Case Study One
For effective healthcare practices, it is important for the nurse practitioner to be aware of Independent Prescribing. Independent Prescribing process is defined as the prescription by a practitioner who is responsible and accountable for the evaluation and assessment of the conditions of patients and makes an appropriate decision regarding their clinical management and prescription (Aronson, 2006). This process, however, must involve the patient as a partner as well, during the consultation process (RPS, 2016). Strengthening and instruction of patients is presently all around perceived as a vital objective however most human services expert. Furthermore, it takes after that if patients are to be included then their specific needs should be found out and tended to, ordinarily in the system of the consultation. A continuous finding in a significant number of the examinations regarding the matter is the way that patients have a tendency to incline toward prescribers who tune in and furthermore enable them to talk about their issues in an unhurried manner. Therefore, this case is especially coordinated to the issue of consultation abilities in connection to nurse endorsing. Even though we have quickly analyzed the general issues of nurse endorsing, the consultation is clearly the center expertise required to build up the conclusion and accordingly the fitting treatment and solution. Numerous investigations have taken a gander at the impact of relational abilities on recommending and different variables identified with the consultation.
The consultation took place at the ABC (pseudo name) facility, a health care delivery facility staffed by physicians of different specialities and other non-physician health care providers who specialise in the diagnosis and management of patients with chronic pain. The primary goal of a pain treatment facility is to provide effective and humane care for those who suffer from chronic pain. The complexities of the chronic pain patient must be recognised to accomplish these goals. As a member of the team, I am strongly committed to the idea that a multidisciplinary approach to diagnosis and treatment is the preferred method of delivering health care to patients with chronic pain of any aetiology.
During the consultation, I rigorously applied the standards of the prescribing competency framework set by the RPS (Royal Pharmaceutical Society, 2016) which consists of ten competencies split into two domains: the consultations and the prescribing governance. In this case study, I integrated the competency framework into my practice using competencies 1 to 9. I then used the Gibbs method to reflect on my practice (Gibbs, 1988).
A 78-years old lady – Mrs Stark was referred to the facility from her GP as she complained of acute asthma and also had a history of arthritis and knee pain. Mrs Stark is a widow living with her dog and has always claimed to be quite independent on daily activities until five months ago when her pain started to become unmanageable. She now has to call her son daily to walk the dog and to help her with food shopping as needed because this, as well as other simple tasks, have become increasingly difficult to accomplish because of the recurring pain.
The medication prescribed was only providing minimal benefit to the patient’s condition, and the use of over the counter medications such as Paracetamol seems to have not made any difference. Also, the use of NSAID’s has exacerbated symptoms of mild asthma she was diagnosed with fifteen years ago (RPS framework competence 2: Consider the options). The rest of Mrs Stark’s medical history was unremarkable; she has no major medical problems and has no known allergies. She lives on her own; her 46-year-old son visits her daily to ensure that she has everything she needs in order be reasonably comfortable at home.
The latest X-ray reports show a severe degeneration in her knees due to bilateral joint space narrowing with medial femur shift and valgus deformity, moderate popliteal and superficial femoral artery calcification.
Mrs Stark was prescribed one capsule of Tramadol HCl (50 mg) capsule twice daily. Furthermore, she was also prescribed one tablet of Amitriptyline HCl (25mg) tablet to be taken at night. She was also taking two tablets of Paracetamol 500mg tablet according to her needs for pain relief. Finally, Mrs, Stark was also prescribed 1 to 2 puffs of Salbutamol (Ventolin) 100mcg inhaler based on the frequency of her asthma complaints.
I utilised the PQRST (Krohn, 2002) pain assessment tool to obtain a holistic description of the pain during the examination. Although this tool was used, the consultation was essentially based on the Calgary-Cambridge model of communication (Greenhill et al. 2011), which consists of six distinct areas (REF)
The first step in this model is about ‘Initiating the session’. This step involves planning for the session and formally initiating the consultation session with the patient. This also involves specifications of all consultation protocols. The second step involves ‘Gathering information’. In this step, information about the patient and their medical history is gathered so that the foundation of the session can be developed. Once the information is gathered, next step is to ‘Provide structure to the consultation’ so that all the formal protocols and specifications can be met appropriately. As the consultation process begins, it is important to ‘Build the relationship’. This helps in ensuring that the right consultation is being provided to the patient sufficiently. Once these specifications and requirements have been met, the fifth step involved ‘Explanation and planning’. In this step, the physician or the consultant explains the scenarios, possible treatments and their implications for the patient. Once the patient and the consultant have been satisfied the session is formally closed.
