NURS 6521 Advanced Pharmacology Assignment
A solid foundation in the concepts and principles of drug therapy across the lifespan is essential to the work of advanced practice nurses. The principles and concepts of pharmacologic therapy incorporate biology, physiology, pathophysiology, and chemistry are the foundations of nursing care. Students in this course comprehensively focus on the pathophysiological dynamic processes that occur in health and illness across the lifespan and related pharmacologic therapies. They explore a range of topics, including advanced concepts of the pharmacodynamics and pharmacokinetics of broad drug categories and their therapeutic implications to clinical nursing practice. Through this course, students prepare to examine complex decisions in the management and treatment of acute and chronic diseases across the lifespan. NURS 6521 Advanced Pharmacology Assignment
WEEK 1 :Pharmacotherapeutics for Advanced Practice
When looking into the legal and ethical responsibilities an advanced practice nurse (APN) is to adhere to, as a mid-level provider, ensuring safe and effective medication prescribing surely ranks near the top, and is straightforward. However, when the APN considers the cost of the medications, and their potential financial impact on the patient, the ethical path becomes somewhat blurred. On one hand, the higher-priced medication does indeed control the patient’s symptoms to a slightly greater degree; however, on the other hand, the lower-priced medication also controls the patient’s symptoms, though to a lesser degree, and also has a significantly lower financial impact on the patient. In the real world, decisions like this can become troublesome, are not easily navigated, and can often have grate impact on the patient’s ability to stay adherent to the treatment regimen—whether or not the patient has every intention/want to remain in compliance. This writing will endeavor to explore the stakeholders’ ethical and legal implications, disclosure versus nondisclosure according to state laws, strategies available to guide decision making, and minimizing prescribing errors that all lead to making sound prescribing decisions that best benefit the patient.
Ethical and Legal
According to Fowler (2015), the APN’s primary commitment is to the patient, whether it includes one or many, and is accountable/responsible to make decisions that are obligatory towards promoting health and providing optimal care for said patient. When thinking of the scenario of less expensive versus more expensive medications, and the quest for providing the most optimal health benefits, it becomes less a legal implication, as it does an ethical one. When considering the stakeholders in this scenario, which would include the APN prescribing the medication, the pharmacist preparing and dispensing the medication, and the patient with his family taking the medication, either medication, high-cost and low-cost, legally fulfills all obligations in this scenario. However, in terms of ethics, knowingly prescribing the higher-cost medication, though the increased benefits are clearly known by all, instead of the lower-cost one, could most likely create a scenario that would pit the patient and his/her family paying for the costly medication against having enough to provide the basic necessities of daily living—i.e. the rent, food, warmth, etc. In this type of situation, though the lower-cost medication has less efficacy in reducing the patient’s symptoms, the likelihood of adherence to the treatment regimen would invariably be much higher. Ethically speaking, the choice then becomes quite clear as to what would most benefit the patient and his/her family.NURS 6521 Advanced Pharmacology Assignment
Disclosure Versus Nondisclosure
When deciding on how the APN could address whether or not disclosing the cheaper/less-effective option to patient, it is first of paramount importance how one’s own state laws may govern it. According to Virginia Law (2002), all providers shall take prompt action in the event of a medication error or adverse drug reaction, and shall record it in the individual’s medication log. Though this law does not directly govern this type of scenario, it does indirectly stipulate, since the patient is guaranteed the right to have full access to their chart, that the patient be fully informed of drug reactions and medication errors; which failing to alert the patient to a lower-cost medication regimen could be construed as a type of medication error. The implied directive from Virginia Law here is clear, full disclosure of all medication options.
Strategies for Decision Making
The two main strategies that would guide the APN’s decision to disclose the cheaper medication option would include that it would be an egregious violation of ethical standards, and the fact that patient often go without needed medication as a way to cut costs. Providers, of which APN’s are one, are bound by their code of ethics, whether or not they may cause some type of harm to the patient, to fully disclose medical errors (Edwin, 2009). Failing to provide all information is a type of medical error already established. According to How patients reduce their prescription drug costs in the US (2015), a survey uncovered that 7.8% of adults neglected to take their medication as prescribed to reduce costs; which the paper went on further to suggest the percentage to be much higher. So, taking these two points into consideration, the course becomes clear that fully explaining the choices of the differing medications both adheres to ethical codes and ensures greater adherence to the treatment regimen.
