Prescribing Episode Case Study

This essay will look at a patient that was seen in a Forensic adult medium secure inpatient Services setting by a mental health nurse under an independent prescribing setting. It will look at an overview of the patient, her presenting symptoms, a brief assessment and the decision to prescribe. The Essay will also look at the rationale for choosing this particular medicine and other options that could have been used instead. The essay will go on to analyse the evidence provided for the use of the product, and its suitability. It will go on to discuss the role of the non-medical prescriber and the professional body that governs them, their responsibilities as a prescriber and accountability to their patients and the public as a whole. The essay will have a brief overview of clinical governance, the fundamental pillars that form the bases of its processes, and it will especially explore staff training and the importance of this in the role of a non-medical prescriber.

The care provider is a mental health nurse working in Forensic adult medium secure inpatient Services setting and has the ability to prescribe medicines. The professional role of a mental health nurse typically includes making relationships with patients by comforting them and listening to them patiently, fighting with any stigma and helping the families of the patients to deal with it, monitoring and reviewing the care plan and assessing the progress along with it, prescribing medications, providing advice and support for the patient and their families, cheering the patient to take part in therapeutic activities, writing and keeping the patient record up to date and visiting the patient at their home. The role of the author allows her to build up a long-standing relationship with the patient and their families which help to manage their conditions by bringing certain changes in their total well being (Roberts, 1998).

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Clinical Manifestations and Background history of the patient: An evidence-based and critical justification of the chosen products:

Tom is a 57-year old male, detained in an adult medium secure inpatient rehabilitation ward, on assessment and treatment under section 37/41 of the 1983/2007 Mental Health Act. He has been an inpatient for eighteen months with a diagnosis of Paranoid Schizophrenia in the year 2001. He worked as a taxi-driver, divorced, lived alone in a council flat and had no pets. He is a heavy smoker, with known history of alcohol and illicit substance use. The subject complained about chest pain and generic Symptom assessment tool – OLDCART was used to assess the event:

Onset- first noticed three months ago, thought it was indigestion more pain noticed last week.

Location -in the middle of chest, radiating to the left arm.

Duration - the pain usually lasts twenty to thirty minutes, but disappears when relaxing.

Characteristics - Pain is described as tightening chest. The pain is not associated with shortness of breath, no recent fever, cough, or infectious symptoms.

Aggravating factors - seems to come when exercising, when present, the pain is worsened by moving about.

Relieving factors – resting and the treatment he was subjected for the last time when he got the pain, and took an Aspirin, which he believed had helped.

The patient had a past medical history of hypertension diagnosed in the year 2008, gastroesophageal reflux disease (GERD) in the year 2010. After analysing the vital signs of the patient the following observations were noted:

Respiratory Rate- 25 rpm

Blood Pressure- 153/96 mm/hg

Heart Rate- 104 bpm

Temperature- 36.5°C

SATS- 90%

Capillary Refill Time (CRT) – delayed.

The patient was advised with the following examinations:

Exercise ECG - to detect acute and/or chronic ischemia.

Pulse Oximetry – to confirm normal oxygenation

Full blood count results - Troponin, Creatine Kinase, CK-MB (MB isoenzyme of creatine kinase), Cardiac Biomarkers

Chest X-Ray

CT coronary angiography.

The following assessments were made:

Cardiovascular system (CVS) is normal except, radial pulse of 104 bpm

Palpation and Auscultation of heart - felt for the apex beat (5th ICS, MCL), no added heart sounds; murmurs or rub

