Model In Nursing Practice

Introduction

Based on a case study, this paper aims to deliver a detailed account of a consultation session with a patient (Miss X) during history taking, physical examination, and disease diagnosis and treatment recommendation. Hence, the paper will describe the whole consultation process with the patient to describe various aspects of patient consultation and treatment. As opposed to other models such as the Scott and Davies model (1979) Bryrne and Long model (1976), the Calgary-Cambridge model of consultation was considered the most appropriate for this session, not only because it is the most recent but also because it is more structured and gives a more patient-centred approach to the process (Thornbory 2013). Patient-centered approach is important in the practice of nursing because it acknowledges patient’s values and preferences (Thornbory 2013). Ultimately, Scott & Davies model was rejected based on the idea that it is an older model that Bryrne and Long model. The penultimate section of this paper will give a practitioner’s reflection of the entire session, highlighting issues of prescription safety and ethical considerations made during the session. Ultimately, there will be an outline of the closing session of the appointment, giving details of how a follow-up appointment with the patient was set for planning future treatments and monitoring of the patient’s progress.

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Initiating the Session

Miss X was a 39-year-old patient who attended clinic without prior appointment hoping to find a slot in the patient day list. Luckily, I had had a session cancelation before and therefore she easily found a slot to consult with me. To ensure I made a good first impression to the patient (Thomas & Monaghan 2014), I prepared for the session by wearing my nursing uniform as recommended by the Nursing and Midwifery Council (NMC, 2015). Moreover, I ensured that the consultation room had adequate privacy and free from interruption by placing the ‘do not disturb’ tag on the door (NMC, 2015).

Upon inviting her into the room, I introduced myself to Miss X and used an open-ended question to allow her to introduce herself and state how she would like to be assisted by me. According to Israel (2018), asking open-ended questions encourages the patient to explain themselves in their own words; in a manner that enables the physician to have a deeper understanding of the problem at hand. Thereafter, as she was explaining herself, I listened without interruption to enable the patient to have the luxury to fully explain her problem – let me have a clear picture of what she was looking forward to achieving through the consultation (Lowth 2013).

Information Gathering

Miss X, in a worried and distressed tone, explained that she had received an aesthetics treatment two days ago from a physician she explained as ‘well known and experienced’. The treatment was on her forehead lines and was subjected to botulinum type A. However, as she explained, her forehead wrinkles started bothering her some years before, but it was just recently that she decided to seek medical attention. Noteworthy, it was her first time receiving treatment of such nature. The patient also explained that while she has been experiencing difficulties in opening her left eyelid and heaviness in her right eye, she was hesitant to go back to the same physician because she had lost confidence in her capabilities.
Miss X’s mistrust for the previous doctor can be explained by the fact that patients seeking aesthetic treatment have an increased self-awareness and can experience self-image issues especially when treatments do not meet their expectations (Thornbory 2013). Therefore, I considered it important to adopt effective communication with Miss X to avoid confusing her with jargon.
Effective communication is considered important because at this stage, my communication and relationship with Miss X were unstable, and therefore I had to communicate effectively to gather all the relevant and accurate information that I needed from her (Ishakawa et al, 2018). Against this background, I maintained eye contact, used non-verbal communication to maintain the interaction because she seemed anxious and distressed regarding her condition. My aim was to connect with her both mentally and emotionally and have a full understanding of her individuality as well as her point of view (Cohn 2007). Moreover, to ease her distress, I provided her with more information about her condition and answered all her questions comprehensively as recommended by (Tidy, 2014).
In order to perform an informed diagnosis, there is a need to adopt a structured approach to history taking. As argued by Jose (2012), this is because a structured approach will enable the physician to have an understanding of the existing medical conditions and underlying pathology of the patient – as patients have different pathologies. The patient’s medical history is an important source of this information (Lowth 2015).

Using a closed-ended question approach, I gathered information related to Miss X’s medical history and found no previous surgery or serious illness – she was well and fit, except for the symptoms (difficulties in opening her left eyelid and heaviness in her right eye) she started experiencing a day before. Her medical history also revealed that she was not on any prescribed medication at that time, though she takes Aspirin whenever she experiences a headache – which was 10 days ago.