Minimizing Errors
According to Rosenthal and Burchum (2018), writing prescriptions involves collaborating with other professionals, ensuring the prescriptions include all the necessary information and are legible, and reviewing all the factors, (including drug-to-drug interactions, allergies, availability, side effects, liver/renal functionality, and even cost) to ensure any medication errors are avoided and the patient receives the best possible care. Clearly, quite a lot of information must be considered before a prescription can be effectively written for a patient. Special attention should also be paid, considering our scenario, to the cost and availability of the drug; whether or not higher-cost versus lower-cost should be prescribed truly depends on whether or not the patient will be able to obtain said medication.
Conclusion
Having explored the minimization of errors, strategies to help decision making, and the obvious ethical obligations of disclosing medication errors, of which failing to disclose cheaper medication regimens is one, we now understand fully the duty of the APN. I would urge any APN to consider this information when deciding a patient’s regimen. For it may very well mean the difference between helping to increase the patient’s health or helping to decline it.
References
Edwin A. (2009). Non-disclosure of medical errors an egregious violation of ethical principles. Ghana medical journal, 43(1), 34–39.
Fowler, M. D. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application. Silver Spring, Maryland: American Nurses Association, 2015. NURS 6521 Advanced Pharmacology Assignment
How patients reduce their prescription drug costs in the US. (2015). PharmacoEconomics & Outcomes News, 721(1), 13. https://doi-org.ezp.waldenulibrary.org/10.1007/s40274-015-1888-1
Rosenthal, L., & Burchum, J. (2018). Lehne’s Pharmacotherapeutics for Advanced Practice Providers – E-Book. St. Louis, MO: Elsevier Health Sciences.
Virginia Law. (2002, September 19). 12VAC35-105-780. Medication Errors and Drug Reactions. Retrieved from https://law.lis.virginia.gov/admincode/title12/agency35/chapter105/section780/
WEEK 2 : Cardiovascular Case Study
When attempting to effectively manage any patient’s cardiovascular disease process, it always benefits the patient if the provider takes into account co-morbidities. For CB, an 88 year-old female patient with a history significant for strokes, it is no different. Considering CB’s concurrent diagnoses, which include diabetes mellitus type 2 (DM2), hypertension (HTN), and hyperlipidemia (HLD), it seems fairly straightforward which factors should be considered—advanced age and renal function. This writing will endeavor to explore how both advanced age and renal function influence the pharmacokinetic and pharmacodynamic processes, how they impact the current drug therapy, and how they may impact potential drug therapy changes.
Influencing Factor
According to Munshi (2019), with advanced age, in terms of how it impacts drug therapies, a generalization can be made that the bodies systems will generally not be able to effectively process medications appropriately which can often lead to drug toxicities. Also, due to advancing age and decreased function of the body systems, polypharmacy is generally a concern and often leads to increased negative side effects. And when advanced age is coupled with decreased renal function, considering CB’s diagnosis of DM2 and HTN that generally leads to decreased renal function, drug therapy can be greatly affected. According to Collard, Brouwer, Peters, Vogt, and van den Born, (2018), patient’s with decreased renal function, have an inability to effectively filter out medication metabolites, and generally have a reduced creatinine clearance that can often limit the types and amounts of DM2 and HTN medication therapies. So, it would appear that certain medications will invariably be excluded for use in CB’s drug therapy regimen, or at the very least will require lower doses and increase frequency of monitoring of her renal function.
