24TH Annual Meeting Panel: Practice Pearls from the Pros Prescription Medication: Office Protocols Kathy Jones, BSN, RN, CPSN Upon completion of this presentation, the participants will self-report an increase in knowledge about: A. The importance of having a prescription protocol and how nursing scope of practice affects protocol. Disclosure: ACE trainer for Allergan
Slide 1 Slide 2 Allergan Trainer PMT/Permark Consultant Director of Training Receives Royalties Slide 3
Slide 4 Identify the common prescriptive medications used in medical skin care. Identify the various skin conditions which present in the skin care clinic. Provide resources for continuing education and references for prescription drugs. Employ prescriptive documentation. State the reasons for having a written protocol. Develop protocol for the skin care clinic. Slide 5 Acne Actinic Keratosis Atopic Dermatitis Aging Skin Dry Skin Eczema Herpes Simplex Hypotrichosis Infections Hyperpigmentation Keloids Keratosis Pilaris Melasma Psoriasis Rosacea Scars Seborrheic Dermatitis Shingles Skin Cancers Stretch Marks Sunburn Vitiligo Warts Slide 6 Acne is a skin disorder that leads to an outbreak of lesions called pimples or "zits." The most common form of the disease in adolescents is called acne vulgaris. Anti-acne drugs are the medicines that help clear up the outbreak of pimples, blackheads, whiteheads, and more severe forms of lesions that occur with acne.
Slide 7 Age Lifestyle Gender Severity Skin type Dry, Oily, Sensitive Economics Compliance Underlying Issues PCOD Medications Infection Slide 8 Antibiotics Contraceptives Topical Acne Agents Topical Keratolytics Sulfonamides Aldosterone Receptor Antagonists Slide 9 Tetracycline Do not prescribe to children or pregnant women Minocycline Pustular acne Doxycycline Non-responsive to Tetracycline Erythromycin Anti-inflammatory and anti-bacterial Clindamycin Severe bacterial infections Bactrim Cystic acne
Slide 10 Reduce androgens (male sex hormones) Reduce the level of free testosterone by coaxing the ovaries and adrenal gland to produce less. Increase the level of SHBG (sex hormone binding globulin) which inhibits the conversion of free testosterone into DHT (dihydrotestosterone). Progestin component lowers androgen levels. Slide 11 FDA approved Ortho Tri-Cyclen Estrostep Yaz 30-60% reduction in acne lesions Slide 12 Benzoyl Peroxide Preparations NeoBenz Micro Duac Gel Benzomycin Gel Clindamycin Cleocin Erythromycin Emgel Erygel Theramycin Z Combination Drugs Epiduo Retinoids Retin-A Micro Differin Gel Tazorac Cream Ziana Gel Sulfacetamides Klaron Ovace
Slide 13 Salicylic acid Urea Slide 14 Bactrim Septra Slide 15 Spironolactone Aldactone
Slide 16 Accutane (isotretinoin) is a form of vitamin A and is used to treat severe nodular acne. Slide 17 Anti-Hypertensives for severe flushing Short term oral steroids A week or less Antibiotics Tetracycline, Doxycycline, Minocycline Isotretinoin For severe cases involving cystic acne Slide 18 Metrogel/Metrocream Metronidazole Gel Finacea azelaic acid 15% Rhofade oxymetazoline hydrochloride Mirvaso Brimonidine tartrate gel
Slide 19 https://www.rosacea.org/management/inde x.php http://www.pharmacytimes.com/publications /issue/2016/may2016/rosacea-a-newcrop-of-treatments Slide 20 Liquid Nitrogen Solaraze Gel nonsteroidal anti-inflammatory therapy FDA approved Aldara Cream immune response modifier TCA peels Efudex 2% or 5% fluorouracil Slide 21 Tretinoin Mechanism of action poorly understood. 68%-73% of patients improve Hydroquinone Destruction of melanocytes Azelaic Acid Inhibits tyrosinase TCA Liquid Nitrogen OTC Skin Care Products
Slide 22 Slide 23 Valtrex 500mg 1gm Zovirax 200mg Slide 24 Kenalog injections Silicone gel sheeting
Slide 25 No cure Morning Salex AmLactin Night Tazorac Tretinoin Slide 26 Anti-inflammatory Prednisone ASA Rx strength NSAIDs Vitamin C Slide 27 Psoriasis Eczema Dermatitis Allergies Rash Cordran SP 0.05% Lidex Cream Hydrocortisone 1% Triamcinolone acetonide 0.1% Topicort.025,.05%
Slide 28 Bimatoprost Latisse 0.03% PRP Slide 29 Condition that does not improve. Lesions Atopic Dermatitis Eczema Psoriasis Seborrheic Dermatitis Shingles Skin Cancers Vitiligo Warts Slide 30 http://www.drugs.com http://acnehubs.com http://dermatology.about.com http://www.acne.org http://emedicine.medscape.com http://www.webmd.com/drugs/indexdrugs.aspx
Slide 31 Prescription Medications Slide 32 Nursing Board nurse practitioner formulary Medical Board DEA www.justice.gov/dea FDA www.fda.gov Slide 33 List the Rx drugs Description and use Route of administration Dosage Refills authorized
Slide 34 Chart Document Drug name Dose Route Refills Slide 35 Patient Name: Date: Pharmacy #: D.O.B.: Chart #: Diagnosis: Drug Name Dosage Refills Adaplene Gel 0.3% Topical Apply nightly as directed 5 refills Am Lactin 12% - Topical Apply as directed Over the counter Amoxicillan 500mg 2gm (4 500mg tabs) take 1hr prior to invasive oral procedures No refills Ativan (Lorazepam) 2mg 2mg 1tab Bring to office No refills Bactrim DS #20 1 tab PO BID No refills Anyone needing more than 2 weeks must have it prescribed by PCP. Benzomycin gel Topical Apply BID as directed 1 refill refer to Derm if no improvement Celebrex 200mg 200mg #14 PO BID No refills Cipro 500mg 500mg #20 PO BID No refills Cleocin 1% Topical gel/solution/lotion Apply BID as directed 3 refills Cordran SP 0.05% Topical Apply thin film 1-3 times daily for 10 days No refills refer to Derm if no improvement Slide 36 August 2006 FDA proposed ruling to ban hydroquinone for OTC products August 2009 FDA warning letter to Galderma August 2010 Galderma recall of Tri-luma October 2010 Dermatologics Clinic Journal Report April 2011 Lawsuit-Rodan and Fields May 2011 Texas ban
Slide 37 Hydroquinone Log Patient Name: DATE PRODUCT Frequency of Use/Area TECH INITIALS Slide 38 Prescription Protocol Dr. or Nurse Practitioner evaluates patient on initial visit and reviews medical history. Text or call Dr. or Nurse Practitioner for verbal order and approval of Rx prior to calling in the prescription. It is the nurse s responsibility to complete. Fill out the top portion, mark the script being prescribed, nurse to sign and paperclip the form with the signature side up & the script prescribed highlighted. Place in the doctor or nurse practitioner s box to sign off on order. These forms are to be filled out for all scripts whether they are called in or hand written by doctor or nurse practitioner. Place the signed form in the patient s chart in chronological order. Approved Dr. X Date Slide 39 Initial Evaluation by MD or NP Rx given to patient Evaluate condition Determine appropriate Rx Complete forms Copies into the chart Reviewed by nurse Sign off by nurse practitioner or physician
Slide 40 Patient safety Legal-rules and regulations