CASE STUDY OF FACTORS IN NURSE PRESCRIBING PROCESS

Over the recent years, there was an escalating emphasis on the need for nurses to develop assessment consultation and history taking skills for prescribing patients with drugs as well as to gain knowledge within sophisticated clinical practice roles. Specifically, nurses are qualified to learn and apply patient assessment and consultation skills in their nursing practice. These skills can form a corner stone of becoming a proficient, well-trained nurse.

The present essay focuses on the assessment skills, principles of drug history taking process and Clinical Management plan reflecting on a specific case study where in which the nurse prescriber indicated an Allevyn adhesive dressing to manage the healing process of Leg Ulcer in a patient.

Assessment Skills

Within primary and community health care, the methodological and systematic assessment plays a major role and it is the crucial requirement of government policy. In the face of congregating dependence upon care management and public fund targeting, the role of assessment skills was increasingly becoming important policy tool (Charles et al., 1996).

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Connecting to the present case study, the nurses must demonstrate and utilise all of his/her senses in assessing the patient. Typically, these involve listening (hearing), feeling (touching), observing (visual) and therapeutic communication processes (Wright, 2007). Generally, an approach pertaining to cephalocaudal type must be utilised by all nurses in assessing the patient from head to toe region. In performing an assessment with relation to Leg Ulcer (or any disease), it is very important for the nurse to possess basic requirements related to stethoscope, sphygmomanometer (to check the blood pressure), thermometer and penlight (Kimmel, 2005). The hospital and the instrumental setting are also important in carrying out an assessment. The nurse must indicate high observant skills and must strive hard in obtaining as much information as possible (about the Leg Ulcer disease) from the patient to effectively formulate the nursing diagnosis (Kimmel, 2005). Additionally, the nurses need to have the following skills:

Broad Experience

This specific skill can enable the nurse to identify the similarity patterns of the events associated with the Leg Ulcer and linking them to the previous encounters visualised with other patients (Kimmel 2005). Nurses must recognise the subtle changes within the person’s health status, comprehend the potential consequences of the Ulceration and then act accordingly to specify the treatment (Wright, 2010).

Implicit Knowledge

This may help the nurse to engage within the process of holistic problem solving skills and to analyse the premonitions or intuitions. Particularly, this becomes significant in opening up the complexities associated with the disease (Kimmel 2005).

Empirical Knowledge

This feature develops from the fundamental sciences through which Nursing Sciences has been originated-physiology, sociology, pharmacology, ergonomics, medicine, philosophy. In addition, the knowledge gained through nursing practice, research and allied health professionals can also be included in this skill (Wright 2007).

Observation

Help in recognising formulating options and considerable changes persistent with the Leg Ulcer disease (Kimmel 2005).

Psychological

These skills get developed with the interpersonal communication with patients and residents, their families and colleagues. Supporting, enhancing, facilitatory and counselling skills in relation to the progression of the Leg Ulcer disease are the other types of skills that are essentially needed in patient diagnosis (Wright 2010).

Lastly, the Standards of Care pertaining to diagnosis, outcome identification, planning and evaluation must be implemented to achieve a relatively higher level of wellness towards physical and emotional perspectives (Wright, 2010).

By imbibing the above skills, the nurse carried out the initial assessment process soon after meeting the patient. Subsequently, other follow up measurements must be implemented on a weekly basis with special attention oriented towards the following characteristics:

Signs of Infection

For the patient with identified Leg Ulcer, the signs of infection involve decreased blood pressure, tachycardia, fever (septic symptoms), pain, redness and warmth including swelling near the ulcerated tissue, purulent drainage from the diseased area (yellow and greenish fluid draining out from the portion) (Morgan, Thomas 2010).

Stage of Wound, Category and its Type

Wound Staging is an effective way to effectively categorise the Leg Ulcer or any form of Progressive Ulcer. This involves understanding the stage or degree of wound (ranging from I-IV and alleged deep seated tissue injuries) (Harding, Leaper 1998).

Additionally, it enables in classifying the wound type (Arterial or Venous) based on the partial or complete thickness of discharged fluid (Harding, Leaper 1998).

Slough

Is the dead (devitalised) tissue that is soft and moist and which is usually adherent to the base portion of the wound. This indicates the infection processes near the wound site (Kimmel 2005).

Detection of Eschar

It is the dried, firm and harder dead tissue covering the wound surface. Typically, it can be black, red or brown in colour depending upon the necrosis in wound progression and amount of blood presence. This form must not be confused with the slough and should be evaluated by the Nurse as a part of wound assessment (Harding, Leaper 1998; Morgan, Thomas 2010).

