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The aim of this assignment is to demonstrate the use of safe and effective prescribing in practice. I will achieve this by presenting and analysing a prescribing scenario which I have encountered in my current area of practice within a District Nursing Team. During the case study the patient I have chosen will be referred to as Jean. This is to maintain her anonymity in line with the Nursing and Midwifery Council (2008) guidelines of confidentiality. I feel it is important for the purpose of my scenario to acknowledge the new skills which I have acquired whilst undertaking the V150 and explain the background to Nurse Prescribing.
The Cumberledge Report (DHSS, 1986) made the initial recommendations for nurses to prescribe. The report identified that, although nurses often new what they wanted they spent valuable time waiting around for prescriptions to be signed by G. P’s. As the nurses were already contributing to the prescribing decision; particularly around wound care products, enabling them to prescribe would be a more effective use of resources. An advisory group went on to produce The Crown Report (DOH, 1986).
This recommended that a certain nurses holding District Nurse or Health Visitor qualifications should be allowed to prescribe from a limited formulary. As a result of this The Medicinal Products: Prescription by Nurses Act (1992) became the primary legislation. This allowed community nurses with a District Nursing or Health Visiting qualification to prescribe from a limited formulary in the Nurse Prescribers Formulary (NPF). Whilst this enhanced the role of the nurse, reviews continued and legislation was passed.
Implementation of the Health and Social Care Act (2001) enabled extended independent nurse prescribing. This was however still limited to those nurses with a specialist practitioner qualification. This changed in 2007 with the introduction of the V150 prescribing course. The V150 allowed first level nurses with no specialist practitioner qualification to undertake necessary training to prescribe from the Nurse Prescribers Formulary for community practitioners. To help me structure my case study I will make use of the Prescribing Pyramid from the National Prescribing Centre (NPC, 1999).
The prescribing pyramid provides a seven step process which includes the core principles of prescribing. During my case study I will consider each individual step of the pyramid before I approach the next step. Jean was referred to the District Nursing team by her GP with a trauma wound. She had a laceration to her left calf which had been caused by a supermarket trolley. It was necessary to undertake a holistic assessment in order to plan the wound care management. It was also necessary to determine whether or not a prescription was needed, as this is not always the case (NPC, 1999).
It was therefore essential that we achieved an effective consultation, this was done with the aid of a consultation model. I used the model to help guide my actions and focus on the important points. I used the Pendleton et al model (1987) and it helped to provide a logical structured approach to achieve an affective outcome. Having introduced myself to Jean the initial consultation began. I explained the reason for the referral from the GP which helped to allay any fears or anxieties Jean was experiencing. Ellis et al (2003) identified that the use of verbal and non-verbal communication skills ensure effective communication.
Jean initially appeared anxious, but once I reassured her that she would be included in any decisions made and that I would explain each stage of the assessment to her, she appeared to relax. I gained Jeans consent and proceeded with the consultation. I obtained a full surgical and medical history from Jean which was documented as per NMC guidelines. This showed me that Jean was in good health and had no underlying medical conditions. Following advice from her GP Jean was currently taking Paracetamol 1g every 4-6 hours for pain relief.
She told me this was effective and I discussed with her that she should not exceed 4g of Paracetamol in any 24 hour period (NPF 2009-2001). She informed me she was already aware of this. Jean had no known allergies or previous adverse reactions to medicines, dressings or adhesives and was not taking any other prescribed or over the counter medication or alternative therapies. We also discussed Jeans nutritional intake. I explained to Jean the importance of a balanced diet as optimal wound healing requires adequate nutrition. Deficiencies in a persons diet can impede progression through the normal stages of wound healing.
Malnutrition has also been related to an increase in infection rates. Jean understood this and assured me she would take this in to account to enable the healing process. Jean went on to explain that the injury was caused when somebody ran into her leg with a supermarket trolley. She had initially applied a dry dressing but attended her GP’s when the wound became wet and painful. The Practice Nurse at the GP’s surgery had administered a tetanus booster injection as Jean could not remember when she had one last and the trolley had appeared to be rusty. I undertook a full wound assessment which showed a wound 3cm by 3. cm to the left calf area. The wound bed was 70% yellow sloughy fibrous tissue and 20% granulation tissue. There was moderate haemoserous exudate present which Jean stated had increased over the past couple of days. This indicated to me that an infection could be imminent. White (2003) suggests that the symptoms Jean was experiencing indicate critical colonisation. As there was an absence of positive signs of infection such as cellulitis, pyrexia and malodour (Patel 2007) my clinical experience advocated treating the wound as being critically colonised.
Following full assessment of the wound and further discussions with Jean we agreed on a plan of care. We decided that there was a need for a wound dressing to be prescribed. Moffatt and Vowden (2008) suggest that discussions combined with clinical skills are important in care planning. Once the need for a prescription was agreed upon I utilised the mnemonic EASE (NPC, 1999). This helped me consider the choice of products I was prescribing by looking at how effective the product was, how appropriate it was in Jeans care plan, how safe the product was and whether or not the prescription would be cost effective.
