Independent Prescribing Flashcards
Define competency
A quality or characteristic of a person that is related to effective performance, competencies can be described as a combination of knowledge
When did the RPS release the new competency framework for all prescribers?
JULY 2016
List the competencies 1-6 required in the ‘consultation’ section of the prescribing framework
1) assess patient
2) consider the options
3) reach a shared decision
4) prescribe
5) provide information
6) monitor and review
List the competencies 7-10 in the ‘prescribing governance’ part of the prescribing framework
7) prescribe safely
8) prescribe professionally
9) improve prescribing practice
10) prescribe as part of a team
Two types of independent prescriber:
1) prescribe licensed meds within clinical competence
2) a community practitioner nurse can prescribe against formulary in BNF
What’s supplementary prescribing?
Voluntary partnership between doctor/dentist and a supp prescriber to prescribe against an agreed patient-specific clinical management plan
What proportion of MURs should community pharmacists provide to 4 target groups?
70%
What are the four target groups for an MUR
1) high risk meds (NSAID, anticoagulants, anti platelets &diuretics)
2) patients recently discharged from hosp who have had changes
3) patients with respiratory disease
4) patients at risk of or diagnosed with CVD & being prescribed more than 4 meds
What’s NMS
New medicines service- was the 4th advanced service to be added to the community pharmacy contractual framework
Name 4 conditions/therapy areas that were selected to be included in the initial NMS rollout:
1) asthma and COPD
2) type 2 diabetes
3) antiplatelet/ anticoagulant therapy
4) hypertension
What are the 5 headings that are included in the Cambridge-Calgary observation guide
1) initiating the session
2) gathering information
3) physical information
4) explanation and planning
5) closing the session
What heading in the Cambridge-Calgary observation guide can be left out?
Physical examination
When did the NHS put £15million in to a 3 year scheme for pharmacists in GP practices
JULY 2015
The GP forward view published in April 2016 suggests by 2020 what?
1500 pharmacists could be working in GP practices and extra funding in the region of £112 million will be made available for this
What 4 key areas can pharmacists help with in GP surgeries?
1) clinical services
2) prescription management
3) audit and education
4) medicines management
Do supplementary prescribers need to complete the independent prescribing course?
NOPE
What three CDs can pharmacist independent prescribers NOT prescribe?
Diamorphine, dipipanone or cocaine for treatment of addiction
List the 12 objective signs of opiate withdrawal
Yawning Coughing Sneezing Runny nose Lachrymation Raised BP Increased pulse Dilated pupils Cool, clammy skin Diarrhoea Nausea Fine muscle tremor
List 7 subjective signs of opiate withdrawal
Restlessness Irritability Anxiety Sleep disorders Depression Drug craving Abdominal cramps
What does DSM V stand for
Diagnostics and statistics manual
What does ICD-10 stand for?
International classification of diseases
What can be a consequence of chronic intravenous injecting
Poor vascular return
Psychosis can be precipitated by what?
Amphetamine use
In substance misuse what 3 factors does zinbergs model include
Drug
Set
Setting
Name the two licensed treatments available in the U.K. To treat opiate dependence via substitution therapy
Methadone
Buprenorphine
Why should an ECG be done before increasing the methadone dose to over 100mg
Because there’s a link with prolonged QRc and torsades des pointes syndrome
What drug is licensed and used in opiate withdrawal under ‘supportive pharmacological therapy’
The alpha-adrenergic blocker lofexidine
Is cocaine dependence supported by pharmacological interventions?
NO
What are the 5 main sections in the guidance on capacity/confidentiality/consent?
Seeking consent Adults without capacity Children & young peeps Withdrawing & withholding life-sustaining treatment Other exceptions to the principles
Name two types of informed consent
Implicit
Explicit
When a patient is ‘informed’ what does this mean
1) they have sufficient info in a format and language they understand
2) they can remember info for long enough to make decision
3) they can weigh up pros/cons
4) they can make a decision about whether the treatment is appropriate for their needs
When did the DH publish ‘confidentiality :NHS code of practice’
July 2003
The data protection act 1998 is built around how many key principles?
8
What year did the caldicott report recommend 6 key principles which govern the release and use of patient information?
1997
What are the 6 caldicott principles that govern the release and use of patient information?
1) Justify the purpose
2) do not use patient identifiable info unless absolutely necessary
3) use the minimum necessary
4) access to patient info on need to know basis
5) everyone should be aware of their responsibilities
6) understand &comply with the law
Each organisation should have a caldicott guardian - what are they responsible for?
