NU 641 Discussion: Ophthalmic Disorders

Sample Answer for NU 641 Discussion: Ophthalmic Disorders Included After Question

Initial Post

In your initial post, answer all the questions and provide rationales for your answers with supporting evidence using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.

Read the scenario and answer the following questions:

Ophthalmic Disorders

V.S., age 12 Hispanic male, presents with a feeling that there is sand in his eye. He had a cold a week ago and woke up this morning with his left eye crusted with yellowish drainage. On physical examination, he has injected conjunctiva on the left side, no adenopathy, and no vision changes. His vision is 20/20. Fluorescein staining reveals no abrasion. He is allergic to sulfa.

Diagnosis: Conjunctivitis

  1. List specific goals of treatment for V.S.
  2. What drug therapy would you prescribe? Why?
  3. What are the parameters for monitoring the success of the therapy?
  4. Discuss the education you would give to the parents regarding drug therapy.
  5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
  6. What would be the choice for second-line therapy?
  7. What over-the-counter or alternative medications would be appropriate for V.S.?
  8. What dietary and lifestyle changes should be recommended for V.S.?
  9. Describe one or two drug–drug or drug–food interactions for the selected agent.

Reply Posts

Reply to at least two of your classmates, in a well-developed paragraph (300–350 words) to each peer integrating an evidence-based resource that is different than the one you used for the initial post.

Respectfully agree and disagree with your peers’ responses and explain your reasoning by including your rationales in your explanation.

Please refer to the Grading Rubric for details on how this activity will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations

A Sample Answer For the Assignment: NU 641 Discussion: Ophthalmic Disorders

Title: NU 641 Discussion: Ophthalmic Disorders

List specific goals of treatment for V.S.

The major goal for the treatment of bacterial conjunctivitis is for V.S.’ symptoms to resolve. For example, the feeling of sand in his eye should go away and there should be no more discharge from his eye. 

What drug therapy would you prescribe? Why?

Although most cases of bacterial conjunctivitis clear up on their own, topical antibiotic treatment can speed the recovery process (Woo & Robinson, 2020, p.843). However, the recent systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis revealed that initial observation without treatment is highly recommended for bacterial conjunctivitis that is not chlamydial or gonorrhoeal for the first three days (Chan et al., 2021). Therefore, if V.S.’ symptoms did not resolve after three days, I would prescribe him erythromycin ointment to use, with the instructions of instilling a 1-cm ribbon of ointment in his affected eye four times a day for one week (Azari & Arabi, 2020; Epocrates, 2018).

Erythromycin ointment is an FDA-approved topical antibiotic used to treat conjunctivitis (Viriya & Mah, 2021, p.372). It is a bacteriostatic macrolide that binds to the 50S ribosomal subunit which prevents bacterial protein synthesis (Woo & Robinson, 2020, p. 840). This drug is mainly effective against gram-positive organisms, including S. aureus, S. pyogenes, S. pneumoniae, S. viridans, C. diptheriae (Woo & Robinson, 2020, p. 840). It is more limited in its gram-negative coverage but is active against C. trachomatis (Woo & Robinson, 2020, p. 840). Erythromycin is generally one of the least expensive ophthalmic preparations for conjunctivitis (Woo & Robinson, 2020, p. 845). 

According to Azari and Arabi (2020), it is not likely that there is a significant difference in the effectiveness of one broad-spectrum antibiotic eye drop as compared to another when treating bacterial conjunctivitis. The major factors in the consideration of which antibiotic to choose should be the local resistance patterns and availability, cost, and individual patient needs, such as allergies (Azari & Arabi, 2020). Since V.S. is allergic to sulfa drugs, that class of antibiotics would not be considered. Even though systemic absorption is minimal with most ophthalmic antibiotics, there may be some systemic absorption (Woo & Robinson, 2020, p. 840). Therefore, since V.S. is a 12-year-old boy and may be very active, I would avoid fluoroquinolones due to the potential risk of tendon rupture (Vallerand & Sanoski, 2020, p. 587). Aminoglycosides are not recommended as first-line treatment due to their potential to cause damage to the cornea and conjunctiva (Woo & Robinson, 2020, p. 843). Below is my prescription for V.S.:

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 28, 2022 

Patient: V.S. DOB: 03/08/2010 Weight: 45 kg Phone: (231) 818-5090

Erythromycin ophthalmic ointment 0.5%

Disp: One tube

Sig: Administer 1-cm ribbon of ointment to the affected eye four times a day for seven days to treat bacterial conjunctivitis. 