Current Therapy Impacted
Since CB’s advanced age and decreased renal function are a concern, it is important to identify potential pitfalls associated with her current drug therapy regimen. CB’s drug therapy regimen includes Glipizide 10mg daily, HCTZ 25mg daily, Atenolol 25mg daily, Simvastatin 80mg daily, and Verapamil 180mg CD daily. Though Glipizide, a sulfonylurea, has a slightly increased potential for hypoglycemia in elderly patients, due to CB’s impaired renal function, it is preferred over Metformin for monotherapy of DM2, due to Metformin’s known harshness on kidney function. For HCTZ, and considering the decreased renal function, this medication has a large propensity for affecting the kidneys further, potentially reducing filtration effectiveness, and also, due to CB’s age, could cause hyperkalemia. With Atenolol, if it is being used for angina, this would be good medication as it does not impact renal function. Due to CB’s HLD, Simvastatin’s dose being maxed out is critical to avoid potential cardiac issues, especially considering her age, despite the potential for myopathy. Lastly, Verapamil has two major impacts on CB, the first is that it has been known to cause sick-sinus syndrome in elderly patients, and secondly, it has been known to have a harsh effect on renal function as well (Vallerand, 2018).NURS 6521 Advanced Pharmacology Assignment
Drug Therapy Changes
CB’s drug therapy regimen, considering the information revealed earlier, is in definite need of a change to better optimize her therapy’s effectiveness. Although the Glipizide is appropriate for CB at this time, an A1c should be done to evaluate the effectiveness of it and to see if additional medicines could be needed. As for the HCTZ, it would need to be eliminated from her regimen, and if she was on the medication specifically for the need for a diuretic, and not simply to aid in blood pressure management, Bumex 1mg should be initiated as it would not effect her renal function. Next the Atenolol should remain untouched if being used for angina; however, if used for blood pressure management, Amlodipine 5mg could take its place as the need for a beta-blocker’s benefits are not needed. Next, due to Verapamil’s negative effects, Amlodipine 5mg is yet again the better choice, as it is in the same class, but has none of the adverse side effects of Verapamil. Though the Simvastatin should stay exactly the same due to the high potential of CB’s potential for developing cardiac issues, (myocardial infarction (MI), angina), the addition of an anticoagulant is sorely needed to ensure stroke prevention. Due to CB’s history of strokes, the recommendation would be to incorporate an 81mg Aspirin daily; as well as adding Plavix 75mg to ensure effective anticoagulation is achieved and the reduction of future strokes, and even prevention of MI’s are prevented (Rosenthal and Burchum, 2018).
Conclusion
Having thoroughly explored the potential pitfalls of CB’s current drug therapy regimen, as well as her factors of advanced age and reduced renal function, and the recommended drug therapy changes, we now have a more focused picture of CB’s needs. I would encourage any provider to ensure they consider carefully any patient’s history in full, their factors that could impact their drug therapy regimen, and even their patient’s ability to procure those medications. For in the end, correct treatment brings about correct therapy, but only if the patient can afford said therapy.
WEEK 4 :HL Drug Abuse and Hepatitis C
Considering HL’s symptoms, nausea/vomiting/diarrhea, history of drug abuse, and potential diagnosis of Hepatitis C, the most likely diagnosis for HL’s current symptoms an be attributed to Hepatitis C. According to Medline plus (2018), nausea/vomiting/diarrhea are common symptoms of opioid withdrawal, but are also accompanied with goose flesh, agitation, anxiety, dilated pupils, and even frequent yawning—none of which HL is displaying. The website also points out that most opioid abusers need to be screened for Hepatitis C, as they often have it. Considering this knowledge, drug therapy change suggestions will be explored.
Therapy Plan
The most appropriate therapy for HL, considering HL’s current regimen, (levothyroxine 100mcg daily, nifedipine 30mg daily, and prednisone 10mg daily), involves both a short-term and long-term solution.In the short-term, the prednisone must be tapered down and eliminated, the other two drugs can continue, and the addition of polycarbofil 1gram 4 times daily for a few days, until diarrhea subsides.The addition of po electrolyte-heavy fluids, (i.e. Gatorade), would also be encouraged to replace what is being lost by the diarrhea.In the long-term, the combination tablet ledipasvir 90 mg and sofosbuvir 400 mg (LVD/SOF), would be initiated, after a confirming diagnostic genotype test and liver fibrosis test are performed, if HL can afford the therapy (Kish, Aziz, Sorio, 2017).NURS 6521 Advanced Pharmacology Assignment
Justifying Plan
According to Vallerand (2018), levothyroxine 100mcg daily is the normal therapeutic dose and only has issues with patients who have liver impairment at higher doses.With the nifedipine 30mg daily, it is recommended to keep a lowered dose with hepatic impairment, and with the normal dose being 30mg three times a day, HL is safe with this dose.However, it was shown that chronic use of prednisone can cause adrenal insufficiency, which can cause immune deficiency, and subsequent increase in live viral loads as a result.As for the polycarbofil, it is recommended over say loperamide, as this patient has a history of drug abuse/decreased liver function, and polycarbofil is simply a bulking agent that will not affect the liver.Lastly, the use of LVD/SOF can help to lead HL towards recovering from the Hepatitis C and restore liver function; however, the cost can be prohibitive and HL’s ability to afford must be assessed.