Using EASE would help ensure that I prescribed the most appropriate items. It was important that I chose products based on effectiveness and wasn’t influenced by commercial factors or by others (NMC, 2006). Jean advised me at this point that she was exempt from prescription charges. The choice of primary dressing was aquacel AG, a silver containing hydrofiber with hydrocolloid fibres. Allevyn adhesive was chosen for the secondary dressing. My aim was to debride the sloughy tissue and effectively manage the exudate levels which would reduce the risk of maceration to the surrounding skin.
My decision to use a silver hydrofiber dressing was based on my clinical knowledge and previous experience of use in similar wounds. Evidence suggests that the use of ionic silver destroys bacteria in the wound. The hydrofiber absorbs the exudate promoting autolytic debridement through the provision of a moist wound environment. Although the use of silver dressings has increased over recent years their efficiency has been questioned. In 2010 a study was done which focused on the use of silver containing foam dressings. It suggested that silver containing dressings should only be used in wounds with clinical infection O’Meara 2010). It was only a small study but it concluded that more research into the dressing was needed. Cutting et al (2007) suggested that the use of silver dressings should be determined by clinical need and discontinued if there are no positive results. I checked with Jean that she was not sensitive to silver and explained the primary dressing could cause some discolouration to the skin. During the assessment Jean had expressed concerns regarding not being able to shower with a dressing on her leg. This was discussed and taken into consideration when deciding on the secondary dressing of Allevyn adhesive.
Allevyn adhesive consists of a layer of soft hydrophilic polyurethane foam. Although the outer film is permeable to moisture vapour, it provides an effective barrier to water or wound exudate and also prevents the passage of microorganisms through the back of the dressing. By suggesting the use of this as a secondary dressing I was addressing and dealing with the concerns Jean had over not being able to shower. I felt this was important as in order for us to achieve the best outcome Jeans concordance with the treatment was imperative. The aim of concordance is to improve satisfaction with the process f health care consultations, the ultimate goal being to reduce waste of health care resources (BMJ, 2006). Concordance reflects a shift in culture of health care interventions as its aim is to empower patients. Jean was being empowered by being involved at each stage of the decision making process. I advised Jean that she would initially require twice weekly dressing changes, she was happy to attend the District Nursing clinic so it was decided this was where future appointments would take place. During the follow up visits I would monitor the effectiveness of the treatment and if necessary change the plan of care.
If Jeans wound were not to heal within a six week period she would be referred to The Tissue Viability Team for a wound assessment as per local trust policy. Jean was given contact numbers for the District Nursing Team and advised to make contact should she have any concerns before her next visit. A prescription was provided for Jean with the required dressings (Appendix 1). A copy of the prescription was filed in her notes to prevent duplication (NMC, 2006) and a copy was also sent to her GP in line with the local trust policy. The whole episode of care was documented and a care plan was formulated Appendix 2). This was done in order to maintain accurate records of treatment plans and rationales (NMC, 2009). On reflection the case study has enabled me to appreciate the benefits of nurse prescribing to both the patient and the nurse. Johns (2004) identified that reflection should be a process of confronting, understanding and moving towards a resolution between ones vision and actual practice. Undertaking a holistic assessment of Jean was essential in order to ensure a safe evidence based decision was made. As a nurse prescriber I am accountable for my actions and must nsure my decisions cause no harm to my patients (NMC, 2008). On reflection I feel I made good decisions based on the best evidence available as well as on my previous clinical experience. At all stages of the decision making process Jean was involved, ensuring concordance and enhancing her understanding of the decisions we made regarding her plan of care. A week later at one of Jeans follow up appointments it was noted that the wound was de-sloughing and the exudate levels had reduced. Jean stated she felt empowered and was pleased with her progress. Although nurse prescribing improves patient care and will enhance y professional development, I feel it also carries a high level of responsibility and accountability. I feel that undertaking reflection in my future practice and continuing to add to my own P-Formularies, whilst working within the NMC guidelines, will enable me to give safe and effective patient care. REFERENCES Cutting,K. White,R. Edmunds,M. (2007) The safety and efficacy of dressings with silver- addressing clinical concerns. International Wound Journal. 4 p. 177-184 Department of Health,(1989) Report of the Advisory Group on Nurse Prescribing. (Crown Report) London, DOH.
Department of health and Social Security, (1986) Neighbourhood Nursing: a focus for care, (Cumberledge Report) London, HMSO. Ellis,R. Kenworthy,N. Gates,B. (2003) Interpersonal Communication in Nursing: theory and practice. 2nd Edition London, Churchill Livingstone. Health and Social Care Act (2001) OPSI Johns,C. (2004) Becoming a Reflective Practitioner. 2nd edition, Oxford, Blackwell Science Ltd. Nursing and Midwifery Council (2009) Record Keeping: Guidance for nurses and midwives. London, NMC. Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London, NMC.
Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife prescribers. London, NMC. National Prescribing Centre (1999) Signposts for prescribing nurses-general principles of good prescribing. London, Prescribing Nurse Bulletin. Nurse Prescribers Formulary (2009-2011) London, BMJ Group and RPS. Patel, S (2007) Understanding Wound Infection and Colonisation. Wound Essentials, 2. p132-142. The Medicines Act 1968, (Amendment) Regulations (1992). Statutory Instrument 1992, No 604 OPSI White, R. (2003) The wound infection continuum. In: White, R (ed) Trends in Wound Care, Volume 2. London, Quay Books.