No refills.

What are the parameters for monitoring the success of the therapy?

Parameters involved with monitoring the success of therapy have to do with the resolution of his symptoms. As stated above, the resolution of the feeling of sand in his eye and no more eye discharge would be indications of successful treatment. In addition, it would be important to ensure that V.S. is not experiencing severe or prolonged burning of his eyes or any other unusual symptoms associated with his treatment (Woo & Robinson, 2020, p. 846). If his symptoms did not seem to be resolving, I would explore how he is taking the medication and his technique for instilling the eye drops to ensure that he is taking the medication correctly. It would also be important to monitor any adverse reactions to the medication, which would affect the success of treatment. 

Discuss the education you would give to the parents regarding drug therapy.

I would let V.S. know that the ointment he is being prescribed is given to fight the bacteria that is causing his eye infection, and that it should be stored at room temperature away from heat or moisture-prone environments (Epocrates, 2018). Further, V.S. needs to be aware that this medication should not be shared with anyone else (Woo & Robinson, 2020, p. 846). In addition, I would use the teach-back method to educate him on the proper way to instill the ointment. For example, I would tell him to begin by washing his hands (Epocrates, 2018). The first time he opens the tube of medication, I would tell him to squeeze out and discard the first quarter of an inch of the drug (Woo & Robinson, 2020, p. 846).

Then, I would tell him to tilt his head back and pull his lower eyelid down while looking away from the tip of the tube (Epocrates, 2018). Then, he should squeeze out a ribbon of the medication into the pocket in his lower eyelid without touching the tube to his skin and then close his eye for one to two minutes (Epocrates, 2018). I would let him know that he may wipe excess ointment off of his eyelash or surrounding area with a clean tissue and that he may experience short-term blurry vision directly after medication application (Epocrates, 2018). I would also make sure to answer any questions that he has about the procedure or the medication in general. 

List one or two adverse reactions for the selected agent that would cause you to change therapy.

Mild eye redness or irritation are common side effects of erythromycin ointment (Epocrates, 2018). However, I would stop this treatment and change therapy if he experienced any signs of an allergic reaction, such as hives, difficulty breathing, or facial, tongue, or throat swelling (Epocrates, 2018). In addition, I would change his therapy if his symptoms were not improving after a few days or his condition was worsening, such as if he were experiencing severe pain or discomfort, increased swelling, crusting, or drainage, or sensitivity to light (Epocrates, 2018). 

What would be the choice for second-line therapy?

If erythromycin was not effective for V.S., my choice for second-line therapy would be the combination product of trimethoprim/polymixin B (Polytrim), with one drop given every three hours while awake for a maximum of six doses per day for seven days (Epocrates, 2022). This product is active against many of the organisms that often cause bacterial conjunctivitis (Woo & Robinson, 2020, p. 845). In addition, it is safe to give to patients with a sulfa allergy, since this drug lacks the SO2NH moiety that is linked directly to a benzene ring, which is a vital characteristic in order to be considered a sulfa drug (Shah et al., 2018). Below is my second-line prescription for V.S.:

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 28, 2022 

Patient: V.S. DOB: 03/08/2010 Weight: 45 kg Phone: (231) 818-5090

Polymixin B/trimethoprim ophthalmic solution 10,000 units/1mg per mL

Disp: One bottle

Sig: Administer one drog to the affected eye every three hours while awake for seven days to treat bacterial conjunctivitis. Do not take more than six doses each day. 

No refills.

What over-the-counter or alternative medications would be appropriate for V.S.?