According to Lowth (2015), a patient’s social history may be quite broad because it entails a wider range of inquiry including the patient’s housing, employment, smoking, food, exercise and alcoholic history. Nonetheless, Thornbory (2013) argues that physical history is important because it helps to have a general understanding of the patient’s social life and how it may affect their health. In this regard, information gathered reveals that Miss X is a single mother who lives with her 65-year-old mother and 11-year-old son (both are healthy). She is a hairdresser and often enjoys a glass of wine after a long day of work.

A detailed physical examination reveals that Miss X has a Ptosis on her right eye. Miss X was also able to point to the right places where the Botox injections were made (above the eyebrows). Other physical characteristics of the patient include: Blood pressure: 125/83 Pulse: 85 and Body temperature: 36.5

Diagnosis & Treatment Planning

According to Thomas et al (2017), eyelid ptosis is the most common adverse event after botulinum toxin injection for cosmetic purposes. While patients who have natural ptosis complex have a higher risk of developing eyelid ptosis, Wassenberg et al (2017) assert that older patients with an attenuated orbital septum and loose skin are also as a higher risk because these conditions facilitate the diffusion of botulinum toxin.
According to Krohn-Hansen et al (2015), upper eyelid ptosis is caused when the toxin is diffused into lavatory palpebrae muscles through the orbital spetum. When toxin defuses, as Laurenz et al (2015) also explain, it irreversibly and selectively binds to a presynaptic terminal of the neuromuscular junction to prohibit the of release acetylcholine – which subsequently leads to a reduction in the muscular activity. Further information by Nagaraju et al (2015) indicate that upper eyelid ptosis symptoms can present within 48 hours or 7-10 days after treatment, yet the complication can be resolved within 2-6 weeks.
It is rare that a patient develops a fully closed upper eyelid (i.e. a true upper eyelid ptosis). Nonetheless, according to Wassenberg et al (2017) injections into the corrugator supercilii, procerus muscles, and orbicularis oculi are a major risk factor for upper eyelid ptosis. Moreover, Maheshwari & Maheshwari (2011) write that often, upper eyelid ptosis is caused when toxin diffuses away from the original site of injection, or when the injection is made on an improper landmark. Similarly, as argued by Ho & Valenzuela (2014), an increased rate of toxin diffusion may be developed when excessively deep injections are made on the periosteum, leading to a

dispersion of medication from the injection site and causing eyelid ptosis. According to Naimtu (2009), this condition is majorly associated with novice injection. Nishijima et al (2015) write that Alpha-adrenergic eye drops of apraclonidine 0.5% are known to induce several millimetres of eyelid opening by inducing Muller’s muscles. Muller’s muscles are responsible for elevating the upper eyelid by adjoining the levator palpebrae superiorsis (Akkaya et al 2015). On the other hand, according to Artunay et al (2010), Apraclonidine 0.5% may offer short-term relief from eyelid ptosis but does not provide a cure. On the same note, whereas Apraclonidine is licensed in the UK for medical use, the license only allows it for use as a short-term treatment for glaucoma because it primarily acts by reducing ocular pressure (Scheinfeld 2005). Hence, Apraclonidine 0.5% eye drops are not recommended for treatment of upper eyelid ptosis, but can be used as off-label prescription because according to Medicines and Healthcare Products Regulatory Agency (MHRA, 2012), some clinical situations may require that certain medications are used outside the terms of licence so long as the prescription is in the best interest of the patient according to the prescriber’s judgment. However, MHRA (2012) makes it categorically clear that the practitioners must take full accountability for any off-label prescription they make by paying attention to associated risks.

Medical Prescription

I explained to Miss X all the alternative medicines she could be prescribed for, including Apraclonidine (iopidine) drops, brimonidine 0.2% or 0.1%, and neosynephrine hydrochloride 2.5%. Firstly, I explained to her that Apraclonidine, especially iopidine drops are the most common and can be used frequently during the day (Thomas et al 2017). Also, I explained that both neosynephrine hydrochloride and brimonidine act by increasing muscle tone to create a full eyelid opening (Akkaya et al 2015). I also explained to Miss X the side effects of the alternative prescriptions, including the fact that she may develop an allergic reaction to brimonidine. Whereas the three drops (brimonidine, neosynephrine, Apraclonidine) are effective for treatment of eyelid ptosis, I recommended Apraclonidine for Miss X because it is the most commonly used and is available in most medical outlets (Thomas et al 2017). Ultimately, she agreed to Apraclonidina 0.5% prescription.

