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In healthcare, aesthetic medication is the broader term for the special care that is used for focussing on changing the cosmetic appearance of the skin through treatment of conditions such as wrinkles, moles, scars, skin laxity and others (Urdiales-Gálvez et al., 2017). The dermal filler is referred as one of the aesthetic medication approaches used in altering the cosmetic appearance of the skin. However, though in rare condition, the process can lead to cause soft skin infection. The soft skin infections are clinical entities of different presentation, severity and aetiology which includes invasion of microbes on the skin layers and its underlying of tissues to cause infection (King et al., 2018). In this study, the case study of an individual named Jenny is to be discussed who have suffered skin infection due to dermal filler process. This is to develop ideas regarding the signs, symptoms, red flags and others of the disease to develop effective concept regarding it and for this purpose a thorough clinical assessment process is to be mentioned. I met the patient while she attended the clinic before and after the procedure. My role in the clinic is being an aesthetic nurse who have the responsibility to provide care consultation to the patients that do not involve any surgical cosmetic procedures. Further, the therapeutic management required to resolve soft skin infection is to be discussed. The legal, ethical and clinical governance to be followed in respect to management of skin infection and controlling dermal filler process is to be discussed.
Clinical Assessment process
The clinical assessment of any patient is required to determine the extent of their health problem and determine what led to the health condition. The Calgary-Cambridge Model is to be used in determining the way health consolation with the patient is to be done that would lead to their thorough health assessment. The Model mentions that there are five stages to reach effective health consultation with the patient that are initiation of the session, gathering information, physical examination, explanation and planning and closing the session (Baniaghil et al., 2020). The initiation of the session includes three stages which are preparing for the session, establishing rapport and identifying the need for consultation (Iversen et al., 2020). In regard to the preparation stage of the model, for initiating medical consultation with Jenny, the physician ensured all her medical reports regarding skin condition are present at their hand like skin evaluation form, informed consent form and others. This is because it would make the physician concerned regarding the way health assessment and consultation of the patient is to be done with confidence so that the patient feel value and supported effectively (Jeong et al., 2021). The skin evaluation report is required to understand the nature of microorganism that has the ability to affect the skin leading to the expression of infection (Kim, 2019). The skin analysis report developed followed by skin culture of Jenny informed that her skin infection is caused by bacterial contamination.
In executing health consultation, the model mentions that effective rapport with the patient is to be developed so that the individual trust the physicians or clinicians to inform their health issue without any issue (Widyastuti et al., 2018). Therefore, the clinicians to initiate effective health consultation with Jenny communicated with her in an empathetic, warm and reassuring way that her any health condition could be resolved if she truly mention her complication and action post treatment of the dermal filler approach. This is because empathetic and warm communication helps the patient to feel at ease to inform any health issues to the clinical out of trust and belief that they would be effectively listened and respected (Lorié et al., 2017). After initiation of the consultation, gathering information for the patient’s health condition is important as it assists to determine the root cause of the problem from the patient (Derksen et al., 2017). In this condition, the narrative of Jenney regarding her skin condition is effectively listened. This is to identify the action taken by Jenny post-treatment of dermal fillers that may have influenced in resulting the skin inflammation because in executing the process proper guidelines are followed from all aspect in the clinic to deliver the skin treatment.
In gathering patient narrative, Jenny is asked questions regarding her medical history for skin allergies and actions taken by her post-treatment. The medical history of skin allergies is important in assessing soft skin infection because it leads the clinicians to identify if the patient is prone to develop allergy or any actions may have currently led to the condition (Hibler et al., 2018). It is evident as for instance angioedema which is rapid inflammation and swelling of skin occurs due to any allergic reaction toward certain type of foods (Mohamed, 2020). Jenny reported that she never has any nature of skin allergies and have previously done dermal filler in which she also never faced any allergic reaction. It ensured to avoid the ideas that she may be affected by angioedema and further assessment was made to determine what may have led to her current skin infection. The effective guidance mentioned in the after-care of dermal filler is important to be followed. This is because during this phase the skin remain damaged due to the insertion of hyaluronic acid through injections and minimum time of 48 hours is to be provided to help the skin heal (Fallacara et al., 2017). However, on consultation with Jenny it was revealed that she did not appropriately followed the post-care guidance and applied make-up which was asked to be avoided during the tenure. This is because opened and used make-up remains contaminated by bacteria while remaining exposed in the environment and their application on the damaged skin leads to immediate entry of the micro-organisms in the skin in turn causing skin infection (Bhojani-Lynch, 2017).