Using artificial tears or lubricating ointments may assist in relieving the symptoms related to bacterial conjunctivitis (Chan et al., 2021). In addition, the use of the over-the-counter povidone-iodine ophthalmic solution 1.25% may assist in the treatment of bacterial conjunctivitis (Sahdev et al., 2018). I would make sure to let V.S. know to wait at least ten minutes before instilling any other adjunctive medications into his eye after applying his prescribed ophthalmic antibiotic ointment (Woo & Robinson, 2020, p. 846).

What dietary and lifestyle changes should be recommended for V.S.?

An important piece of information to discuss with V.S. is for him and his family members to engage in frequent and effective hand washing, especially when the infected eyes are touched and before administering eye drops, to decrease the risk of spreading the infection (Woo & Robinson, 2020, p. 846). In addition, he needs to be informed to not share towels with anyone else while he has an eye infection (Woo & Robinson, 2020, p. 846). Further, I would let V.S. know that he may remove any purulent eye discharge with warm water-moistened cotton balls that are wiped from the interior to the exterior canthus (Woo & Robinson, 2020, p. 846). He should be instructed to use a clean cotton ball with each wipe and each eye (Woo & Robinson, 2020, p. 846). In addition, I would advise V.S. to use a cold compress to relieve his symptoms of discomfort (Chan et al., 2021). 

Describe one or two drug–drug or drug–food interactions for the selected agent.

There are no common drug interactions noted with the ophthalmic preparation of erythromycin ointment (Woo & Robinson, 2020, p. 841). There are also no common interactions associated with the use of Polytrim (Epocrates, 2022). However, it would be important to reinforce to V.S. to wait at least ten minutes before instilling two different types of treatments, such as artificial tears and ophthalmic antibiotics, to ensure both act in the way they are intended (Woo & Robinson, 2020, p.846). 

References

Azari, A. A., & Arabi, A. (2020). Conjunctivitis: A systematic review. Journal of Ophthalmic & Vision Research, 15(3), 372.

Chan, V. F., Yong, A. C., Azuara-Blanco, A., Gordon, I., Safi, S., Lingham, G., Evans, J., & Keel, S. (2021). A systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis. Ophthalmic Epidemiology, 1-10.

Epocrates (2018). Erythromycin ophthalmic. Retrieved March 28, 2022, from https://online.epocrates.com/drugs/2408/erythromycin-ophthalmic/Patient-Education

Epocrates (2022). Polytrim. Retrieved March 28, 2022, from https://online.epocrates.com/drugs/238302/Polytrim/Peds-Dosing

Sahdev, A. K., Sethi, B., Singh, A., Sharma, N., & Purwar, S. (2018). Conjunctivitis: Types, diagnosis and treatment under different therapies. Asian Journal of Pharmacy and Pharmacology, 4, 421-428.

Shah, T. J., Moshirfar, M., & Hoopes, P. C. (2018). “Doctor, I have a sulfa allergy”: Clarifying the myths of cross-reactivity. Ophthalmology and Therapy, 7(2), 211-215.

Vallerand, A., & Sanoski, C. (2020). Davis’s drug guide for nurses (Seventeenth ed.). F.A. Davis Company.

Viriya, E. T., & Mah, F. (2021). Bacterial conjunctivitis. Cornea, E-Book, 370.

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th edition). FA Davis.

A Sample Answer For the Assignment: NU 641 Discussion: Ophthalmic Disorders

Title: NU 641 Discussion: Ophthalmic Disorders

The purpose of this week’s discussion post is to identify goals of treatment, first and second-line pharmacologic and non-pharmacologic treatment options for a patient diagnosed with bacterial conjunctivitis. V.S. is a 12-year-old Hispanic male that presents to the office because he feels that he has sand in his eye. His history is notable for having a cold a week ago and then this morning woke up his left eye crusted with yellowish drainage. On physical examination he has injected conjunctiva on the left side, no adenopathy, and no vision changes. His vision exam is 20/20 and fluorescein staining reveals no abrasion. Of note, he is allergic to sulfa.