Conclusion
Having explored the medication regimen for HL, we now have a better understanding as to why it fits best with HL’s diagnosis of Hepatitis C. I would encourage any clinician to ensure drug abuse is not their automatic first response for these types of cases, as the potential medical causes can often outshine, and are generally more common sensical, as compared to opioid withdrawal. Ignoring best practice because the patient has a checkered past is never acceptable.
WEEK 5 :Types of Diabetes Mellitus
The four classifications of diabetes include type 1, formally known as insulin-dependent diabetes, type 2 formally known as non-insulin-dependent diabetes, gestational, and diabetes secondary to diseases of the pancreas and hormonal abnormalities. Type 1 diabetes is an autoimmune disorder where beta cells of the pancreas are damaged, resulting in the inability to secrete insulin (Arcangelo, Peterson, Wilbur & Reinhold 2017). When the pancreas does not produce insulin, blood glucose levels are elevated. It is also recognized as juvenile diabetes because it is primarily typically diagnosed in children, teens, and young adults. When the pancreas produces less insulin than the body required or the muscles and adipose cells becomes less responsive to the actions of insulin, it is known as type 2 diabetes. In some pregnant women, progesterone, cortisol, and human placental lactogen produce anti-insulin effects causing intolerance to glucose known as gestational diabetes. It usually resolves after the delivery but increases the risk for type 2 diabetes later in life (Arcangelo, Peterson, Wilbur & Reinhold 2017).NURS 6521 Advanced Pharmacology Assignment
Gestational Diabetes
Diet and activity modifications are the first treatment options for the management of gestational diabetes mellitus (GDM). It is recommended to limit carbohydrate intake to 33% to 40% of calories and 30 minutes of aerobic exercise and resistance training most days of the week to improve glycemic control. Monitoring maternal weight gain is also essential in reducing the risk of fetal macrosomia (Garrison, 2015).
Treatment
In pregnant patients, there are two pharmacologic options which include insulin and selected oral antihyperglycemic agents. Oral medication is usually started first; however, when blood levels remain elevated despite diet modifications, increased physical activity, and the use of oral medications, insulin is required. Studies show that between 15 and 40% will need insulin after the use of oral medications initially. Rapid, intermediate, and long-acting insulins are safe to use in pregnancy because it does not cross the placenta. When initiating insulin therapy, one approach is to calculate a total dose of 0.7 to 1 unit per kilogram. Glargine (Lantus) and detemir (Levemir) are long-acting insulin options that are given as a single dose at half of the total daily requirement. The other half is administered in three divided doses at mealtimes with rapid-acting insulins, including lispro (Humalog) or aspart (Novolog) (Garrison, 2015).
Educating patients on the proper preparation, administration, and injection techniques of insulin are vital with this therapy. Lantus is given subcutaneously once daily at the same time every day. It is administered in the abdominal area, thigh, or deltoid and injection sites should be rotated within the same region to reduce the risk of lipodystrophy. Rapid-acting insulin should be administered 15 minutes before eating a meal into the abdominal wall, upper arm, or thigh. Injections should be ½ inch from the previous injection site. Patients should prepare injection only when they are ready to give it, and patients need to inspect the insulin for any visible particles as the solution should be clear and colorless (“Insulin Regular,” n.d.).
Short/Long Term Effects
GDM can contribute adverse short term and long-term health effects on the woman and fetus. Short term effects for the mother include increased risks for pre-eclampsia, pre-term labor, induced labor, and the need for intervention at birth. GDM can adversely influence intrauterine development that can result in spontaneous abortions, congenital anomalies, respiratory distress syndrome, neonatal hypoglycemia, and jaundice (Keygan, 2013).
The long-term effects on women include a higher risk of recurring GDW with following pregnancies and a greater risk of developing type 2 diabetes after pregnancy. According to Keygan (2013), women are six times more likely to develop type 2 diabetes than women who have a normoglycemic pregnancy, 17% will develop it within ten years, and 50% within thirty years. Babies exposed to maternal diabetes may have increased risk of impaired glucose intolerance, obesity, and type 2 diabetes in early adulthood (Keygan, 2013).
