolerance

patho

age

bodyweight

Do you need informed consent for genetic testing?

yes

What is the purpose of the Genetic Information Non-Discriminatory Act?

Protects patients from discrimination by employers and insurance providers based on genetic information

Difference between practice authority and prescriptive authority?

Practice authority refers to the nurse practitioner's ability to practice without physician oversight, whereas prescriptive authority refers to the nurse practitioner's authority to prescribe medications independently and without limitations.

Who regulates prescriptive authority?

the jurisdiction of a health professional board. This may be the State Board of Nursing, the State Board of Medicine, or the State Board of Pharmacy, as determined by each state.

What is scope of practice determined by?

is determined by state practice and licensure laws.

What is full practice authority?

Nurse practitioners have the autonomy to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight.

What is reduced practice authority?

Nurse practitioners are limited in at least one element of practice. The state requires a formal collaborative agreement with an outside health discipline for the nurse practitioner to provide patient care. ex/ physician involvement for 5 yrs than independent

What is restricted practice authority?

Nurse practitioners are limited in at least one element of practice by requiring supervision, delegation, or team management by an outside health discipline for the nurse practitioner to provide patient care.- typically doctor on site

What are components of Rx?

Prescriber Contact info

Prescribers name

NPI

DEA

Patient name

DOB

Date

Allergies

Medication name

Strength

Quantity

Indication for use

Direction for use

Refills

Signature

What are some potential problems that arise with written prescriptions?

Must contain all elements

May have pre-populated information

Write legibly

Avoid error prone abbreviations

Tamper resistant scripts are often required

Reasons for monitoring drug therapy

determining therapeutic dosage

evaluating medication adequacy

identifying adverse effects

serious or life-threatening risks.

Which schedules of drugs can APRNs prescribe?

depends on state - most II-V

How does limited prescriptive authority impact patients within the healthcare system?

longer wait times to sign a prescription

limits practitioners that are needed in rural areas

unequal relationships between providers. Ex. one has more power

high need for providers due to lack of providers and high amounts of patients.

Independent practitioners= more patients being seen= lessens the patient/provider load

Provider key responsibilities when prescribing?

safe and competent practice

understanding of the drugs, reactions, and pharmacology

Be aware of the age group you are prescribing to

Ex. Children vs older adults

What should be used to make prescribing decisions?

documented provider-patient relationship, not prescribing for family or friends, documenting a thorough H&P, including discussions with the patient, drug monitoring/titrating.

cost, guidelines, availability, interactions, side effects, allergies, hepatic and renal function, need for monitoring, and special populations

What happens when someone has a poor metabolism phenotype?

medications metabolized slower, medication might not work or put them at risk for side-effects

What does the US food and drug administration regulate when it comes to medications?

Whether the drug is safe, effective, and benefits of a drug outweigh the risks

reasons for medication non-adherence

patients never filling/refilling prescriptions (resulting in therapeutic failure)

multiple chronic disorders

multiple prescription medications

multiple doses per day for each medication

drug packaging that is difficult to open

multiple prescribers

changes in the regimen (adding meds, changes in dose or timing)

cognitive or physical impairment (reduction in memory, hearing, visual, color, or manual dexterity)

living alone

recent discharge from hospital

low literacy

inability to pay for meds

personal conviction that a drug is unnecessary or the dosage is too high

presence of side effects