The control of patient confidentiality throughout the organisation including assessing the relevance of clinical trials
Name three acts related to capacity and confidentiality
1) data protection act 1998
2) the freedom of information act 2000
3) health and social care act 2012
Name two acts that give patients access to medical and health records
1) access to medical records 1988
2) access to health records 1990
What does ‘access to medical records 1988’ allow
This sets out criteria for when a patient has a right to see what is written about them in medical records
What does ‘access to health records 1990’ allow
This enables a person to access medical records of a deceased individual if there is a claim arising from that death
In difficult situations involving decisions about patients, a secondary agency may be involved this includes what 3?
1) a professional regulatory body
2) a local clinical ethical team
3) a court of law
Name the two principle philosophical viewpoints in ethical decision making
1) utilitarianism
2) deontological
What is utilitarianism?
Decision is made on the risk to benefit outcomes of all the relevant factors to the particular patient
What is deontological?
Duty of care is owed to the patient
Name the 4 theoretical ethical principles of pharmacy
Beneficence
Integrity
Competence
Accountability
What are the 4 steps to ethical decision-making in pharmacy
1) gathering information
2) prioritisation and value judgment
3) relevant options
4) decision time
Can supplementary prescribers prescribe for family/Friends
This is decided by the independent prescriber
Can non medical independent prescribers prescribe for family/friends?
NO only in exceptional circumstances
NICE guidance says someone has hypertension what they have a persistent BP above what?
140/90mmHg
Patients should be treated immediately when their BP in clinic is greater than or equal to what?
180/110mmHg
What is the BP target for people under 80yrs old?
Below 140/90mmHg or below 135/85mmHg if using ABPM/HBPM
What’s the target BP for people aged 80yrs and over?
Below 150/90mmHg or below 145/80mmHg if using ABPM/HBPM
Do patients with renal disease or diabetes have higher or lower BP targets?
Lower duh
Hypertension is a major risk factor for what 6 things?
Ischaemic/haemorrhagic stroke MI Heart failure CKD Cognitive decline Premature death
What is ‘essential hypertension’?
When the underlying cause is NOT identified
What is ‘secondary hypertension’?
When the underlying cause IS identified
Name 2 causes of secondary hypertension
1) renal or endocrine disease
2) drug induced
Name 4 drugs that can induce hypertension
1) venlafaxine
2) COC
3) sympathomimetics
4) alcohol
True or false: ‘patients with essential hypertension usually have normal cardiac output, but raised peripheral resistance’
TRUE DAT
Vascular endothelial dysfunction has been implicated in what type of hypertension?
Essential hypertension
Give a possible future therapeutic option for hypertension?
Modification of endothelial function through restoration of impaired nitric oxide production
Name two non-dihydrophridine CCBs that are rarely used
Diltiazem
Verapamil
Name 3 long acting dihydropyridine CCB
Amlodipine
Felodipine
Modified release nifedipine
Name a short acting dihydropyridine that should be avoided due to its rapid onset of action
Capsular nifedipine
Name 5 side effects of calcium channel blockers
Oedema (usually ankle swelling) Headache GI disturbance Flushing Constipation with verapamil
Why aren’t ACEi it’s line for over 55s and Afro Caribbeans?
They have lower levels of renin so lower response to these drugs
Name 3 side effects of ACEi
Worsen renal function
Hyperkalaemia
Persistent dry cough
What can cause the dry cough side effect of ACEi?
Build up of bradykinin
Name 6 side effects of thiazides
1) Impaired glucose tolerance
2) Hypokalaemia
3) Hyponatraemia
4) Unfavourable increases in plasma lipids
5) Gout
6) Impotence
What’s the most commonly prescribed beta blocker and why?
Atenolol as it is once daily and inexpensive
Name an early short acting alpha blocker
Prazosin
Which alpha blocker causes significant problems with postural hypotension, dizziness and vertigo?
Prazosin
Name two longer acting alpha blockers
Doxazosin
Terazosin
What can alpha blockers also be prescribed to treat?
Benign prostatic hyperplasia
What type of drug is spironolactone and what do you have to be cautious of?
Aldosterone antagonist and be cautious of hyperkalaemia
Why is hydralazine used as add on therapy and not alone?
Because it causes tachycardia and fluid retention
What type of drug is hydralazine
Short acting non-selective vasodilator
What drug is marketed as a topical solution for male pattern baldness because of its hair growth side effects?