The consultation process was established in accordance to the RPS Framework competencies. The consultation was initiated by developing an initial rapport with Mrs Stark who was asked to describe the problem she was experiencing. Here, the RPS framework competence 1 i.e. Assess the patient, was ensured. She described the pain in her knees as a constant ache that gets unmanageable especially in the morning, only partially relieved by the Tramadol that she takes twice a day as prescribed by her GP.
The PQRST (Provoking, Quality, Radiation, Severity, Timing) Pain Assessment Tool has been used during the consultation to formulate specific questions to adequately understand Mrs Stark’s pain:
According to Mrs Stark, her pain improves in the afternoon but does get worse after prolonged periods of rest as well as following stressful activities. The quality of the pain can be described as an achy, cramping and numb sensation on both hips and knees that can suddenly radiate down from her knees to her feet. The patient’s pain score is a seven on a scale of 0 out of 10.
The osteoarthritis is a type of degenerative joint disease (Loeser et al. 2012) that results from the breakdown of the joint cartilage and the underlying bone, with the most common symptoms being joint pain and stiffness.
In the early stages of the disease, symptoms might occur following exercise or activity, but over time they can manifest without any aggravating factor at all. There is no cure for osteoarthritis, and the condition can get worse over the years, so the best goal is to find the appropriate combination of pharmacological and non-pharmacological treatment to ensure that the condition doesn’t evolve to become a significant limitation for the patient.
After careful consideration of the patient’s pre-existing diagnosis of osteoarthritis, the symptoms reported, the drugs she is currently taking, as well as the patient’s preference, I deciisde to prescribe Morphine Sulphate (Zomorph) modified-release 30mg capsules twice daily to start immediately as a substitute for the Tramadol 50mg oral capsules. According to the WHO ladder of pain (Burton & Hamid, 2007), if the pain persists or is increased after treatment with an opiate for mild/moderate pain such as Tramadol, the next option is to consider an opioid for moderate/severe pain like Morphine sulphate.
I opted for the modified release form considering Mrs Stark’s social history and age to facilitate ease of administration, maintain constant drug concentration during the day and to minimise side effects. Since the patient has to be informed about the prescription process and plan, I explained to Mrs Stark the reason I suggested to start with a relatively high dosage of 30mg twice daily is that she used to take Tramadol and over time her body has developed a tolerance to small doses of opioids. Also, the BNF (2017) suggests a Morphine dose of 40mg to 60mg daily in divided doses when switching from a regular weak opiate regime. An increase of the dosage at a later point in time may be considered to compensate for any gradual reduction of the analgesic effect associated with oral administration. Here, the RPS framework competencies 3,4,5 i.e. to Reach a shared decision, prescribe and provide information, were ensured.
Morphine Sulphate is an opioid analgesic, and it acts mainly on the central nervous system and smooth muscle (Hanks et al. 2001). It comes in a sustained-release form, which makes the twice-daily oral administration possible. Morphine is immediately absorbed from the digestive tract, the percentage of the drug binding to plasma proteins was considerably low, i.e. about 34%, the liver metabolises a considerable quantity of the drug to glucuronides which undergo enterohepatic recirculation. In the end, the product is eliminated essentially in the urine and a small amount in the faeces. Here, it is important to understand the metabolism and excretion process of the morphine, and the way it impacts the physical dynamics of the patients to ensure that no side effects are being exposed for the patient. The individual health concerns of the patients must also be ensured during the prescription of opioids such as morphine.
The patient has also been informed of common side effects of the drug such as nausea, constipation, confusion and some occasional vomiting. I have the professional responsibility to review and evaluate the treatment outcome, therefore, arranged a follow-up visit with Mrs Stark in a weeks’ time to establish if there have been any improvements in her symptoms.