1. List specific goals of treatment for V.S.

Specific goals of treatment for V.S. are to provide symptom relief and to eradicate the bacteria causing his symptoms. Patients presenting with conjunctivitis require a timely diagnosis, appropriate differentiation of the various etiologies, and prompt appropriate treatment to decrease the potential negative consequences that prolonged infection and inflammation can cause on the eye (Azari & Arabi, 2020, p. 372).  Ensuring that the correct diagnosis is made is important to selecting the appropriate treatment course or determining if consulting an ophthalmologist is required (Woo & Robinson, 2019, p. 840). The goal is to prevent the adverse effects of untreated bacterial conjunctivitis including an infection of the cornea, scarring, and vision changes (Woo & Robinson, 2019, p. 840).

2. What drug therapy would you prescribe? Why?

Bacterial conjunctivitis is typically caused by a staphylococcus or streptococcus species, Haemophilus influenzae (H. influenzae), Moraxella catarrhalis, and gram- negative intestinal bacteria (Azari & Arabi, 2020, p. 381). The most likely pathogens that could have caused the conjunctivitis for V.S. include H. influenzae, Staphylococcus aureus (S. aureus), Streptococcus pneumonia (S. pneumoniae) and Moraxella catarrhalis (Woo & Robinson, 2019, p. 842). H. influenzae is more commonly seen in patients under the age of six, so it is less likely that is the causative organism for V.S. but it still cannot be excluded (Woo & Robinson, 2019, p. 842). Prior to initiating treatment it may be beneficial to culture the drainage, in case the treatment course is unsuccessful allowing the bacteria to be identified for next treatment option. Typically, conjunctivitis is self-limiting but school- aged children require treatment before returning to school and treatment yields faster improved clinical outcomes (Woo & Robinson, 2019, p. 843). Therefore, V.S. will be treated with an antibiotic ophthalmic ointment at this visit.

The drug therapy that would be prescribed to V.S. is Erythromycin (5mg/gram) ophthalmic ointment with instructions to apply 0.5 inch of ointment to the inside the lower eyelid four times a day for seven days to the affected eye (left eye) (Jacobs, 2020, Table 2). Erythromycin is a bacteriostatic macrolide antibiotic, that binds to 50S ribosomal subunit inhibiting the synthesis of bacterial protein resulting in the blockage of transpeptidation, and is effective in treating gram-positive organisms such as  S. aureus, S. pneumoniae, and Streptococcus pyogenes (Woo & Robinson, 2019, p. 840). Erythromycin is not as effective in treating gram-negative bacteria including H. influenzae therefore, V.S. should be instructed to seek follow up if his symptoms do not resolve (Woo & Robinson, 2019, p. 840).

Prescription #1

March 29, 2022

Victor Smith              DOB: 03/20/2010   Weight: 40 kilograms   Allergies: Sulfa

300 Someplace Ave

Somewhere, RI 02198

555-222-7777

Erythromycin (5mg/gram) ophthalmic ointment

Instructions: Apply 0.5 inch of ointment to the inside the lower eyelid four times a day for seven days to the affected eye (left eye). 

Dispense: One tube        No refills

Signature

Jacklyn Finnigan CPNP

DEA No: XXXXXXXXX

Finnigan Medicine  100 Boston Drive   Boston, MA

555-555-5555

3. What are the parameters for monitoring the success of the therapy?

The parameters for monitoring the success of the therapy for V.S. includes a decrease in the discharge from the eye, decreased redness, and eye irritation (Jacobs, 2020, 7 section). Ensuring success of the chosen therapy also includes that he can return to school after twenty-four hours of antibiotic treatment initiation and that the bacteria will not be transmitted to the unaffected eye (Jacobs, 2020, 7 section). V.S. should be instructed to follow up within two days if his symptoms do not resolve (Jacobs, 2020, 7 section).

4. Discuss the education you would give to the parents regarding drug therapy.

The education that would be provided to V.S. and his guardian includes a review of the drug chosen, instructions for how to administer the mediation, the frequency of the application, the treatment duration, instructions of when to follow up if symptoms do not resolve, and the potential adverse effects. The most important piece of education for this drug therapy will be instructions for how to properly administer the ophthalmic agent. V.S. and his guardian will be instructed to always wash their hands before and after administering any eye medication (Woo & Robinson, 2019, p. 846). They will be instructed that when they pick up the prescription and prior to its first use to squeeze out and discard the first 0.25 inch of the ointment (Woo & Robinson, 2019, p. 846). Then V.S. will tilt his head back, pull down on the lower eyelid forming a pocket, squeeze out 0.5 inches of the medication into the eye careful to not touch the tip of the tube to his eye (Woo & Robinson, 2019, p. 846).

