Independent Prescribing Flashcards by Rachel Cornish

Define competency

A quality or characteristic of a person that is related to effective performance, competencies can be described as a combination of knowledge

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When did the RPS release the new competency framework for all prescribers?

JULY 2016

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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

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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

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Two types of independent prescriber:

1) prescribe licensed meds within clinical competence

2) a community practitioner nurse can prescribe against formulary in BNF

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What’s supplementary prescribing?

Voluntary partnership between doctor/dentist and a supp prescriber to prescribe against an agreed patient-specific clinical management plan

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What proportion of MURs should community pharmacists provide to 4 target groups?

70%

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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

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What’s NMS

New medicines service- was the 4th advanced service to be added to the community pharmacy contractual framework

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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

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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

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What heading in the Cambridge-Calgary observation guide can be left out?

Physical examination

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When did the NHS put £15million in to a 3 year scheme for pharmacists in GP practices

JULY 2015

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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

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What 4 key areas can pharmacists help with in GP surgeries?

1) clinical services
2) prescription management
3) audit and education
4) medicines management

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Do supplementary prescribers need to complete the independent prescribing course?

NOPE

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What three CDs can pharmacist independent prescribers NOT prescribe?

Diamorphine, dipipanone or cocaine for treatment of addiction

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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

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List 7 subjective signs of opiate withdrawal

Restlessness 
Irritability
Anxiety 
Sleep disorders 
Depression 
Drug craving 
Abdominal cramps

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What does DSM V stand for

Diagnostics and statistics manual

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What does ICD-10 stand for?

International classification of diseases

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What can be a consequence of chronic intravenous injecting

Poor vascular return

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Psychosis can be precipitated by what?

Amphetamine use

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In substance misuse what 3 factors does zinbergs model include

Drug
Set
Setting

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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?

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?

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

Independent Prescribing Flashcards

(125 cards)