In the present study, the patient suffering with Leg Ulcer was prescribed with treatment to enable the healing process. Before analysing the therapeutic outcomes, it is very important to consider the complete drug profile together with the benefits and challenges of prescribing process. Following sections clearly provide us the full profile of the drug that need to be taken and allergies along with its potential contraindications.

Complete Drug History taking process

The foremost prime step in understanding that elders achieve safe and effective drug use is by carrying out interviews with the diseased patients for an inclusive drug history. In many cases, a pharmacist carries out this process and occasionally the physician may also be involved (Wright, 2010). Additionally, a clinical nurse specialist or nurse practitioners can be concerned in interviewing the patients (Klemperer, 1994). Nevertheless, good interviewing and effective communication skills will enable the nurse in taking the drug history and to conduct the interview with the patient (Klemperer, 1994).

Generally, the nurse must initiate the process by questioning the patient about the prescribed medications used for the Ulcer treatment followed by a systematic approach of gathering information. The medication questions about the routine problems (like headache, endocrine, ear and eye infections) will also be involved (Hocking, et al., 1998). In addition, the information pertaining to drug management perspectives can also be collected at the time of interviewing the patient. These involve names of various medications used, frequency and purpose together with their dose (Hocking et al., 1998).

With relation to the present Case study, Open ended questions were posed as they establish impetus and beliefs associated to taking of medication process (Hocking et al., 1998). The nurse necessarily gathered the information about the number and type of current prescriptions (Prioreschi, 1998), Over the Counter drugs (OTC), herbal and other supplements along with administration schedule. Besides these, the patient knowledge about the medications used, side effects and medication related problems, remedies used, incidence of visits towards the care practitioners along with smoking forms and types of social drugs (like nicotine or tobacco, gum and so on) were also been questioned (Klemperer, 1994).

Conversations about illicit and additive drugs were prevailed during the interview process and this demanded the presence of non-judgemental attitude and sensitivity. The discussion also included the intervening plans in a way by encouraging communication with the interdisciplinary care teams who are highly important in the well-establishment of safe-medication. Furthermore, the nurse explained the patient about the Allevyn dressing that play a key role his/her leg Ulcer treatment and underlined its indications and usage along with precautions. Such information can be understood through the following sections (Hocking, DeMello 1997).

Indications and Usage

This dressing can be used in managing the wounds through secondary target on chronic thickness of Ulcerous areas and thin granulation of discharging wounds. It is the layered adhesive coat of polyurethane ranging from films to foams with 5% of Silver Sulphadiazine (Sweetman, 2007)

The hydro cellular foam dressing can be specified for exudate absorption and the treatment of ulcers, pressurised soles, excisions as well as incisions that prevail during surgical injuries, first and second degree burns and donor sites (Mehta, 2002).

Designing and upholding of a tacky wound situation. These tacky environments were considered to be as the most favourable environments for wound management.

Presents corporeal severance of wound with its exterior environments in a way to aid in prevention of bacterial contamination of the ulcerous tissue (Martin et al., 2009)

These dressings can be divided in a comfortable manner to ensemble with a variety of shapes and areas. As these dressings absorb the discharged exudates, a persistence problem of slight swelling can be observed. However, it does not leave any debris upon the wound (Pharmaceutical Press, 2009)

Additionally, it provides a wide range of flexibility for the nurse by enabling easier dressing changes. Besides these, it creates less traumatic conditions to the patient in a way by effectively minimising the wound irrigation processes. The exudate progression is visible through the pink top film of the dressing. Furthermore, it can be used in various forms like non-adhesive type, water proof layers, trilaminate structured forms, hydro cellular (highly absorbent) layers and Non-adherent layer (Mehta, 2002).

Precautions and Warnings for Allevyn

Though the dressing can be utilised effectively during X-Rays treatment, contact must be avoided with electrodes as well as other conductive gels used throughout electromagnetic measurements (like Electroencephalogram and Electrocardiogram). Care must be taken by the patients undertaking the Magnetic Resonance Imaging (MRI) scanning, as these dressing may cause warming effect (Pharmaceutical Press, 2009).

Must be completely avoided by the patients with an identified sensitivity to silver (Pharmaceutical Press, 2009).

If breathing difficulties persist during inhalation process, medical attention need to taken to avoid deleterious effects in future (Pharmaceutical Press, 2009).

Contact with skin and eyes may not cause any known adverse effects (Pharmaceutical Press, 2009).

The product should be stored necessarily in cool, dry place with a temperature less than 250C and away from ignition, strong light sources (Pharmaceutical Press, 2009).