The Calgary-Cambridge Model mentioned that after gathering basic health information thorough physical health assessment is required to determine if any physical health problem in leading to raise the skin infection (Baniaghil et al., 2020). Thus, to execute further assessment of Jenny’s skin condition post-treatment, she was asked to mention if she recently suffers from dental condition. This is because dental health has adequate impact on causing skin inflammation over the face due to damaged gum or teeth in the mouth (Mahendran et al., 2020). Therefore, the physical assessment of her dental condition and mouth is checked that revealed she expresses no issues with pain in gums or any aberration in the mouth. This confirmed that her skin inflammation on the cheeks is not raised due to infection from the mouth. The physical assessment of the entire skin where dermal fillers are made in case of Jenny is checked and analysed thoroughly. This is to determine if any damage was done to the skin during the dermal filler injection in the surrounding areas that has acted as an effective ground for bacterial growth and cause skin inflammation (Ortiz‐Brugués et al., 2020).
The skin inflammation may occur due to immune response of the body towards any drugs. It is evident as medication such as retinoids which are used in enhancing vision are seen to cause skin itching and inflammation. This is because retinol causes the skin cells to turnover at a faster rate which temporary sloughs off dead skin creating lag in time before the formation of healthy cells on the skin surface that eventually causes redness, inflammation due to itching on the skin (Deaville and Tomlinson, 2017). Jenny reported that she is not using any drugs and has steady health condition without presence of any firm of health issue for co-morbidities. The Calgary-Cambridge Model informs that following the physical assessment is explanation and planning of care to finally close the consultation session (Baniaghil et al., 2020). The clinical consulting with Jenny understood that apart from violating to use make-up within 48 hours of the dermal filler process, she expressed no other issue that could have led to her skin infection which represents signs of redness and inflammation (King et al., 2018). Thus, it can be determined that the skin infection may have been caused through bacterial contamination from the make-up used by Jenny. In this respect, Jenny explained regarding the way violation of the after-care led to the condition and care plan is developed that includes therapeutic intervention for the condition by consulting with Jenny to ensure her well-being.
The therapeutic management plan is referred to the medical service intervention plan that are provided to help for health improvement of the service user. The therapeutic management plan is important because it assist the carers to determine the systematic way different care approved with due permission from the health practitioner and the patients to be provided for enhancing their deteriorated health condition (Sævareid et al., 2019). Thus, the plan I important to let the service providers be consistent and adhere to specific medication that are deemed to be use for the patient that I Jenny. Moreover, it helps to avoid making medication error out of confusion and ensures better self-management of therapy plans by the patients (Chan et al., 2018). This is because the therapeutic management plan creates opportunity of knolwdege for the service users like Jenny to understand which specific medication and in which dose are to be taken by them. The non-pharmacological approach to be taken by Jenny in managing her skin inflammation is trying to keep the affected area disinfected and clean by using doctor prescribed cleaner. This is because it would avoid worsening of the infected area through transmission of additional microorganisms ensuring faster healing (Heydenrych et al., 2018).
The pharmacological approach includes prescription and use of medication for treatment of skin infection. According to Collier (2018), one of the first line of treatment provided in case of skin edema from dermal filler approach is flucloxacillin 500mg. The medication is mainly provided orally for 7 days following 8 hours interval and the mentioned dose is appropriate for adult like Jenny. The study by Diwan et al. (2020) mentions that Flucloxacillin is a narrow-spectrum antibiotic that belong to the antibiotic group in which pencillin lies and it mainly works by breaking down the cell wall of the bacteria. This is evident as Flucloxacillin mainly binds with the penicillin-binding proteins (PBPs) present inside the bacteria cell wall as flucloxacillin inhibit the third and last stage of the bacterial wall synthesis. It leads to development of cell lysis that is supported by autolytic enzymes such as autolysins that is mediated by bacterial cell wall causing the cell wall of the bacteria to be destroyed and making them die (Goodman et al., 2020). The side-effect of using flucloxacillin for skin infection includes diarrhoea, bloating and indigestion (Goodman et al., 2020). Therefore, Jenny was asked to report any side effects or adverse drug reaction while on the course of antibiotics.