Ideally, in this case, I provided Miss X with all the relevant information regarding her condition, to enable her to understand what to expect during the treatment procedure, how long her recovery may take, and any potential complications that she might encounter both in the long-term and immediately after treatment. This exemplifies the assertions by Artunay et al (2010) that a nurse should only perform an aesthetic procedure in which they are experienced in, and should give full information to the patient about the treatment.

My understanding of the risks of Apraclonidine 0.5% prescription reveals that it should not be used by a patient that has used an MAO inhibitors such as Selegiline, rasagiline, phenelzine and isocarboxazid within the past 14 days because it could cause a dangerous drug interaction (Thomas et al 2017). Similarly, I prescribed Apraclonidine 0.5% based on Miss X’s history that she does not have heart disease, liver disease, high blood pressure or kidney disease. This is because according to Akkaya et al (2015), patients with these complications may need a dose adjustment to ensure they safely use Apraclonidine – it may also react with medications of such complications such as heart rhythmic medication

Ethical Considerations

A major ethical consideration I made during my session with the patient is that there was a documentation of all the procedures involved in the session to come in hand in an event of a formal complaint or claim for damages by the patient (Svider et al, 2014). Moreover, I ensured that the patient made an informed consent to the treatment procedure.
Based on the outcomes of Montgomery v Lanarkshire Health Board’s case in 2015, I made efforts to ensure that Miss X understood all the material risks involved in the prescribed treatment or those that are associated with the alternative treatments (Shailesh 2018). I did this by explaining the side effects of both Apraclonidine and brimonidine as aforementioned.
Paul et al (2006) argued that healthcare decisions must be made by involving the patients and their family members responsible for them. Moreover, the authors remarks that the consent process must be systematic and not just a spontaneous process that take a few minutes. In line with this, I prescribed Apraclonidine 0.5% for Miss X after involving her in the process of decision-making characterized by an understanding of all the treatment alternatives and their side effects. Professionally, I was required to inform the GP who had previously handled Miss X but this was impossible because she declined to disclose her contacts.

Closing the Session

My session with Miss X was closed by a notification that she would receive a follow-up call the next day to check on her progress or any difficulty with taking the medicine. Secondly, I planned and informed her of a face-to-face follow-up meeting with me in two weeks’ time to check on how her eyes improved or not – for any necessary further treatments. By the time I was making the follow-up call, Miss X reported improved symptoms even though she had not completed her dosage.

The most interesting part of this session was how I interacted with the patient to hear her anxieties and worries – to an extent that she shared details of her previous encounter with another GP whose treatment did not yield a positive outcome. This realization may be relevant for one major reason i.e. it is only after building a good rapport that the patient becomes free to open up and express their opinion, beliefs, and fears. This concept of building a good rapport with the patient is valuable because it will guide the way I approach my consultation sessions with patients. Ultimately, this experience will be useful in my future career and in my life as a medic.

Another significant lesson that I learned during my interaction with the patient is that the explanation and planning section of the consultation model is important in any medical interview. A possible advantage of this activity is that the patient ends up convinced and comfortable with the treatment plan because they are involved in the entire process. This insight is connected to the concept of patient-centered care because it allows the patient to agree to a treatment plan upon being convinced that the plan will solve their health problem.

Last but not least, I realized that using visual methods such as written instructions to convey information is an important part of a medical interview; because the patient is able to keep the records for future reference. During my interaction with Miss X, she suggested that I should write the medical prescriptions on a piece of paper so that she could not forget. A possible meaning of this new idea is that patients sometimes can forget medical instructions and the best way to remedy this is through the use of visual aids. Having realized that, I wonder how illiterate patients or those with reading incapability (e.g. visually handicapped) can be handled. However, medical facilities should accommodate patients with all types of incapability.