WEEK 6 : Diabetes and Drug Treatments
Diabetes mellitus is a metabolic disorder that results from impaired insulin secretion with various degrees of insulin resistance that lead to hyperglycemia. The symptoms of hyperglycemia include polydipsia, polyuria, polyphagia, and blurred vision. Terms that were used to describe the two main categories of diabetes are no longer accurate because of the overlap in age groups and treatments between disease types (Merck Manual, 2017). The two classes of diabetes are determined by age of onset (juvenile or adult) or type of treatment (insulin– or non–insulin dependent). This paper will discuss the different types of diabetes, to include Type 1, Type 2, Gestational, and juvenile diabetes. It will detail type one diabetes to include the drugs used for treatment as well as dietary considerations and the short and long-term impact on patients diagnosed with type 1 diabetes NURS 6521 Advanced Pharmacology Assignment
Different Types of Diabetes
More than 13,000 youths are diagnosed with diabetes every year, making it one of the most common chronic childhood diseases in the United States (Peterson, Silverstein, Kaufman, Warren-Boulton, 2007). Type 1 diabetes, formerly known as juvenile diabetes, is “a chronic condition in which the pancreas produces little or no insulin” (Merck Manual, 2017). It is an autoimmune disease leading to absolute insulin deficiency resulting in hyperglycemia and its associated manifestations (Hamilton, Knudsen, Vaina, Smith and Paul, 2017). It is the most common type of diabetes seen in children, characterized by the 4Ts (toilet, thinner, thirsty, tired) according to Hamilton et al. (2017). The signs and symptoms can sometimes be non-specific causing a delay or missed diagnosis which can be catastrophic for the child.
Type 2 diabetics can produce insulin, but hyperglycemia occurs as a result of a combination of insulin resistance, where the body does not recognize the secretion of insulin, and relative insulin deficiency, where the beta cells do not produce enough insulin to counteract this resistance. Type 2 diabetes accounts for 1.9% of cases in children, however its incidence is rapidly increasing in adolescents and is associated with the obesity epidemic.
Gestational diabetes occurs during pregnancy. Like others forms of diabetes, it affects how the cells use glucose. In gestational diabetes, hyperglycemia affects the baby and the mother. Hyperglycemia can be dangerous for the mother and the baby. It increases the risk of miscarriage, stillbirth and congenital disabilities when glucose is not controlled. Diabetic complications are increased for the mother; they include diabetic ketoacidosis, retinopathy, pregnancy-induced high blood pressure and preeclampsia (Mayo Clinic, n.d.).
Treatment for Type 1 Diabetes and Treatment Options
Type 1 diabetes makes up more than 95% of diagnoses in children and young people under 25 years of age; its prevalence is increasing annually by 3% (Hamilton et al., 2017). Type 1diabetes has historically been more common in patients aged eight to 19 years of age, but type 2 diabetes is emerging in this group “accounting for 8 to 45 percent of new childhood diabetes” (Peterson et al., 2007). Life expectancy for people with type 1 diabetes is likely to be reduced by 5–14 years. Diabetes was the sixth most common cause of death worldwide in 2015, killing 1.6 million people (World Health Organization, 2017). The immediate goal of treatment in diabetes is to correct blood glucose levels and fluid and electrolyte imbalances. The long-term goal is to maintain normal glucose levels. “This requires diabetes education for both child and family regarding insulin administration, carbohydrate counting, and maintaining a healthy lifestyle” (Hamilton et al., 2017). Diabetic education should provide reinforcement on “healthy eating, daily physical activity, insulin and medication administration, and self-monitoring of blood glucose levels” (Peterson et al., 2007) is essential. A proper diabetic diet contains plenty of fruit, vegetables, and carbohydrates with a low glycemic index for optimal glycemic control and general well-being (Hamilton et al., 2017). Insulin can be prescribed based on a daily bolus dosage or a continuous pump. The insulin pump allows for greater flexibility and provides better glycemic control for children (Hamilton et al., 2017). Anyone who has type 1 diabetes needs lifelong insulin therapy (drugs.com, 2017). Insulin use includes rapid-acting, long-acting, and intermediate options
NURS 6521 Advanced Pharmacology Assignment
Short and Long Term Implications of Type 1 Diabetes
Complications of diabetes include vascular disease, peripheral neuropathy, nephropathy, and predisposition to infection. Heart complications include coronary artery disease (CAD), heart attack, stroke, and hypertension. Diabetes can cause nerve damage (Neuropathy) by injuring the walls of the small vessels. Nerve damage in the lower extremities can lead to amputations. Nerve damage can also affect the gastrointestinal tract (gastroparesis) causing nausea, vomiting, diarrhea, and constipation. In males, neuropathy can cause erectile dysfunction.