In contrast, if the person with skin edema due to dermal filler found to be allergic to penicillin, then Clarithromycin in 500mg dose as oral medication is to be provided (Collier, 2018). The mechanism of action of Clarithromycin includes preventing the bacteria from multiplying rather than letting it die. They act as a protein synthesis inhibitor which bind with the 23S rRNA that is a component of the 50 subunits of the ribosome of the bacteria, in turn, acting to inhibit the translation of peptides that support in multiplication of bacteria. The bacteria without the power of division gradually die and help the patient in overcoming the infection or prevents it further spreading on the skin (Davidson, 2019). Thus, while recommending Flucloxacillin to Jenny, it is to be ensured that she is not allergic to- penicillin as it would lead to further worsen her condition and instead to be provided Clarithromycin of the same dose as the first line of treatment. The side-effect of Clarithromycin is similar to flucloxacillin which includes stomach pain, vomiting, diarrhoea, heartburn and others (Garonzik et al., 2019).
In case of Jenny, it is reported that she has malar edema which is inflammation of the under eye after the dermal filler process. The malar edema in most cases are found to be temporary and therefore close monitoring of the condition for Jenny is to be made. In case the malar edema persist, the initial treatment measures to be applied are heat and cold compression, manual compression and use of methylprednisolone according to suitable dose of the patient (Funt and Pavicic, 2013). The mechanism of action of methylprednisolone for lowering inflammation is through suppression of migration of polymorphonuclear leukocytes and changing the increased level of capillary permeability. It mainly acts to supress the activity and volume of the immune system for inflammation (De Boulle and Heydenrych, 2015). The side effects to be faced by Jenny on administration of methylprednisolone is similar to Clarithromycin and flucloxacillin. Moreover, the heat and cold compression could also reduce malar edema because they directly create compression on the affected area where the lymphatic fluid has migrated in the subcutaneous layer in turn slowing down the process of migration of the fluid and gradual resolution of edema (Funt and Pavicic, 2013).
Legal, ethical and clinical governance
The legal and ethical considerations regarding any aesthetic medication practise is important to limit and control the delivery of the process to required people based on their needs and ensuring effective professionality is maintained while providing the practice (Goodman et al., 2020). However, in the UK, it is seen that there are no deigned legal and ethical quality approval system regarding delivery of services for dermal fillers (saveface.co.uk, 2019). The lack of established ethical and legal approval system for aesthetic medication leads the individuals willing to avail the medication be at risk of depending on the quality approval provided according to the rules of the clinic. It indicates that Jenny’s skin inflammation and infection could have been controlled and prevented in case the dermal filler process had specified legal standards for deliver set by the competent individuals from the UK government. This because such lawful practice would be suggested and controlled by the Department of Health in the UK which is competent body with expert people to dictates effective law that leads toward better quality delivery of different care with less error and side-effects on the patients (assets.publishing.service.gov.uk, 2013).
In the condition of lack of any presence of UK government specified ethical principles for evaluating the morality of the dermal fillers, the four ethical principles mentioned by Beauchamp and Childress is to be considered to assess the ethical aspect of the procedure followed for Jenny. This is because the ethical principles mentioned by the Beauchamp and Childress are widely accepted in the medical and common moral actions to be ensured in providing any services ethically (Jacobs and Huldtgren, 2018). The four ethical principles mentioned by Beauchamp and Childress are autonomy, beneficence, justice and non-maleficence (Jotkowitz et al., 2017). The ethical principle of autonomy means providing ability to an individual to act on their own values and interest to make decision regarding their care (Braun, 2020). In providing care to Jenny before and after the dermal filler procedure, autonomy is maintained. This is evident as before the dermal filler procedure she was allowed to take own decision to approve the process. Moreover, after the skin infection was detected she was provided approval to take decision regarding the nature of care she wish to avail from the mentioned care procedure to overcome the infection. The autonomy is supported for Jenny because it allows the individual or patient feel self-worth and increased self-respect that their opinions are being heard and supported to provide them care accordingly (Marceta, 2019).
