PPT/ITP Model Flashcards
Who can prescribe medication?
Advance Practice Nurses (NP, CNS, NMW, CRNA)
Physicians (MD, DO, ND) and Physician Assistants
Dentists
Veterinarians
Pharmacists and clinical psychologists, sometimes
Who makes prescribing regulations
Federal laws (ex. DEA) State laws (ex. Marijuana) Professional standards and professional licensing boards (ex. MN BON) Local formularies (ex. insurance formularies)
Nurses have had an active role in prescribing both
formally and informally for over 50 years around the globe
Early reports of contraceptive prescribing in US and lower income countries in
1970s
Prescriber role emerged in 1980s with the
expanded role of nurse practitioners in the US`
Increased nurse prescribing continued as
national and regional statutes were changed in Europe, Canada, and Australia
Nurse prescribing spread in
Africa in early 2000s because of the increased use of inexpensive antiretroviral drugs for HIV or AIDs
How do prescribers make prescribing decisions?
Prescribing Pyramid
STEPs
Prescribing Competency Framework
Ali Murshid & Mohaidin (2017) model for prescribing decisions
Psychopharmacotherapeutics (PPT) model for nurse prescribing
Steps of prescribing pyramid
(Top) Reflect Record Keeping Review Negotiate a contract Choice of Product Which Strategy Consider the patient (bottom)
STEPs of Clinical Psychopharmacology
S= Safety; know the safety profile of the drug
T=Tolerability; evaluate short and long-term effects
E= Efficacy; evaluate clinical evidence
P= Practicality; consider cost, adherence, monitoring issues
Updated RPS Prescribing Competency Framework
There are ten competencies split into two domains
The Consultation
- assess the patient
- consider the options
- reach a shared decision
- prescribe
- provide information
- monitor and review
Prescribing governance
- prescribe safety
- prescribe professionally
- improve prescribing practice
- prescribe as part of a team.
Ali Murshid & Mohaidin Model for Prescribing Decisions
Patient characteristics: patient expectations and request for drug
Marketing efforts: drug information, drugs’ brand, marketing rep. effectiveness, promotion sales
Pharmacist factors: pharmacist-MD collaboration, pharmacist expert power
Contextual factors: trustworthiness, physician habits, cost/benefit ratio of a drug, drug characteristics
PPT model was developed in
1996 to guide PMH APRNs with psychopharm decision-making when MN first legislated prescriptive authority for APRNs in 1995
The PPT model incorporated
a holistic, nursing framework which is patient centered, rather than drug centered
The PPT model revised
over time to include integrative nursing concepts
the PPT model has been used in
N5225 and other psychopharm courses in TN, WA, MI
5 components that inform the PPT model treatment options
Patient context - what is wrong and what are the goals of treatment.
Scientific Evidence - Which treatment should be used, and how should it be used?
Legal and ethical standards
situational issues - What are the patient, provider, family and settings isuet to consider.
Which is best - non-pharm, medication, watchful waiting, or no fruther contact.
After considering what informs the PPT model for decision making what comes next
Cost benefit considerations
Patient/Clinician shared decision making
Treatment Plan
Treatment outcomes.
PPT to ITP Model
Evolving from a prescribing model to psychiatric APRN treatment planning framework
Can be used after diagnostic assessment/ problem identification
Incorporates all components of treatment planning, including medication prescribing
Now includes principles of Integrative Nursing
Uses a care mapping tool for patients and clinicians for shared decision-making and treatment planning
ITP model what four items inform treatment options
Patient context
Scientific Evidence
Legal and Ethical Standards
Situational Issues
ITP what comes after treatment options
Risk Benefit Patient/Clinician Decision Treatment Plan Care Mapping Tool Treatment Outcomes
The focus of the Patient Context is to
determine the patient variables that may influence our joint decision about treatment
Patient Context Questions
What is the patient’s age/gender/culture or ethnicity?
What are the presenting physical and psychological symptoms?
How does the patient describe the problem and what is causing it?
What has the patient done so far to cope with the problem? Did it help or not?
What is the patient’s general health status? Are there any co-existing physical illnesses? What over the counter (OTC), prescribed, and herbal medications does the patient take and how often?