He will then close his eye for one to two minutes and be instructed to not rub the eye (Woo & Robinson, 2019, p. 846). If there is excess medication around the eye, he can wipe that off with a clean tissue, from the inner eye to the outer part of eye (Woo & Robinson, 2019, p. 846). If V.S. is also using an over-the-counter mediation he will be told to wait at least 10 minutes between medications before instilling the next medication (Woo & Robinson, 2019, p. 846). It is important to inform V.S. and his guardian that blurred vision might occur after the medication is applied to the eye but that this is temporary, and he should refrain from rubbing it because it will resolve spontaneously (Woo & Robinson, 2019, p. 846).

5. List one or two adverse reactions for the selected agent that would cause you to change therapy.

Erythromycin ointment is a relatively safe drug of choice with minimal adverse effects and has no reported drug interactions (Woo & Robinson, 2019, p. 841). However, an adverse reaction for the erythromycin ointment that would cause a change of therapy includes a hypersensitivity reaction (Sterling & Zand, 2022b, 18 section). All ophthalmic ointments can cause temporary local irritation including burning, itching and inflammation, which should resolve quickly after application but if continued irritation occurred with this drug a change in therapy may be warranted (Woo & Robinson, 2019, p. 841). Worsening symptoms would always indicate a prompt need to change therapy because of the potential that the antibiotic ointment chosen is not effective in treating the type of bacteria causing V.S. conjunctivitis (Woo & Robinson, 2019, p. 841).

6. What would be the choice for second-line therapy?

The choice for second-line therapy for V.S. is Bacitracin-polymyxin B 500 units- 10,000 units/ gram ophthalmic ointment 0.5 inch applied to the affected eye four to six times a day for seven days (Jacobs, 2020, Table 2). This is a combination drug product that is active against both gram-positive and gram-negative bacteria which is important as it covers for H. influenzae a bacterium the erythromycin did not cover (Woo & Robinson, 2019, p. 840). Polymyxin B is active against gram-negative bacteria and binds to cell membranes and phospholipids in the cell wall causing increased cellular permeability (Woo & Robinson, 2019, p. 840). Bacitracin is active primarily against gram-positive bacteria and is a cyclic peptide antibiotic that inhibits bacterial cell wall synthesis (Sterling & Zand, 2022a, 18 section). This drug combination product is relatively inexpensive but Polymyxin- trimethoprim (Polytrim) ophthalmic solution is another treatment option that is less expensive (Sterling & Zand, 2022b, 20 section). For easy of transition and patient education, sticking with an ointment for continued treatment may be easier for the patient and their family but if financial constraints were a factor, Polytrim ophthalmic solution could be used instead.

Prescription #2

March 31, 2022

Victor Smith              DOB: 03/20/2010   Weight: 40 kilograms   Allergies: Sulfa

300 Someplace Ave

Somewhere, RI 02198

555-222-7777

Bacitracin-polymyxin B 500 units- 10,000 units/ gram ophthalmic ointment

Instructions: Apply 0.5 inch of ointment to the inside the lower affected eyelid every 4 hours, not to exceed 6 times a day. Please use for seven days to the affected eye (left eye). 