Conclusion
Diabetes is a common chronic condition in children that requires the appropriate management and support from an interdisciplinary team of health professionals. Early diagnosis and immediate treatment is imperative to prevent medical emergencies.
WEEK 8 : Antimicrobial Agents
There are several factors which must be considered when choosing appropriate antimicrobial agents to treat an infection. Empiric antimicrobial treatment is aimed at treating the most likely infectious organisms. Gram stains and culture and sensitivity studies help identify the organism and its susceptibility. In the end, efficacy, toxicity, pharmacokinetic profile, and cost determine which antimicrobial to use. The ideal dose and duration of treatment are influenced by patient factors like age, weight, other diseases the patient may have and the site and severity of the infection (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Categories of Antimicrobial Agents
Penicillins, cephalosporins, monobactams, carbapenems, and the beta-lactam/beta-lactamase inhibitor combinations interfere with cell wall growth by binding to and inactivating the penicillin-binding proteins(PBP). Fluoroquinolones are inhibitors of DNA gyrase and topoisomerase, which prevents the bacterial DNA from replicating. Macrolides, ketolides, aminoglycosides, tetracyclines, glycylcyclines, streptogramins, anti-anaerobic agents (clindamycin), Chloramphenicol and oxazolidinones inhibit bacterial protein synthesis by binding to ribosome subunits. Sulfonamides inhibit folic acid synthesis required for bacterial cell growth. NURS 6521 Advanced Pharmacology Assignment Glycopeptides are also cell-wall active but through a different process than those that inactivate PBPs. Daptomycin is the only lipopeptide antibiotic, and its action is different than any other antibiotic. Lipopeptides cause depolarization of bacterial membrane potential which leads to cell death. Metronidazole is categorized as an anti-anaerobic agent; it causes DNA strands to break which results in protein synthesis inhibition. Rifampin is a macrocyclic antibiotic which suppresses RNA synthesis. Nitrofurantoin’s mechanism of action is not well understood. It inhibits bacterial enzymes which also causes impaired cell wall synthesis (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Many of the antibiotics overlap in the infections that they treat. Bacteria are classified as gram-negative or positive, aerobic or anaerobic, and by the resistance, they have developed. Each group of antibiotics treats specific types of bacteria and often target different areas of the body, such as skin or lungs. It is important to get the right type of coverage for the pathogen (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Differences Between Viral and Bacterial Infections
It is important to be able to distinguish between a bacterial and viral infection. Antibiotics are ineffective against viruses. Antibiotics either kill bacteria or stop them from multiplying. Overuse of antibiotic therapy has led to an increase in bacterial drug resistance. Bacteria and viruses can cause similar symptoms and are often spread in the same way (Health Direct, 2016). Most viral infections are managed by treating the symptoms. These treatments are usually over-the-counter preparations.
Proper Identification of Infections is Key to Selecting the Proper Antimicrobial Agent
It is important because antibiotics do not treat viruses and anti-virals do not treat bacterial infections. “At least 80 million antibiotic prescriptions each year are unnecessary, which makes improving antibiotic prescribing and use a national priority” (Centers for Disease Control and Prevention, 2018). “Antibiotic resistance is one of the most serious public health problems in the United States and threatens to return us to the time when simple infections were often fatal. When we optimize how we use and prescribe these drugs, we protect patients from harm and combat antibiotic resistance” (Centers for Disease Control and Prevention, 2017). NURS 6521 Advanced Pharmacology Assignment References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Philadelphia: Wolters Kluwer.
Centers for Disease Control and Prevention. (2017, September 25). Antibiotics prescribing and use in doctor’s offices. Retrieved from www.cdc.gov: https://www.cdc.gov/antibiotic-use/community/index.html
Centers for Disease Control and Prevention. (2018, April 6). Antibiotic prescribing and use. Retrieved from CDC.gov: https://www.cdc.gov/antibiotic-use/
Health Direct. (2016, May). Differences between bacterial and viral infection. Retrieved from Healthdirect.gov.au: https://www.healthdirect.gov.au/bacterial-vs-viral-infection NURS 6521 Advanced Pharmacology Assignment