What is the patient’s mental and functional status? What is the patient’s primary language? What is the educational level and/ or how does the patient learn best?
What is the neurological assessment?
Is there a personal or family history of psychiatric illness, diagnosis, and/or treatment?
What is the social support or social network of the patient? Can the patient access treatment options?
What are the patient’s preferences for treatment? What is important to the patient’s quality of life?
Ethical and Legal Questions
Are there regulations related to providing/prescribing this treatment?
Am I qualified to provide/prescribe this treatment?
What are the professional standards of practice the guide the provision of this treatment?
What ethical principles guide the treatment decisions?
Does the patient understand the risks and benefits of this treatment? Is there a question of competence?
Is there consent for treatment?
Scientific Evidence Questions
What are the objectives of treatment?
What are the practice guidelines and/or scientific evidence for treating the
illness/symptoms?
What treatments are available?
What are the side effects and adverse effects of the treatment?
Is this a short term or a long term treatment option?
Situational Issues considers
This component of the ITP model considers acceptability, availability, accessibility, and affordability of treatment options and resources to ensure successful treatment.
Situational Questions
Is this treatment available to the patient?
Is the patient able to access this treatment?
Is this treatment acceptable to the patient?
Is the patient able to pay for this treatment? Is this treatment affordable short term and long-term? Are there outside resources that will help this patient afford this treatment?
Is there environmental/social support for the patient to engage in this treatment appropriately?
Does this treatment fit well with other interventions or activities patient is engaged in?
i.e. does it interact well with other treatments?
Risk Benefit Questions
What are the specific target symptoms that can be treated?
What are the treatments that could be used to effectively treat these target symptoms?
What are the benefits of using this particular treatment?
Does the likely benefit of the treatment justify the risk of it?
How can I help my patient minimize the disadvantages to get the best effect from the treatment?
How will I monitor the side effects or adverse effects of the treatment?
Patient/Clinician Questions
What are the options for treatment at this time?
What are the patient’s preferences for treatment?
What are the clinicians preferences for treatment?
Is the patient ready for treatment now?
What are the expected outcomes of the treatment?
Watchful waiting: the best choice if:
close surveillance of the patient’s symptoms or illness is needed before making a decision
more information/records are needed
patient is undecided/ambivalent about treatment
includes self-care approaches for diet, exercise, nutrition, spirituality
could include traditional healing approaches
Non-pharmacologic approaches:
natural products (aromatherapy, vitamins, melatonin)
movement ,energy and mind-body therapies; psychotherapy
light therapy, transmagnetic cranial stimulation, (TMS), biofeedback, EMDR
Medication Management:
allopathic medicines
evidence-based homeopathic and Ayurvedic medicines
No further contact:
consultation, end of treatment
Treatment Options
Treatments to address illness and improve health
Management of treatment side effects
Patient/Family Education
Emergency/crisis management plans
Referrals
Follow-up appointment(s)
ITP Care Mapping ToolStrengths-based –What are they already doing
Lifestyle and Environmental Health
Physical Health
Emotional and spiritual support
We fill in what people are already doing to be as strengths based as possible. Then we add in evidence based individualized suggestions that fit their needs and they they can do until next session without it adding more stress or overwhelm them. This may include specific referrals (E.g. for GP or MDR) or things we start (e.g. medications, vitamins, psychotherapy) or educate about or teach/train.
All of this then goes through other factors in the model (patient preference, risk benefit analysis, etc)
Over time both client and provider start thinking holistically and collaboratively about recovery, coping and interventions. Always adding things, taking away what does not work and keeping what does.
ITP Care Mapping Tool - Physical Health
Medications On or off alcohol and drugs? Recent labs and a NP/GP visit Vitamins and supplements Diet Sleep hygiene Addressing long term and short term physical illness Exercise
ITP Care Mapping Tool - Lifestyle and Environmental
Social activities and support Nurturing activities Management of stress School work, training or courses for growth and/or nurture Occupational rehabilitation Financial stability Environmental health
ITP Care Mapping Tool - Emotional and Spiritual Health
Psychotherapy modalities
Meditative practices
Spirituality
Philosophy and outlook
