Posted: January 17th, 2023

NSG-533-IKC – Advanced Pharmacology Discussions

State Legal Requirements for CRNP Prescriptive Authority

Course Outcome: Fulfill legal requirements for writing prescriptions as a CRNP in this Commonwealth of Pennsylvania in accordance with § §  21.283—21.287 (relating to CRNP).
  • Link: http://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/049/chapter21/subchapCtoc.html&d=reduce
  • The link provided for the Pennsylvania Code outlines the legal requirements that govern nurse practitioners in Pennsylvania. Although each state may vary somewhat with regards to its requirements, the basic framework is provided. Each student should take some time to familiarize themselves with these requirements and determine if the requirements in their own state may vary.
  • If there are any questions or comments, please post as necessary. This Section is Not Graded
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Introductions

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Please introduce yourself to the class.

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Unread for topic Introductions:(48)

Module I: GI Topics Discussion

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Proton pump inhibitors are a class of novel drugs that are the most potent acid suppressors on the market today.  Since omeprazole’s introduction in 1990, they have been clinically proven to be better than H2RAs.  Over the past decade their use has been scrutinized because of several harmful disease associations.

How would you handle a patient who wants to begin long-term PPI use?

What would your discussion with them entail?

In what patients or disease states would you not recommend PPI use?

What if H. Pylori is found to be present?

 

The following FDA warning appears in the clopidogrel package insert: “Drug interactions: Co-administration of Plavix with omeprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of Plavix if given concomitantly or if given 12 hours apart. ” Plavix (clopidogrel) [package insert] Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership Bridgewater, NJ. 2009.

Evidence-based guidelines such as those provided by the AGA state: “PPI therapy does not need to be altered in concomitant clopidogrel users as there does not appear to be an increased risk for adverse cardiovascular events”. (Strong recommendation, high level of evidence) Am J Gastroenterol 2013; 108:308–328; doi:10.1038/ajg.2012.444.

This leaves the provider to make a professional decision.

You may wish to read the portion of clopidogrel’s package insert [link below] regarding pharmacogenomics as well as the article found in Medscape [link below] regarding genetics in pharmacotherapy before answering the last question. Pharmacogenomics is, and will become, an increasingly bigger part of care as we move forward.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020839s044lbl.pdf
https://www.medscape.com/viewarticle/888159_2

 

After reviewing the package insert for clopidrogel and available evidence regarding this combination, what would you recommend if a patient is taking esomeprazole and clopidrogel together?

 

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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Module II: Diabetes/Endocrine Topic Discussion

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Often we see a great deal of misinformation in the care of patients with diabetes, and often this misinformation is centered around the role and choice of medications.  Many patients, especially newly diagnosed patients, are prescribed medications that do not fit into the scheme of the ADA / AACE guidelines / best evidence based practices – for instance, starting on Januvia (sitagliptin) or Jardiance (empagliflozin) or Byetta (exenatide) as initial monotherapy without a compelling indication or reason.

In this discussion, please talk about how patients get put on these medications and why/how they should be transitioned to more evidence based treatments.

  • Is it okay to start a patient on a drug (particularly an oral drug) other than metformin as an initial drug?  Please cite possible circumstances where this could be reasonable.
  • What anti-diabetic medications have compelling evidence for use in select populations, possibly as initial therapy, and is this benefit a “class” effect?
    • (eg. SGLT2Is – Patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo)
  • How can patients and practitioners be convinced to change their behavior and opt for more evidence based approach to therapy?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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Unread for topic Module II: Diabetes/Endocrine Topic Discussion:(2)
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Unread for topic Module III: Men’s and Women’s Health Discussion:(6)

Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion

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Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let’s discuss their use in our health care systems and the impact on our patients.
Things to consider might include (just getting you thinking):

Safety: How could the side effect profile affect your patients?
Efficacy: Are benzodiazepines efficacious for anxiety and sleep?
Use: Are they under or over prescribed? How can we ensure safe use of these medications?

Consider the following cases:

KT is a 24 year old female completing her studies. While home for spring break, she presents to her primary care physician because she has been worried about her academic, professional, and personal future since class restarted in late August. She is constantly worried about passing all of her exams and that she is going to be the only one of her friends that graduates school without a ring on her finger.