Follow up assessment should take place once a week for the first two months. Further appointments will then be carried out every six months by a member of the team as well as annually by the pain consultant. Any undesired pharmacological effect should be reported to the Hospital facility during working hours, from Monday to Friday, to 111 or A&E during nights and weekends. Here, the RPS framework competence 6,7,8 i.e. Monitor and review, prescribe safely, prescribe professionally, were ensured.
I concluded the consultation with Mrs Stark advising her to avoid any stressful activities or sudden strenuous movement, to have a little rest in the afternoon when possible and to consult a chiropractor of her choice if the pharmacological treatment results in pain improvement. Mrs Stark needs to make sure her pain due to arthritis is well managed and controlled while she is undergoing the treatment for asthma as well. Medications for asthma tend to induce joint pains that need to be reported immediately (Smyth et al. 1999).
The case study represents a common type of patient who visits the facility regularly. When I encounter people like Mrs Stark, I can appreciate a better understanding of their chronic condition, feeling empathetic for patients that have to learn how to coexist with pain. I am now aware that the same pathologic condition between individuals does not mean that the treatment should also be the same because every individual have different pharmacological responses to medications, Here, the RPS framework competence 9 i.e. to Improve prescribing practice, was ensured.
The challenge is to find a way to improve patient’s life allowing preservation of the individual physical needs and self-esteem. Chronic pain like other degenerative conditions can seriously debilitate the individual; when constantly subjected to it patients can experience a gradual withdrawal of their autonomy. My tools are the knowledge gathered along the path of this course and the experience that the facility has offered me. I consider the skills that I have acquired to be a completion of my holistic approach to pain management. I have always felt 100% responsible for the wellbeing of my patient whether they are on a theatre table, on a bed in a ward or attending the facility. Therefore, I believe that every single health care professional is accountable for patients’ safety, it is our duty to make sure that any treatment, assistance or care for which we are responsible is delivered effectively. I’m aware that I’m accountable for my actions to practice competently, I also understand the limitations of my professional competence, and I will only accept responsibilities for those activities in which I am competent (NMC 2004).
It is important to include the patient in the prescribing decision to ensure that they can adhere to the proposed drug regime without any problem or reluctance.
I was dissuaded from proposing an alternative treatment that would involve physical activity at the moment because of the patient’s reduced mobility due to severe pain. I would consider it an option for future consultation if Mrs Stark’s symptoms improve. Overall the consultation was a positive experience for the patient and myself, as she seemed to be grateful and positive about the new treatment regimen.
The entire consultation and prescription process helped me in understanding the importance of positive consultation as well as ensuring that the prescription of medication is done in such a way that it may not trigger secondary pains and discomforts in the patient. The experience and exposure to such cases will enable me to improve my competencies and enhance my self-confidence (Jones et al. 2004). This is important because the good prescription routine is not only a theoretical practice. Instead, it requires analytical, and critical thinking skills to ensure that prescription is appropriate for individual needs of the patients (Jones et al. 2004). Therefore, the inclusion of the patient in the process is very important. In order to ensure this competency as suggested by RPS, I explained the rationale of my choices of prescription to the patient and waited for her feedback or queries so that she can be satisfied with the prescription process. Furthermore, the background health analysis and history check also ensured that the individual needs of the patients are being considered throughout the consultation process.
Therefore, it is important to understand that success is only possible when nursing prescription process is ensured in accordance to RPS competencies. The dynamic acknowledgment of the worldview of concordance offers all social insurance experts an instrument to move towards ever more secure and more effective recommending. Exact recognizable proof of the patient’s points of view, needs and convictions and after that the tending to of any noteworthy contrasts amongst these and the prescriber’s prerequisites, are believed to be dynamically more vital in the fruitful conveyance of nurse endorsed social insurance. The appearance of nurse recommending conveys added obligation to the more conventional part of the nurse. It is essential not to disregard the significance of the part of intelligent practice here. It isn’t only the demonstration of working out the solution that is imperative, however it is the comprehension of the procedures and progression of the cooperation that are occurring amongst prescriber and patient that are the basic key to great endorsing practice.
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