and financially sustainable, the accessibility of the treatment, and the ease of use. Patients should be informed of the most common and serious side effects as well as key monitoring tests that contribute to patient safety. For example, a psychiatric NP will need to monitor levels of lithium at periodic levels to avoid toxicity. Many patients have conducted considerable Internet research prior to their visit which prompts medication questions or issues. Through education, a patient is provided with relevant facts to make a decision about whether to take a medication. Consent is typically verbal, but there may be situations in which written consent is obtained such as when prescribing a medication “off label,” i.e. when a medication is prescribed for a reason not approved by the Food and Drug Administration (FDA).
The APRN should work collaboratively with pharmacists who are experts in their field to educate patients about their medications. Patients may read information about medications and become fearful of the potential side effects and thus do not fill the prescription or do not take the medicine once obtained from the pharmacy. This requires a balance between providing too much and providing too little information about medications. At a minimum, patients should be sufficiently informed to understand the action of a drug, the dosage, and the most common and severe adverse reactions. They also need to be informed about how to handle common problems, missing a dose, follow‐up if the drug is not effective, and under what conditions the medication can be discontinued.
It is also important to provide guidance about how long the patient should expect to take the medication, particularly for non‐communicable conditions. A guiding principle of prescribing is to use the lowest dose for the shortest period of time possible. An ideal medication is one that is effective with minimal or no side effects and is low cost. Sometimes the patient’s health issue resolves. Lifestyle modifications such as exercise and sodium reduction may result in lowered blood pressure. In other instances a person may need antihypertensive medication despite these modifications.
Maintaining a trust relationship with the patient
APRN prescribing is based on recommendations about medications that reflect the patient’s best interests. Decisions also reflect patient preferences. Additionally, the APRN should guard against participating in relationships that conflict with the patient’s best interests. Licensed prescribers in the District of Columbia’s Medicare Part D program who accepted gifts from pharmaceutical companies were more likely than those who did not to take gifts to prescribe more medications, more expensive medications, and more brand‐name drugs (Wood et al., 2017). Although voluntary rules are in place to limit the relationships with and gifts from pharmaceutical companies, sample medications provided at the clinic by a company’s representative and educational programs continue to influence practitioners.
One of the most challenging aspects to prescribing can occur when patients have strong, erroneous, or unrealistic beliefs about their care. Some patients may be demanding, complaining, or rude, and require more extensive interaction than other patients. While these situations may prompt the label of “difficult patient,” alternative terminology such as “difficult patient situations” or “complex patient interactions” is more appropriate. “Standing one’s ground” with rational prescribing can be difficult in the face of patients’ demands for specific medications such as antibiotics. How can the APRN handle situations in which the patient assumes an adversarial role? Chapter 6, Managing Difficult and Complex Patient Interactions, has a full discussion of this topic. There are times, however, when a patient’s specific medication request may be appropriate to consider. For example, when the next step in treatment of depression is medication, a patient may request the specific drug a family member had success with. Provided there are no contraindications to that specific drug and there is not a superior option, working with the patient’s preference can build rapport.
SPECIAL CONSIDERATIONS FOR PRESCRIBING
Overview
APRNs have clinical competencies to provide healthcare for diverse populations in diverse settings which include emergency departments, primary care clinics, retail clinics, extended care facilities, prisons, and hospitals. APRNs also work in specialties such as oncology, geriatrics, dermatology, rheumatology, orthopedics, nephrology, cardiology, and palliative care. The prescribing role will be influenced by factors such as national certification and licensure, the population focus or specialization, the setting, and the community.
Prescribing for specific populations
Many psychiatric mental health NPs work with children. There are few medications approved by the FDA for use with children with mental health problems including depression, bipolar disorder, and schizophrenia. Conversely, there is an abundance of CSs marketed to treat children with attention deficit hyperactivity disorder (ADHD). This may lead parents to request these medications for behavioral issues even if the APRN does not diagnose ADHD.
The neonatal, pediatric, and family NP and pediatric CNSs may prescribe medication for children. Prescription challenges in this population sometimes involve calculating doses based on weight. As a vulnerable population, there is limited research on medication use in children. Consequently, a great deal of prescribing for children is not FDA approved and is known as “off label.” Factors such as size, age, renal function, cardiac output, hepatic blood flow, and genetics affect pharmacokinetics and pharmacodynamics among children. Pediatric prescribing must consider various factors such as absorption of drugs, drug distribution, drug metabolism, and drug elimination (Garzon Maaks et al., 2020). Over‐the‐counter medications for children pose potential risks. Cold and cough preparations have not been adequately studied and are not recommended for children younger than six years of age (Lowry & Leeder, 2015). For example, excessive acetaminophen is associated with hepatic toxicity and use of aspirin during a viral infection may induce Reyes syndrome. It is critical therefore to routinely educate parents about seeking APRN guidance before using over‐the‐counter medications with children.
Adult gerontology primary and acute care NPs often work with patients who have polypharmacy complicated by mental and physical deficits. Polypharmacy increases the complexity of therapy, increases costs, and increases the risk of adverse consequences. As previously noted, use of the Beers Criteria and the STOPP screening tool can enhance rational prescribing.
The types of drugs that CRNAs order and administer have potentially serious and immediate consequences. For example, when propofol is used for sedation, the CRNA must be alert to the rapid onset of action, which is often within a minute. This rapid onset is dose‐dependent and can result in an impaired respiratory drive, cause apnea, and require airway management.
CNMs, CNSs, and NPs must constantly consider the potential teratogenic effects of drugs in pregnant women. They must also consider the safety of drugs in lactating women. There are few randomized controlled trials regarding the safety of medications during pregnancy and lactation. To address this, the safety of medications is rated based on what information is available. Often the safety of a drug is unknown, and the APRN must proceed with caution and respond with evidence to the patient about her perception of risks and benefits.
NPs, CNSs, and CRNAs who work in pain management and palliative care typically prescribe a wide variety of CSs. Pain management requires expertise both in selecting medications and in dealing with patients who request medications that may not be indicated. Compliance with state laws implemented to deal with the US opioid crisis is imperative to assure patient safety and protect the APRN’s license (see Chapter 7). In contrast, APRNs who work with patients in palliative care may need to provide education to dispel concerns about opioid addiction at the end of life.
Other