The ethical principle of non-maleficence mention that it is obligation of the carer or healthcare practitioners to avoid inflicting any harm on the patient or others (Jotkowitz et al., 2017). This is required to be followed as it otherwise violates the NMC Code which mentioned care is to eb provided in best interest of the patient and minimum to no harm is to be inflicted on them during care as well as safety in their care is to be maintained (NMC, 2018). In case of Jenny, the non-maleficence is abided as none of the care provided was made to harm her in anyway and the skin infection was mainly determined to be raised because she violated the rule of avoiding applying make-up within 48 hours of the dermal filler procedure. The ethical principle of beneficence indicates that all the care practitioners have the responsibility in delivering quality care to the service users without error (Braun, 2020). In case of Jenny, quality care both before and after the dermal procedure are followed by the care practitioners which is evident as immediate actions to detect and resolve her skin inflammation and malar edema was taken. However, ethical principle of Justice indicates that fair treatment to all individuals is to be provided by the healthcare professionals (Braun, 2020). In case of Jenny, justice is maintained because she is provided equal care like the other patients for the dermal filler procedure in the clinic without making any form of discrimination in part of care.
In the UK, the use of nature of dermal fillers are not prescription-only due to which there is no limit toward using them (assets.publishing.service.gov.uk, 2013). This condition may have led to hindered delivery of the dermal filler services to Jenny that caused her to develop the deteriorate condition of the skin after the treatment. However, few standards of practise are set by the Save Face in partnership with the Aesthetic Complications Expert (ACE) Group for delivering services regarding dermal fillers with effective clinical governance (Davies, 2019). The study by Davies (2019) mentioned that for administering dermal fillers the standard of care is that professionals administering the process are to ensure that effective medicines and devices from reputable sources are to be used. Moreover, they are to analyse the health of the patient and determine any “red flags” such as social, medical and psychological risks of the patient to ensuring delivering high standard care that also approves clinical governance. In case of Jenny, we as professionals effectively identified and used most professionally-adequate and medically approved devices for the dermal filler process. However, we failed to identify “red flags” regarding her is that she is professionally a model due to which she always requires to remain presentable socially and for it she is addicted along with prone towards using make-up. This led us to be partly responsible behind her current skin condition and fail establishing clinical government which is delivering quality care to the patients because we informed her that she need to avoid make-up for the next 48 hours but failed to inform about the risk she may face on applying make-up.
In regard to legal and clinical governance for dermal filler as explained by the ACE guidelines, the professionals before the initiation of the management process of adverse events regarding dermal filler approach are accountable to assess the patient face-to-face. They are liable to keep records of any physical symptoms along with take photographs as proof for their facial condition (Davies, 2019). The mentioned ethical guidelines are essential and followed in arranging support for Jenny. This is because it helps the professional to develop overview regarding the health condition of the patient during infection and identify the probable root cause of the skin problem. It in turn helps in improved diagnosis as well as care management for patients like Jenny. The NMC Code of Practise which is used as standard ethical practise guidance by professionals in any healthcare field mentions that consent regarding the application of any healthcare services or use of any devices is to the taken from the patients prior to its implementation (NMC, 2018). In case of Jenny, this perspective of the ethical practise was appropriately followed as we as professionals took her consent in written format through the consent form regarding the dermal filler process we are going to perform on her in the clinic. In the consent form, detailed information of the medicine and devices to be used along with the procedure to be followed was explained to gather informed consent from Jenny.
The ACE guidelines mentions the professionals involved in delivering dermal filler process to individual to be professionally competent and trained in executing the process (Davies, 2019). The guidance is also highlighted in the NMC Code of Conduct where it is mentioned that professionals are to be competent in delivering determined care for the patients and are to act within their competence (NMC, 2018). In case of Jenny, this legal aspect of the care delivery was appropriately followed. This is evident as the professional who was trained and practising dermal filler process for the past 5 years without single report of adversity in the clinic was allocated for the delivery of the care to Jenny. The ACE guidelines mentions that professionals have the duty to take pre- and post-treatment photographs without edit from the patients. They are to attach it with the medical record of the patients where detailed information for the process of care for the individual is mentioned and need to store the record in a confidential way (Davies, 2019). The guidance is effectively followed in the clinic and was followed for Jenny which is evident as her real identify was not revealed and all her records were stored in the confidential way to be only accessed by the professionals involved in supporting her care.
