PMHNP prescribing questions

Specialties NP

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So I am just curious if a PMHNP can ever prescribe any non psych medications in certain situations?

For example, an elderly patient has a ua done to r/o a uti due to a change in mental status. The ua comes back positive.... does the pmhnp go ahead and order an antibiotic? I know of psychiatrists that will.

If a patient is in pain are there any type of pain meds a pmhnp would be OK with ordering? Or medications that will alleviate side effects of a prescribed psychotropic (ie colace for constipation, etc?) Or what about refilling routine meds? (Simvastatin, etc?)

Lastly, are all abnormal labs referred to a pcp?

Sorry, probably dumb questions, but I am just curious.......

Specializes in Psychiatric and emergency nursing.

In my state, while someone with an MD or DO degree can prescribe whatever their heart desires, specialty nurse practitioners such as PMHNPs must stay in their own lane, as it were. I am allowed to prescribe any psychotropic medication that is on my collaborating formulary (which is pretty much everything because my collaborating physician is awesome), but I am not allowed to prescribe any general practice medications (BP, BG, etc) unless specifically directed to do so by my physician. While I understand that I'm smart enough to prescribe these medications, there's a reason we have FNPs and AGPCNPs and the like. They don't do what I do, and I don't do what they do. Besides, rarely is there a situation like a UTI, high A1c or other metabolic concern that is urgent to the point that it cannot wait for a primary care referral, and do I really want to be in front of the board of nursing d/t a patient's serious adverse reaction to a medication that I really shouldn't have been prescribing in the first place?

That being said, when I did clinical hours at a veterans home, there was one PMHNP and one AGPCNP full time, and one physician for the entire home. When one of the nurse practitioners was out or on vacation, the other would have to pick up and write the medications for the other. So unfortunately, there may not be a clear cut answer to your question, and the answer may be more situational than anything. Clear as mud, I know.

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Would then just screening for A1C and monitoring weight in patients on atypicals and then referring it to the PCP as indicated be more appropriate? I'm curious where the line is. Some prominent psychiatrists consider metformin use as a prophylactic for weight gain/metabolic syndrome to be, to borrow a phrase from someone in this thread, "enlightened practice."

Speaking of staying in one's lane, I know plenty of FNPs who prescribe SSRIs and even some atypicals regularly. I've seen some weird patterns here.

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10 minutes ago, TheNietzsche said:

Would then just screening for A1C and monitoring weight in patients on atypicals and then referring it to the PCP as indicated be more appropriate? I'm curious where the line is. Some prominent psychiatrists consider metformin use as a prophylactic for weight gain/metabolic syndrome to be, to borrow a phrase from someone in this thread, "enlightened practice."

Speaking of staying in one's lane, I know plenty of FNPs who prescribe SSRIs and even some atypicals regularly. I've seen some weird patterns here.

You don't need more of us to get access to someone who can easily collaborate with you and get patients on appropriate meds and effectively monitor the patient. We on the other hand don't have the luxury of a myriad of psych NPs or providers to prescribe for our populations. Not to say we should be, but FNPs prescribe those meds out of necessity. Not because we actually want to. You can have all the enlightened practice you want so long as you're willing to monitor their a1c, renal function, and any other parameters that go along with it.

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Fair enough, and I certainly am not arguing that FNPs or PCPs should never prescribe psych meds. My point here is just that I find these lines fuzzy and in some cases arbitrary. Is propranolol in our lane? Benztropine/cogentin is in our lane, but it isn't really a "psych drug", and its also a dirty drug that is often inappropriately used (IMO). I would feel safer prescribing metforming to a patient that I'd be in the case of some of our meds, say clozapine for instance.

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Specializes in Psychiatry.
On 6/17/2019 at 6:44 AM, myoglobin said:

Again, I ask what is the functional difference between adding a drug like Cogentin to manage dystonic reactions from 1st generation antipsychotic medications or Austedo to manage tardive dyskinesia and putting a patient on a drug like metformin to manage pre-diabetes from Seroquel or perhaps Topamax to mitigate weight gain from Zyprexa? In both cases the PMHNP is attempting to mitigate side effects directly attributable to their primary psychotropic intervention. Also, in the real world of 15 minute medication management appointments significant collaboration between providers is largely a fantasy.

You have to examine a few things including your actual training, largely irrelevant of anything you did as a RN, and the area standard of care.

In psych, bupropion and topiramate are routinely utilized to mitigate weight gain, however, they're also easily articulable as mood-specific adjuncts. If you think they're a sort of food addict then you could even try naltrexone with/without bupropion.