Dispense: One tube        No refills

Signature

Jacklyn Finnigan CPNP

DEA No: XXXXXXXXX

Finnigan Medicine  100 Boston Drive   Boston, MA

555-555-5555

7. What over-the-counter (OTC) or alternative medications would be appropriate for V.S.?

Over the counter or alternative medication that would be appropriate for V.S. includes ocular lubricants or artificial tears to aid in symptom relief (Woo & Robinson, 2019, p. 857). Ocular lubricants are balanced solutions that maintain ocular tonicity, improving irritation and preventing injury to they eye caused by dryness (Woo & Robinson, 2019, p. 857). Ocular lubricants come in two types of formulations, solutions and ointments (Woo & Robinson, 2019, p. 858). The prescriber can recommend Lacri Lube, artificial tears, Duratears Naturale, or Bion Tears to V.S. (Woo & Robinson, 2019, p. 858). If V.S. endorse any eye itching an over the counter antihistamine such as Zaditor 0.05% solution one drop every eight hours can help relieve ocular itching (Woo & Robinson, 2019, p. 856).V.S. can also remove the drainage crusted from his eye with a cotton ball moistened with warm water, but should be instructed to wipe from the inner eye to the outer eye and only use one cotton ball for each wipe (Woo & Robinson, 2019, p. 846).

8. What dietary and lifestyle changes should be recommended for V.S.?

 Bacterial conjunctivitis is highly contagious, and this must be emphasized to the patient and his family upon diagnosis (Jacobs, 2020, 7 section). V.S. should not share tissues, towels, linens, or eating utensils with anyone in his family, he should also be encouraged to refrain from touching his eye and should participate in frequent handwashing (Jacobs, 2020, p. 7). After having conjunctivitis, it is important that a patient throw away and replace any eye or face-make-up brushes to prevent re-infection, which is likely unnecessary for V.S, but if he does wear glasses or uses sunglasses those should be cleaned before reusing and contact lenses must be thrown out (Jack, 2019, 4 section). V.S. vaccination records should be assessed to ensure he is properly vaccinated against the viral and bacterial diseases that have been shown to be associated with conjunctivitis such as Measles, Varicella, Pneumococcal, and Haemophilus influenzae type b (Hib) (Jack, 2019, 5 section). A vitamin A deficiency can be associated with conjunctivitis, so increasing the intake of vitamin A into V.S. diet can aid in improving eye health and preventing infections (Azari & Arabi, 2020, p. 373). Food such as carrots, spinach and broccoli are great source of vitamin A.

9. Describe one or two drug–drug or drug–food interactions for the selected agent.

There are no significant drug interactions reported for the use of ophthalmic erythromycin (Sterling & Zand, 2022b, 21 section). If V.S. were using the erythromycin ointment and an eye drop concurrently he should be told to always use to eye drop solution first, wait ten minutes then apply the ointment (Woo & Robinson, 2019, p. 856). Ophthalmic antibiotic agents have minimal systemic absorption and only penetrate the ocular fluid and tissue hence the minimal drug-drug and drug- food interactions (Woo & Robinson, 2019, p. 840). If V.S. required a prolonged or repeated use of antibiotic ophthalmic agents, a risk for superinfection may occur (Woo & Robinson, 2019, p. 841).

Thanks,

Jacklyn

References

Azari, A. A., & Arabi, A. (2020). Conjunctivitis: A systematic review. Journal of Ophthalmic and Vision Research, 15(3), 372–395. https://doi.org/10.18502/jovr.v15i3.7456

Jack, L. (Ed.). (2019, January 4). Prevention. cdc.gov. Retrieved March 29, 2022, from https://www.cdc.gov/conjunctivitis/about/prevention.html

Jacobs, D. S. (2020, October 2). Conjunctivitis. UpToDate. Retrieved March 29, 2022, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/conjunctivitis?search=bacterial%20conjunctivitis%20children%26source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1

Sterling, A., & Zand, J. M. (2022a). Bacitracin (ophthalmic): Pediatric drug information. uptodate.com. Retrieved March 29, 2022, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bacitracin-ophthalmic-pediatric-drug-information?search=Bacitracin%20ophthalmic%20ointment&source=panel_search_result&selectedTitle=2~91&usage_type=panel&display_rank=2&showDrugLabel=true#F24147704

Sterling, A., & Zand, J. M. (2022b). Erythromycin (ophthalmic): Pediatric drug information. uptodate.com. Retrieved March 29, 2022, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/erythromycin-ophthalmic-pediatric-drug-information?search=erythromycin%20ointment&source=panel_search_result&selectedTitle=2~142&usage_type=panel&display_rank=2&showDrugLabel=true#F8086304

Woo, T. M., & Robinson, M. V. (2019). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F.A. Davis Company.