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References

  • Artunay, O., Yuzbasioglu, E., Unal, M., Rasier, R., Sengul, A., & Bahcecioglu, H. (2010). Bimatoprost 0.03% Versus Brimonidine 0.2% in the Prevention of Intraocular Pressure Spike Following Neodymium:Yttrium-Aluminum-Garnet Laser Posterior Capsulotomy. Journal Of Ocular Pharmacology & Therapeutics, 26(5), 513-517.
  • Akkaya, S., Kokcen, H. K., & Atakan, T. (2015). Unilateral transient mydriasis and ptosis after botulinum toxin injection for a cosmetic procedure. Clinical Ophthalmology, 313.
  • Cohn KH (2007) developing effective communication skills. J oncology practice 3: 314-17. Ho, S. T., & Valenzuela, A. A. (2014). A deadly droop: small cell lung cancer presenting as upper eyelid ptosis. Vision Pan-America: The Pan-American Journal Of Ophthalmology, 13(2), 56-58.
  • Israel, C. W. (2018). Tips for taking the medical history in patients with syncope/Tipps fur die Anamnese bei Patienten mit Synkope. Herzschrittmachertherapie Und Elektrophysiologie, (2), 144.
  • Ishikawa, H., Son, D., Eto, M., Kitamura, K., & Kiuchi, T. (2018). Changes in patient-centered attitude and confidence in communicating with patients: a longitudinal study of resident physicians. BMC Medical Education, (1),
  • Krohn-Hansen, D., Haaskjold, E., & Nicolaissen, B. (2015). Suspension surgery with autogenous fascia lata via a less invasive modification of the Crawford method on 85 patients with congenital severe eyelid ptosis. Journal Of Plastic Surgery & Hand Surgery, 49(4), 214-219.
  • Laurenz, W., Gottfried, W., Florian, E., Rene, K., & Michaela, H. (2015). Treatment of Eyelid Ptosis due to Kearns-Sayre Syndrome Using Frontalis Suspension. Archives of Plastic Surgery, Vol 42, Iss 2, Pp 214-217 (2015), (2), 214. doi:10.5999/aps.2015.42.2.214
  • Lowth, M. (2015). History taking for the practice nurse. Practice Nurse, 45(7), 14-17. Maheshwari, R., & Maheshwari, S. (2011). Muller''s Muscle Resection for Ptosis and Relationship with Levator and Muller''s Muscle Function. Orbit, 30(3), 150-153. doi:10.3109/01676831003666447
  • Nishijima, H., Ueno, T., Suzuki, C., Baba, M., & Tomiyama, M. (2015). Eyelid ptosis enhanced after steroid pulse therapy in ocular myasthenia gravis: a case report. Neurological Sciences, (6), 1055. NMC (2015), the code professional standards of practice and behaviour for nurses and midwives on line access balba Nagaraju, Sumitha, M., Chinmayee, & Kailash, P. (2015). EVALUATION OF OUTCOME OF VARIOUS SURGICAL PROCEDURES FOR UPPER EYELID PTOSIS. Journal Of Evidence Based Medicine And Healthcare, Vol 2, Iss 9, Pp 1180 -1187 (2015), (9),
  • Paul S. Tumber, M.D., F.R.C.P.C.; Ihab Louis, M.B.B.Ch. (2006). Botulinum Toxin Type A Therapy and Human Serum Albumin, , Anesthesiology 5 2006, Vol.104, 1108. Scheinfeld, N., (2005).The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face, Dermatology Online Journal SHAILESH, P. (2018). Post-treatment advice following botulinum toxin injections: a review, Journal of AESTHETIC NURSING, 7 (5).
  • Thornbory, G. (2013). Taking a history and making a functional assessment. Occupational Health, 65(3), 27-30. Thomas, G. N., Chan, J., Sundar, G., & Amrith, S. (2017). Outcomes of levator advancement and Müller muscle-conjunctiva resection for the repair of upper eyelid ptosis. Orbit, 36(1), 39-42.
  • Wassenberg, T., Willemsen, M., Dijkman, H., Deinum, J., & Monnens, L. (2017). Congenital eyelid ptosis, decreased glomerular filtration, and orthostatic hypotension: Answers. Pediatric Nephrology, 32(7), 1171-1174. Wassenberg, T., Willemsen, M., Dijkman, H., Deinum, J., & Monnens, L. (2017). Congenital eyelid ptosis, decreased glomerular filtration, and orthostatic hypotension: Questions. Pediatric Nephrology, 32(7), 1169-1170.

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