Abdominal assessment -no concerns

Respiratory assessment - no concerns

The differential diagnosis of the patient revealed the symptoms of Angina Pectoris according to the mentioned guidelines of NICE clinical guideline 95 for chest pain of recent onset and NICE clinical guideline 94 for unstable angina and NSTEMI (Smeeth, et al, 2010; Harker, et al, 2014). The chest discomfort or pain occurs due to the reduction in the blood flow to the coronary heart muscle and it is an indication of coronary heart disease. It happens mainly due to the deposition of fat inside the coronary arteries causing restricted blood flow. The symptomatic signs are chest pain usually described as squeezing pressure or tightness along with discomfort occurring in the neck, shoulder, back and jaw region, shortness of breath, sweating, dizziness and nausea. The risk factors include smoking (the patient has excessive smoking habit), high cholesterol level, overweight and reduced physical activity. Restrictions are there regarding drinking of alcohol (the patient has drinking habits), smoking, increased dietary intake of fat. Medications are prescribed if the lifestyle changes do not improve the condition of angina (Prinzmetal, et al, 1959). The medications that are prescribed in this condition are commonly referred as nitrates such as Glyceryl trinitrate spray (Short acting nitrates), nitrate skin patches and nitrate tablets (long acting nitrates). The patient was prescribed with Glyceryl trinitrate spray (droplets are sprayed beneath the tongue and are quickly absorbed from mouth into the blood stream) which provides immediate relief. The prescribed dosage is GTN 400 micrograms per metered dose; sublingual spray. He was also prescribed with Aspirin 75mg to prevent the symptoms of angina pectoris, heart attacks, stroke and chest pain following the guidelines of NICE clinical guideline 94 and 95 which mentioned about the drugs treating the episodes of angina and secondary prevention of cardiovascular disease (Csont, et al, 2005; Smeeth, et al, 2010; Harker, et al, 2014) . The patient reported to have aspirin in the past and the medicine alleviated the symptoms of the chest pain. The significant medications which the patient was in taking for the mental health disorder are Zuclopenthixol 400mg depot, intramuscular (IM), anti- psychotic, weekly, for maintenance treatment of schizophrenia and paranoid psychoses. To treat the condition of high blood pressure, lisinopril 10 mg tablet, oral once a day is advised. Omeprazole 20 mg Capsules, oral, once daily for the treatment of symptomatic gastroesophageal reflux disease (GERD). Amlodipine 5mg prn, oral is administered for the treatment of symptoms of pulmonary arterial hypertension (PAH). The other medicines such as Paracetamol 1g tablets, oral, up to 4mg daily for pain relief and Peptac 10mls, oral solution, upto 40mls daily for indigestion problems can be taken if required.

Key pharmacology of prescribed medication:

Glyceryl Trinitrate is considered to be a vasodilating agent. It is a vasodilator which operates directly, when administered in small doses, the pressure while loading the ventriauricular chamber gets reduced (preload) and when administered in high doses the systemic vascular resistance gets reduced (afterload). But the simultaneous action of these two events results in an increased cardiac output among infants along with failure of heart. It also reduces pulmonary vascular resistance. The pharmacological action of the medicine occurs via relaxation of the smooth vascular muscle which results in dilation of both the arterial and venous blood in a dose dependent manner. It causes dilation of the post capillary channels, large veins, thereby enhancing the pooling of blood in the peripheral system and diminishes the venous return to the heart as a result the ventricular pressure (left) and the diastolic pressure gets reduced. Due to the effects of Gylceryl Trinitrate on both arterial and venous channels the consumption of myocardial oxygen gets shortened.

The factors which manipulate the results of plasma concentrations of Gylceryl Trinitrate are the speedy metabolism of the compound in blood in- vitro conditions, due to adsorption of the compound to the infusion sets and containers and due to the metabolism of the drug in the vessel walls. The half life of the drug in the plasma level is of two to three minutes nad the value of plasma clearance vary in between 216 to 3270 L/h, which highlights about the extensive non-haepatic metabolism. The drug is administered transdermally via controlled transdermal delivery system and the concentration of the medicine in the plasma level can be maintained for about 24 hours though it varies widely among individuals (Bogaert, 1987).

Aspirin which is scientifically known as Acetylsalicylic acid acts by inhibiting platelets via irreversible acetylation of the serine residue of cyclooxygenase-1 (COX-1) and in turn reducing the level of prothrombotic thromboxane A2 (TxA2). Therefore it is also known as antithrombotic agent. Aspirin gets adsorbed very rapidly from the gastrointestinal tract when taken in the solution form and gets absorbed much slowly when administered in the form of tablets. After going inside the body the aspirin breaks down rapidly to salicylic acid and the concentration of this product has to be maintained within a narrow range relatively to maintain a satisfactory anti-inflammatory effect and also minimizes the systemic adverse effects. The two most important pathways employed for the elimination of salicylate are: synthesis of compounds such as salicyluric acid and salicyl phenolic glucuronide which saturates at relatively low concentrations level of the drug in our body. Therefore, the plateau or the steady state of salicylate levels rises in a proportionate manner with the increase in concentration of the daily dose. The increase in the pH level of the urine indicates about the renal clearance of salicyclic acid (Prüller, et al, 2018; Siller-Matula, et al, 2013; Siller‐Matula, et al, 2010).

Potential Adverse Drug Reactions:

The adverse effects of the drug GNT are: tachycardia, Headache, nausea, restlessness, twitching of muscle, abdominal pain, drug rash or exfoliative dermatitis, methaemoglobinaemia, Hypertension and other Withdrawal syndrome such as increased number of attacks of angina, cyanosis, lightheadedness and anaphylaxis. The adverse reactions observed due to aspirin are: swelling of the tissues of the skin, increased risk of cerebral bleeding, increased level of potassium in the blood, Blood and lymphatic system disorders - increased bleeding tendencies and gastrointestinal disorders (James, 2011; Saloheimo, et al, 2006; Vernooij, et al, 2009 ) .