The ACE guidelines mentions that practitioners in the dermal filler treatment process are to be professionally interact with service users and require to treat the patients and their relatives with respect (Davies, 2018). This legal aspect is also mentioned by the Health and Social Care Act 2012 where it informs all the patients are to be treated and managed equally with respect and compassion along with not be discriminate understand any ground (legislation.gov.uk, 2012). The legal aspect in care is followed while providing care to Jenny as she was never discriminated or disrespected for belonging from the Black African community to deliver care. The ACE guidelines also mention that effective protocol is to be followed for referral of the patient for dealing promptly with complication from dermal fillers (Davies, 2018). The guidance is effectively followed and referral of Jenny to skin specialist in case the skin complication is not resolved is appropriately set.
The above discussion mentions that Jenny who is 42 year of old on currently performing dermal filler experienced skin infection in the form of inflammation and malar edema. The health assessment of Jenny is performed in stages by following Calgary-Cambridge Model. This is because it allows effective consultation with the patient in determining their health background and execute physical assessment to determine and plan care. The health assessment of Jenny mentioned that she used make-up which was asked not to be used within 48 hours of the dermal filling procedure may have led to cause her skin infection, Further, the malar edema may have been raised in Jenny due to hindered filling procedure in the malar bags. The use of medication such as flucloxacillin as first treatment and Amoxicillin as second stage of treatment for skin infection is to be provided to Jenny as therapeutic intervention. However, if Jenny represents allergy with penicillin, then they are to be altered by Clarithromycin and Clindamycin respectively. The use of hot and cold compression is to be used for overcoming malar edema. There are currently no established ethical and legal guidance or standards provided by the UK government to inform regarding dermal filler process. However, the ACE guidance is mainly used for ethical and legal practice promotion in delivery of care regarding dermal filling to patients.
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The case study is regarding a patient named Jenny who is 42-years-old with no medical history of skin allergies or inflammation from any nature of skincare products or others. According to NMC Code of Practise, the patient’s personal details and identity are to be kept private so that their confidentiality is maintained, and they are safe from any harm or abuse due to identity revelation in the public (NMC, 2018). Thus, the pseudonym Jenny is used to indicate the patient so that her privacy and confidentiality is retained. Jenny reported to be doing dermal fillers for the past 10 years and never reported any side-effect or skin problem after doing dermal fillers in the past. However, Jenny after doing undereye and cheek dermal fillers most recently from our clinic reported post-cheek filler inflammation and malar edema within 48 hours of the treatment. She reported to redness along with inflammation of the skin in the filler areas. The development of inflammation following dermal filler procedure is found to be quite uncommon and occurs in 0.04-0.2% cases (King et al., 2018). Thus, considerable focus on analysis of the treatment provided during dermal filler implication and post-management process is required to understand what actions led to cause the infection of the skin in case of Jenny which is rare.
In order to understand the reason behind the cause of skin inflammation in case of Jenny, she is asked if she put make-up within the 48 hours after the dermal filler process. She replied that she did put mild make-up immediately after the dermal filler process while leaving the clinic. It is mentioned in the after-care advice of our clinic for dermal fillers is that individuals are to avoid using any make-up minimum 48 hours of post treatment. The inflammation of the skin can occur due to additional treatment around or in the mouth. Therefore, Jenny was asked if she visited her dentist recently and took any session from him. She replied to have not visited her dentist for the past one year indicating that the skin inflammation is not caused due to any infection through the mouth. In executing the dermal filler process, effective consideration of the guidelines and safety protocols were taken which is evident as canula was used along with other environmental precautions to effective skin treatment process. However, on analysis of the kin area near the dermal fillers it is seen that vascular occlusion has occurred indicates some form of damage may be caused to the skin during the process.
In regard to skin inflammation from dermal fillers, it is reported by Jenny that she is experiencing no irritation on the skin but the redness and inflammation in the area is bothering her. She is found to be calm to interact with us regarding the skin infection in the clinic and did not expressed any tantrums. She reported to mention that she is not under any drug and has no health complication still been identified. Jenny mentioned she has no co-morbidities and is absolutely fine along with living life with well-being. On the basis of the case study, thorough health assessment of Jenny is made to develop therapeutic intervention in helping her to overcome the skin infection problem
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