Читать книгу The Advanced Practice Registered Nurse as a Prescriber - Группа авторов - Страница 29

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.