  • How would you help her assuming she meets the criteria for GAD?

WD is a 49-year-old male who suffered a myocardial infarction one week ago. Upon discharge, it was noted that WD appeared depressed. At a follow-up visit with his physician a week later, WD met criteria for a diagnosis of major depressive disorder. His past medical history includes: treatment refractory hypertension, diabetes mellitus (type II), and severe uncontrolled narrow angle glaucoma

  • How would you help him assuming he meets the criteria for MDD?

JM is a 42 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises.

  • What non-pharmacological and pharmacological therapies would you recommend for JM?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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Unread for topic Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion:(15)

Module V: Pain Management Discussion

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There are hundreds of opioid conversion calculators available online, though they are not all of good quality.  I would like to direct you to one of the opioid conversion calculators that I find to be most useful and evidence based.  Locate http://opioidcalculator.practicalpainmanagement.com/ and evaluate the following case using the calculator as necessary. Discuss your approach to the overall case and results of your calculation.

  • A 79 year old white male is taking hydrocodone/APAP 10/325 for lower back pain (pt diagnosed with degenerative disc disease several months ago). The physician had written a prescription for Vicodin® 10/325  i-ii Q4-6h prn pain with a quantity of 120.  Her expectation was that this would last the patient for one month.  The patient is now requesting refills about every 10-14 days.  He states he has been taking 2 tabs Q4h (12 tablets per day) because “the pain is so bad I just can’t stand it!”.
    • What is the problem with the way the patient is taking this medication versus the way it was prescribed
    • Based on your assessment, it is determined this patient should be converted to extended release morphine for better, more consistent pain control. Perform this conversion and provide an appropriate recommendation (drug, dose, frequency).
Migraine is a major neurological disease that affects more than 36 million men, women and children in the United States. There is no cure for migraine. Most current treatments aim to reduce headache frequency and stop individual headaches when they occur. Let’s look at a case example:
  • CM is 20 years old female with severe, prolonged 2 to 3 day migraines twice per month. She has difficulty sleeping and is mildly anxious. She occasionally utilizes an inhaler for asthma.
    • Provide an evaluation of CM’s condition including non-pharmacological interventions and treatment options
    • Is Cm a candidate for prophylactic therapy, and if so, what option would be best suited to her?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. 

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Module VI: Bone and Joint Disorders Discussion

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Calcium and Vitamin D supplementation are essential to bone health and the management of osteopenia and osteoporosis.  In the past few years, information regarding the potential risks of too much calcium (such as cardiovascular disease and/or events) have been emerging.

  • Using an article from a medical journal, evaluate and discuss the risks and benefits of calcium supplementation for a patient with a bone disease.
  • What would you recommend for is a 59-year-old postmenopausal woman with a T-score of − 2.3. Her past medical history is unremarkable and she only takes a multivitamin with additional calcium and vitamin D. Her family history is remarkable for a mother who had osteoporosis and died of breast cancer and a father who has diabetes
Gout is a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint). Although there is no cure for gout, it can be effectively treated and managed with medication and self-management strategies
  • A 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner
    • Provide an evaluation of the patient including possible risk factors and treatment options, including non-pharmacologic interventions
    • Would this patient be a candidate for prophylactic therapy?
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Unread for topic Module VI: Bone and Joint Disorders Discussion:(10)

Module VII: Respiratory Tract Infections

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When faced with a choice between 2 or more possible answers, using a “STEPS” analysis may be a useful clinical decision making tool.  The goal is to provide information for each agent and compare the results to aid in your decision.

S:  safety – are there any serious drug interactions?  Possible serious side effects or adverse drug reactions?

T – tolerability – consider any adverse drug effects or side effects that may be concerning to the patient such as:  diarrhea, headaches, rash, etc.

E – efficacy – is one agent more efficacious than the other for the infection?

P – price – does the patient have insurance?  will cost inhibit adherence or access to the medication?

S – simplicity – which regimen is simpler?  Once a day dosing will likely have better adherence rates than three times a day dosing.  Also, three days of an antibiotic may be preferable to 7-10 days.  Depending on the drug you choose, the frequency and duration will vary.