Clinical Management Plan (CMP)

Clinical Management Plan can be considered as the basis of supplementary prescribing. Prior to the supplementary prescribing process, it is mandatory for an accepted CMP (in written or electronic form) must be in place (Rodden, 2011). This involves name of the patient along with the detailed medical situation of the patient (Department of Health, 2011). Lastly, the prepared CMP must be incorporated within the patient record.

In the management of Leg Ulcer, the nurse prescribed Allevyn for the patient and CMP made comprised of the following (Sweetman, 2007):

Name of the patient who is suffering with Leg Ulcer.

The conditions of illness and symptoms observed with the patient along with the treatment specifications.

The date from which the plan must be started and when it is needed to be reviewed by the physician.

Description of medicines used (like Allevyn dressing) and kind of appliances prescribed under the plan.

Limitations related to the dose and strength of the Allevyn prescribed and the mode of application (Adhesive dressing) in the treatment of Ulcer.

Warnings and precautions (depicted above) of the drug along with the known difficulties encountered.

Known allergic reactions (like prutitis, rashes and swelling if observed) of Allevyn along with its adverse reactions (such as diarrhoea, headache, vomiting sensation) at the time when it is prescribed to the patient.

Deleterious effects of Adhesive Allevyn if persisted and the overcoming measures that can be taken if the problem is severe and

The circumstances at which the supplementary prescriber is needed to be referred along with the advice of the doctor.

Benefits and Challenges of Nurse Prescribing

Specifically with Leg Ulcer Treatment the nurse prescribing practice help in delivering a complete episode of care, enables greater self-sufficiency and speeder access towards medication, time saving and expedient together with the early interference identifications, greater patient involvement (Courtenay, Berry 2007). Furthermore, it provides a means of formalising present prescribing activities and approaches, allow patients to receive better information from the nurses about the prescriptions and medications and thereby permitting a holistic practice (Courtenay 2007).

Additionally, it enhances rapport with the leg ulcer patient, reduces length of stay owing to accurate prescribing management, improves knowledge and assessment skills in identifying the complications of leg ulcer along with co-morbid complexities and promotes the response time to addressing patient symptoms and withdrawal (dependency) effects (Gray, 2006).

On the other hand, it was observed that the prescribed drug, Allevyn induced allergic reactions in the patient and this can be attributed to the potential implications of prescribing process. However, it cal also happen owing to increased work load and responsibilities upon the nurse, litigation fear, inter and intra professional conflicts, adherence towards medical model of care, lack of knowledge and accountability and absence of skills for prescribing process and dependency (Courtenay et al., 2007).

REFERENCES

Courtenay, M. 2007, Nurse Prescribing-the benefits and the pitfalls, Journal of Community Nursing, 21, 11.

Courtenay, M., Berry, D. 2007, Comparing Nurses and Doctors views of Nurse Prescribing: A Questionnaire Survey, Nurse Prescribing, 5, 5.

Department of Health, 2011, Clinical Management Plans (CMP), Department of Health, London.

Gray, R. 2006, Nurse Prescribing: Raising Standards, Nurse Prescribing, 4, 8.

Hocking, G., DeMello, W.F. 1997, Taking a ‘DRUGS’ History, Anaesthesia, 52, 904-907.

Hocking, G., Kalyanaraman, R., DeMello, W.F. 1998, Better drug history taking: an assessment of drugs, Journal of Royal Society of Medicine, 91, 1-2.

Kimmel, N. 2005, Nursing Education- Patient Assessment Skills, British Journal of Nursing, 13, 21, 1870-1877.

Klemperer, G. 1994, The Elements of Clinical Diagnosis, MacMillan Publishers, USA.

Leaper, D., Harding, K.G. 1998, Wounds: Biology and Management, Oxford University Press, London.

Martin, J., British Medical Association, Royal Pharmaceutical Society of Great Britain, 2009, British National Formulary, BMJ Group and RPS Publishing, 57.

Mehta, D.K. 2002, NPF Nurse Prescriber’s Formulary 2002-2003, Pharmaceutical Press, London.

Pharmaceutical Press. 2009, Nurses Prescriber’s Formulary for Community Practitioners 2009-2011, Pharmaceutical Press, London.

Prioreschi, P. 1998, Roman Medicine, 3rd Edition, Horatius Press, United Kingdom.

Rodden, C. 2001, Nurse Prescribing: vies on autonomy and independence, British Journal of Community Nursing, 6, 350-355.

Shirley, B. 2009, Guidelines for Taking A Complete Drug History, Nursing 2011, 45, 7, 900-910.

Sweetman, S.C. 2007, Martindale: The Complete Drug Reference, 35th Edition, Pharmaceutical Press, London.