Minoxidil
Name two vasodilators used as add on therapy in more severe hypertension
Hydralazine
Minoxidil
Name 3 centrally acting antihypertensive drugs
Clonidine
Methyldopa
Moxonidine
Name three centrally acting antihypertensive drugs
Clonidine
Methyldopa
Moxonidine
Name the only direct renin inhibitor
Aliskiren
In 2009 the MHRA issued warning about what risks with aliskiren?
Warnings relating to angioedema and renal dysfunction
What is the BP target of people with type two diabetes?
<140/80
What is the BP target for people with type 2 diabetes at ‘high risk’
<130/80
What’s first line choice for diabetics with hypertension?
ACEi
Why should the elderly with hypertension be treated less aggressively?
FALLS RISK
Should thiazides be avoided in patient with eGFR <30ml/min
Yes because they are ineffective
Treatment of people with renal failure and hypertension may involve what?
Salt restriction and loop diuretics
Use of ACEi for hypertension in pregnancy is associated with what?
Oligohydramnios
Renal failure
Intrauterine death
What’s the first line antihypertensive in pregnancy?
Labetolol
What can be given in secondary care when there is a hypertensive crisis?
IV: Labetalol GTN Phentolamine Esmolol Hydralazine Sodium nitroprusside
What is coronary heart disease?
When flow of oxygen rich blood to heart is blocked or reduced
Increased strain on the heart in coronary heart disease can lead to what?
Angina
Heart attack
Heart failure
What does TIA stand for and what is it?
Transient ischaemic attack- like a stroke but blood flow to brain is only temporarily blocked
What is peripheral arterial disease?
Occurs when there’s a blockage in arteries to limbs- usually legs
Name 4 classes of cardiovascular disease
Coronary heart disease
Stroke & TIAs
Peripheral arterial disease
Aortic disease
The NHS check over 40s CVD risk how often?
Every 5 years
What does the QRisk-2 calculator work out?
Works out the risk of having a heart attack or stroke over the next 10years
When can you not use the QRisk-2 score?
1) people who already have a diagnosis of heart disease or stroke
2) people with type 1 diabetes
3) people with eGFR< 60ml/min/1.73m^2
4) over 84years old
What drug and strength is given to lower cholesterol for primary prevention to those with 10% greater 10 year risk of stroke/MI
Atorvastatin 20mg
Name 3 drug treatments for smoking cessation
NRT
bupropion
Varenicline
What’s the clinical adverse effect of bupropion
Increased risk of seizures
Which treatment used in smoking cessation has an affected efficacy if it’s been previously used
Bupropion
What drug interactions occur with bupropion
Those known to lower seizure threshold (antipsychotic, some antidepressants, tramadol, quinolone) and monoamine oxidase inhibitors
What are the clinical adverse effects of varenicline
MI
Depression
What are the three A’s to help patients stop smoking
ASK
ADVISE
ACT
Name 5 categories of complementary therapies classified by the US national institute of health (NIH)
1) healing systems
2) mind-body connections
3) dietary supplements
4) manipulation & touch
5) restoring natural energy forces
What is valerian used for?
GSL mild sedative and hypnotic
For CAM, the MHRA assesses the quality and safety of herbal medicines bearing what?
Product licence (PL) Traditional herbal registration (THR) number
Name 3 types of insomnia
1) transient insomnia
2) short term insomnia
3) chronic insomnia
What BMI is classed as overweight?
25-29.9 kg/m^2
What BMI is classed as obese?
Over 30kg/m^2
Patients using statins for primary prevention of CVD should aim for what percentage reduction in non-HDL levels?
Greater than 40%
Name 6 classes of drug that can cause drugs
Corticosteroids Benzodiazepines Levodopa Anticonvulsants Isotretinoin CCB
Name two classes of drug that can cause insomnia
Diuretics
CNS stimulants
Short term insomnia is less than what?
4 weeks
Long term insomnia is more than what?
4 weeks
Name 6 interventions used for long term insomnia
1) stimulus-control therapy
2) sleep restriction therapy
3) relaxation training
4) paradoxical intention
5) biofeedback
6) CBT
Name three drugs used to treat acute insomnia
Zopiclone
Temazepam
Loprazolam
NICE CG127 is what guidance?
Hypertension in adults: diagnosis and management
What is the NICE guidance CG90 for?
Depression in adults
What are the ICD-10 two key symptoms of depression
Low mood, loss of interest and pleasure and loss of energy
For people starting antidepressants who are at low risk when should you see them?
After 2 weeks then at intervals of 2-4 weeks for the first 3 months
For people starting antidepressants who are at high risk when should you see them?
After 1 week