Here’s an example table

Drug 1 Drug 2
Safety Moderate drug interactions No drug interactions / serious ADRs
Tolerability Diarrhea Diarrhea, headaches
Efficacy Similar Similar
Price/Preference $100/7 days $30/3 days
Simplicity 7 days, once daily dosing 3 days, BID dosing

1.  Which one would you choose and why?

2.  Identify the available treatment strategies for CAP in an adult outpatient with comorbidities. Create your own “steps” analysis comparing the use of the available treatment regimens. Be prepared to compare and contrast your ideas with your classmates.

Reference:  Evaluating the safety and effectiveness of new drugs

 

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. 

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Unread for topic Module VII: Respiratory Tract Infections:(5)
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Unread for topic Module VIII: Skin and Soft Tissue/UTI Discussion:(8)

Module IX: Respiratory Disorders

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JR is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to the ER today with h/o shortness of breath for 45 minutes at rest. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. 20 minutes later, he began to feel short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ER. Upon arrival, he was tachycardic, tachypneic, wheezing, using accessory muscles and hypertensive. His last admission for an asthma attack was 2 months ago. He denies a recent cold or URI and says the albuterol usually helps him when he feels an attack coming on and tends to use it on a daily basis. He generally has wheezing and shortness of breath on a daily basis. JR reports poor sleep due to waking about 2 times a week for shortness of breath. He has 2 cats, which sleep next to him on his pillow and he lives in an apartment complex. JR does not smoke, but his neighbor smokes. JR is a carpenter by occupation. He monitors his peak flow once a week at home. He reports that his peak flow generally runs about 325 L/min and his personal best is 480 L/min. His current peak flow is 175 L/min.

Medication Prior to Admission:

Albuterol MDI 2 puffs BID-QID PRN

Salmeterol Diskus 1 inhalation QID

Ipratropium bromide MDI 2 puffs QID

Lovastatin 20 mg po HS

Lisinopril 10 mg po QD

Questions:

  1. Classify JR’s asthma severity and control based on signs and symptoms prior to this most recent exacerbation and visit to the ED.
  2. Classify JR’s exacerbation severity based on PEF and symptoms.
  3. Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.
  4. Which step should JR have been on prior to ER based on severity and current medications?
  5. Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity?
  6. Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?
  7. How would you assess that JR is well-controlled?
  8. If JR is well-controlled, how would you step down in therapy?

 

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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Unread for topic Module IX: Respiratory Disorders:(2)

Module X: Hypertension/Heart Failure Discussion

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A 50yo African American woman presents to clinic feeling tired for the last 3 months.  She also has trouble breathing when walking 2-3 blocks.  She sleeps on 2 pillows at night to help with her breathing.  PMH:  HTN, arthritis.  Physical exam: edema present in both feet.  Medications:  HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee.  Vitals:  height 5’2″, 63kg, BP 134/84, HR 78, EF 30% per echocardiogram.  Her labs are normal including a creatinine of 1.1.  She denies chest pain or palpitations.  Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome.

  1. How would you classify her heart failure?
  2. What changes (modifications, additions, deletions) to her medications do you recommend that will:
    • Improve her symptoms?
    • Impact long term outcomes?
  3. What monitoring parameters do you recommend?
  4. What non-pharmacologic recommendations do you have?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

 

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Unread for topic Module X: Hypertension/Heart Failure Discussion:(12)

Module XI: IHD Discussion

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Bill is a 58yo male recently diagnosed with stable angina.  He has been experiencing chest pain about 2-3 times per week for the last month.  His chest pain typically occurs while walking, which he does about 3 times each week.  He has no other significant past medical history, takes no medications, has no drug allergies, and does not smoke.  His BP is 122/74, HR 72.  His labs are all normal.  His fasting lipid profile is Total Cholesterol 175, HDL 45, LDL 90, TG 125.  Waist circumference is 30”, and BMI is 24.  His family history is unremarkable.