Psych lives off label. Embrace that or go home.

I routinely use antihistamines, both H1 and H2, as well as ondansetron and loperamide. I also routinely handle misc. detox so there's some treating some physiological issues.

I am actually scoped to prescribe thyroid meds as well as dextromethorphan.

Beyond that, cholecalciferol, cyanocobalamin, thiamine, and folate are common prescriptions as are prenatal vitamins.

Additionally, I'm not really shy about ordering an inpatient or residential patient anything they could procure OTC if they weren't captive in an institution.

I look at the DSM 5 as my scope of practice, and if there's something in there I want to treat and know how to I'll do it. I tend to defer limb movement disorders although I've certainly prescribed ropinirole and pramipexole.

We get patients with chronic pain and fibromyalgia hourly so utilizing gabapentin, duloxetine, amitriptyline, and for some venlafaxine specifically to target the psych complaints as an umbrella to alleviate pain. I've prescribed pregabalin as well because there's some evidence of efficacy for anxiety.

I will not prescribe erection meds. It's like opening a Xanax clinic. Once people learn about it they'll come.

Psych also uses propranolol, clonidine, guanfacine, and prazosin with some using terazosin and atenolol.

I've prescribed my weight in desmopressin tablets, and imipramine isn't an uncommon application for enuresis and encopresis. I see imipramine as futile for that so I don't employ this strategy.

At this point, I don't even want to know anything about abx/ID, arrythmia drugs, insulin, or anticoagulants, and I have never known a single chemotherapy drug, lol.

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Specializes in Psychiatry.
On 6/18/2019 at 7:07 PM, TheNietzsche said:

Fair enough, and I certainly am not arguing that FNPs or PCPs should never prescribe psych meds. My point here is just that I find these lines fuzzy and in some cases arbitrary. Is propranolol in our lane? Benztropine/cogentin is in our lane, but it isn't really a "psych drug", and its also a dirty drug that is often inappropriately used (IMO). I would feel safer prescribing metforming to a patient that I'd be in the case of some of our meds, say clozapine for instance.

Don't fear clozapine! You just need a patient with support system to get them to the lab and a support staff to handle all the BS. The required education for certification is informative.

You theoretically don't need benztropine with it and is even shown as contraindicated, but I've still had patients with EPS who responded to benztropine.

And for Heaven's sake, don't be that guy who sends everyone to pharmacogenomic testing.

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Specializes in ICU, trauma, neuro.
8 hours ago, PMHNP Man said:

Don't fear clozapine! You just need a patient with support system to get them to the lab and a support staff to handle all the BS. The required education for certification is informative.

You theoretically don't need benztropine with it and is even shown as contraindicated, but I've still had patients with EPS who responded to benztropine.

And for Heaven's sake, don't be that guy who sends everyone to pharmacogenomic testing.

Genomic testing has evidence in the setting of treatment resistant depression. More information is seldom a bad thing.

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Thanks everyone for your replies.....

Another question I have is do pmhnp's round in non psych hospitals? And do any of yall do ECT?

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Specializes in Psychiatric and emergency nursing.

I work for my grossly medical hospital's in-house psychiatric unit. I do consults for patients on the medical floor, and aid the ER in disposition of the difficult psychiatric patients. We don't do any ECT in my hospital, unfortunately. It's become a rare animal in my neck of the woods.

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Just now, ThePsychWhisperer said:

I work for my grossly medical hospital's in-house psychiatric unit. I do consults for patients on the medical floor, and aid the ER in disposition of the difficult psychiatric patients. We don't do any ECT in my hospital, unfortunately. It's become a rare animal in my neck of the woods.

I'm surprised to hear that. Perhaps its regional. Can you refer out to ECT if absolutely necessary or is it really that hard to find? I'm thinking of the very severe cases, e.g., catatonia, what do you do in those instances.

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Are there any pmhnp's that do ECT?

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Specializes in ICU, trauma, neuro.
1 hour ago, Joebird21 said:

Are there any pmhnp's that do ECT?

Our clinic (where I am in clinical) does not offer ECT however there are several NP's who do the TMS. One of my dreams is to have a clinic near Las Vegas (if I can't convince my SO to move to Kauai) and have five (or more) TMS machines booked around the clock. We had a lecture/dinner several weeks ago by a psychiatrist near Tampa who only does TMS and has eight machines at maximum capacity who "said" that he nets around 2.5 million per year after expenses.

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