Thomas, S., Morgan, D.A. 2010, Formulary of Wound Management Products: A Guide for Health Care Staff, 10th Edition, Euromed Communications Limited, London.

Wright, K. 2007, A Written assessment is an invalid test of numeracy skills, British Journal of Nursing, 16, 13, 828-831.

Wright, K. 2010, Do Calculation errors by nurses cause medication errors in clinical practice? A literature review, Nursing Education Today, 30, 1, 85-97.

Section C: Influences of Prescribing Practice

To date back, National training for Nurse Prescribing was started in England, by the year of 1998 during which around 20, 000 nurses have qualified for the new role. The study carried out by Humphreys and Green (2000) illustrated the potential importance of infrastructure in the focus groups (n=12) obtaining the preparation concerned to nurse prescription at one institution (Humphreys, Green 2000). The implementation of extension standards in to supplementary nursing practice acknowledged the deliberate need for understanding pharmacology as the basis for prescribing process and to identify the nurses who play a major role in selection criteria pertaining to prescriber training (Department of Health, 2002).

In many parts of the United Kingdom, the critical demand for medical care compensates the supply and especially this scenario is observed in economically deprived communities. Although, nurse prescribing is the best approach to meet the rising health care demands and certify equitable service access, impact cannot be identified unless an assessment agenda (for any initiative) is precisely focussed (Department of Health, 1991). The Advisory Group report published by Department of Health (1989) confirmed the potential benefits including the cost analysis of Nurse prescribing (Department of Health, 1989). This created a way for the legislation to allow nurses in prescribing limited drugs and other medications (Department of Health, 1991). Research studies with regard to pharmacological knowledge suggested the presence of knowledge deficits for nurses and specific concerns pertaining to this knowledge adequacy was been reflected and reported as lack of confidence when prescribing. Nevertheless, Rodden (2011) reported the increased autonomy of nurse prescribers and their minimal dependency on General Practitioner colleagues (Rodden, 2011).

Another Advisory Report published by Department of Health (1999) recommended an extension of nurse prescribing and passed legislation to authorize the self-governing prescribing process from an elaborated list of medicinal products and supplementary prescribing in combination with doctors. Duffin (2001) and Luker (1997) indicated that some community nurses are not utilising the prescribing powers (Duffin 2001; Luker 1997). Research study carried out by While and Biggs (2004) indicated that nurse prescribers cannot form a substitute for the general practitioners for the products within the limited formulary. Implementing a major role in the nurse prescribing practice requires assessment of numerous conditions including adequate education, preparation and training and designing formulary that convene patient and practitioner’s needs (While, Biggs 2004). Report on the evaluation of eight pilot sites revealed that nurse prescribing was completely accompanied by anxiety and heightened apprehensions of accountability (Luker et al., 1997).

Towards the other side, in examining the speculative basis for mental health nurse prescribing process, it is very important to discuss the implicit theoretical tensions together with the experiences of registered nurse prescriber. Making a Difference (1999) was the key policy document published upon the extending phenomenon of nurse prescribing with an aim of saving time for the General Practitioners (Department of Health, 1999). However, the implicit support was arrived through National Health Service and it stressed on various ways of working and distorting the demarcating lines between the specialized groups in NHS with an interest on improved access to quality of health care (Brooks, 2001). Thus, it must be understood that benefits and challenges of Nurse Prescribing within the context of mental health include the following (Department of Health, 1999):

Add up the knowledge and allow complete use of experience.

Allow service transition from hospital to community based.

Nurses must reveal that they are diagnostically competent for the process of patient assessment and prescribing.

The prescribing process may distract the attention from other aspects of nursing roles.

May result in developing dangers (like allergic reactions developed for Allevyn in the present study) and these get added up to nurse’s role

Conclusion

Thus, to effective reduce the incidence of deleterious effects due to Nurse prescribing, a helpful action plan must be devised with the following objectives:

To evaluate the prescribing approaches of nurses with relation to health visitors.

To effectively understand the professional and contextual factors which enhance and inhibit the process of Nurse Prescribing

To understand the views of practitioners and patients with relation to treatment offered by the nurses.

Much research was performed with in this field of Nursing and still is needed in future to effectively explore the factors and to determine the steps for carrying out this process. Nevertheless, it is not a solitary effort and it demands the potential involvement of practitioners, patients, Nurses, local health organisations together with the government. Research on decision making process suggests that complex prescribing process is not always rational and it continuously reflects the factors involved in consultation process as well as patient expectations Extension towards prescribing process of medical products provide an opportunity to examine the process of decision making and this role gets extensively integrated in to nursing practice in future.