  1. What risk factors are present and are they modifiable?
  2. What are the goals of therapy?
  3. What medication(s) do you recommend to prevent Bill from experiencing angina-related chest discomfort and to increase exercise capacity?
  4. What do you recommend to treat acute episodes of stable-angina-related chest discomfort?
  5. What additional medications can improve outcomes (e.g. decreased cardiovascular mortality, non-fatal MI, cardiac arrest, etc.) in a patient like Bill who has stable angina?
  6. What is your drug therapy monitoring plan?
  7. What patient education should you provide?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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Unread for topic Module XI: IHD Discussion:(14)
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Unread for topic Module XII: Dyslipidemia/VTE/Stroke Discussion :(17)

Opioid Case Group Discussion

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Group/section restrictions.

Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care. They are used as an educational tool and also help keep everyone on the same page when it comes to the treatment plan. The following case is found in the textbook (Pharmacotherapy: Principles and Practices. Chisholm-Burns et al, eds.  5th edition.  McGraw-Hill.  New York 2019. ISBN-978-1-260-01944-5; Chapter 34. “Patient encounter”). After reading the assigned chapters, resources identified in Dynamed and Evidence based practice guidelines, please present the case to your peers. This will be your initial post. Please be sure to address all the questions and your responses are well researched and include supporting, evidence based guidelines such those of the WHO, CDC, APS, etc.

You will then provide an evaluation of TWO peer submissions of the same case. These response posts / evaluations shall include a complete response (with references) either endorsing or refuting the post you are evaluating based upon your research and references (including the text). The response posts / evaluations will have one additional step; you will assign a rating to each of your TWO peers  initial post using a five star rating system.

  • 5 STARS = Excellent
  • 4 STARS = Above Average
  • 3 STARS = Average
  • 2 STARS = Below Average
  • 1 STAR = Poor

Rate the post by clicking on the number of stars you think the post deserves in the Ratings area of a user’s post. You can give a maximum of five stars. [Ratings: ☆☆☆☆☆]

In essence, you will have three posts total. Your initial post and a two response posts (one for each of two classmates you are grouped with).

Part 1:

HPI:  A 78-year-old man who is to undergo a left above the knee amputation due to a limb abscess

PMH: Peripheral artery disease for 18 years; cardiomyopathy, benign prostatic hypertrophy for 13 years

FH: Mother had osteoporosis; father had diabetes

SH: Lives with wife; has two grown children

Meds: Aspirin 81mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; pantoprazole 40 mg daily; tamsulosin 0.4 mg daily

Pain Assessment: Patient rates pain as 8 on a scale of 0 to 10.

  • Based on the type of injury, what type of pain is this patient likely to experience?
  • What type of pain management regimen would you suggest in the postoperative period? Explain your answer

Part 2:

Following surgery he was placed on morphine patient-controlled analgesia (PCA). He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

Current Meds:  Morphine PCA; aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily; heparin 5000 units twice daily until discharged home. He will be discharged to a skilled nursing facility for rehabilitation therapy.

You would like to convert him to a combination preparation of hydrocodone and APAP for as-needed pain relief.

  • What dosing regimen would you suggest?
  • What would your monitoring plan include for this patient?
  • How would you assess pain response?
  • The patient is concerned about the redness and itching that he developed while on morphine. Would you document this as an allergic reaction?
  • What other interventions or education may be necessary at this time?

Part 3:

The patient was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.

Current Meds: Aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily, heparin 5000 units twice daily until discharged home, hydrocodone/acetaminophen 5/325 mg every 6 hours as needed for pain.

Pain Assessment: Patient reports pain of 7 out of 10; worse with movement.

Physical therapy notes indicate patient is unable to complete therapy goals due to complaints of pain.

  • Based on this information, what would you recommend to optimize pain control?
  • Prescribers play a critical role in prescription drug misuse and abuse prevention. What steps can be taken to identify signs of dependence and abuse and what education can you provide to the patient regarding the negative effects of medication misuse?

Part 4:

The patient has been at the skilled nursing facility for 4 weeks and is making progress toward rehabilitation goals; however, he complains that his leg is throbbing and feels like pins and needles. As a result, he requests to rest several times during her therapy sessions. During unit rounds, his therapist inquires whether her previous pain medication should be reordered.

Pain Assessment: 4 out of 10

Current Meds: Aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily, heparin 5000 units twice daily until discharged home,

  • What additional recommendations would you have at this time regarding pain management?
  • Are there any other therapeutic issues that should be addressed?

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