Consultation Model used:

The case was analysed critically using the Pendleton model (1984) of consultation. This model helps trainers to give objective feedback to their students. The model is based on the idea that while giving any feedback the students and teachers should focus on the positive aspects first and then should think about the other better options to improve the situation. This particular model choose an appropriate action for each problem and also considers the other problems associated, it engages the patient in the management of the problem and encourages to take the accurate responsibility, most importantly the time and other resources gets utilized appropriately and builds up a relationship or rapport with the patient which helps to manage the tasks very easily. The model is also appropriate for patients with complex health care needs such as in rehabilitation setting. Using this model of consultation, the patient presented his entire problem during the session of medical interview. The model works on the principle of joint decision between the patient and clinician and in this case all the detailed history of the patient were recorded and an informed consent was obtained for the treatment of the above patient. For this consultation model to work, the nurse practitioner should build a rapport with the patient as in above case to understand the beliefs and expectation of the patient. All the clinical problems of the above patient were individually analysed and considered individually for the treatment purpose such as angina pectoris and about his mental health conditions. Informed consent was taken to present the above episode as an example of practice and to maintain the confidentiality, the details of the patient such as the name and place all have been anonymised (NMC , 2018).

After critically analysing the past medical and background history (both the psychological and socioeconomic status) of the patient and analysing the present condition the medications have been prescribed following the NICE guidelines (Smeeth, et al, 2010; Harker, et al, 2014). As a part of this model all the risk factors aggravating the health problems of the patient were also considered by the clinicians and the patient was involved to take the responsibility for the management of the diseased condition. The patient was informed about his conditions and also about the prescribed medications. Admission assessment and focused assessment was performed by the nurse to provide care to the patient (Baid, 2016; Bickley, 2009). Regular follow up of the patient symptoms assessed the progressing / worsening condition of the patient and review of the medications provided should be done every fortnight during the ward rounds are advised for the patient care. The patient was advised to make some changes in the lifestyle such as cessation of smoking and drinking alcohol and the use of illicit substances were restricted to control the risks factors of angina pectoris. He was also advised to take proper dietary intake to reduce the cholesterol level of the blood. The non medical prescriber performed personal vigilance and care to avoid medication errors which includes wrong drugs, route and frequency. Errors due to the lack of communication with the patient and poor monitoring were also taken into consideration for the concerned patient. It is expected that a registered nurse should offer high level of professionalism and when the nurse is also performing the role of a prescriber their accountability in terms of professionalism, transparency and their frankness must be entrenched into the clinical practice to establish the increased responsibility towards public care and protection. The other aspects related to legal, ethical and professional matters have to be considered for prescribing (Nuttall, et al 2015). The professional bodies are governed by various ethical bodies such as by the ethical principles of Beauchamp and Childress and Respect for Autonomy. As per the policy of the local and national guidelines, the nurse prescriber should prescribe the medicine to the patient in presence of a designated medical practitioner after the detailed records of the medical interview and shared understanding. The trained nurse should be registered with the Nursing and Midwifery Council, and all the legal, professional and ethical matters has to be considered for providing effective care and protection to the concerned patient. Clinical governance is the initiative by the government for providing excellent quality health care and service to the patient and also augments the integration between the social workers and the health care partners. The following aspects are taken into consideration by the NHS inaspect of clinical governance performance review of the quality issues I, the aspect of the clinical risk management III, clinical auditing II, the aspect of quality assurance IV, clinical effectiveness V, the development of the staff and the organisation (NHS Executive 1999). The following learning outcomes were addressed after critically analysing the case study using the above model were based on two aspects: for the prescribing aspect the detailed pharmacological analysis and the prescribing knowledge has to be applied to ensure safe practice and the other aspect is the effective implementation of the intellectual, practical, affective and transferable skills based on the above mentioned consultation model.

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References:

Baid, H., 2006. Patient assessment. The process of conducting a physical assessment: a nursing perspective. British Journal Of Nursing, 15(13), 710-714.

behaviour for nurses, midwives and nursing associates. London: NMC Publications.

Bickley, L. S., Szilagyi, P. G., & Bates, B., 2009. Bates' guide to physical examination and history taking (10th ed.): Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins,

Bogaert, M.G., 1987. Clinical pharmacokinetics of glyceryl trinitrate following the use of systemic and topical preparations. Clinical pharmacokinetics, 12(1), pp.1-11.

Csont, T. and Ferdinandy, P., 2005. Cardioprotective effects of glyceryl trinitrate: beyond vascular nitrate tolerance. Pharmacology & therapeutics, 105(1), pp.57-68.

Harker, M., Carville, S., Henderson, R., Gray, H. and Guideline Development Group, 2014.

Key recommendations and evidence from the NICE guideline for the acute management of ST-segment-elevation myocardial infarction. Heart, 100(7), pp.536-543.

James, B. and Bron, A., 2011. Australian injectable drugs handbook.

Nursing and Midwifery Council (2015). The Code: Professional standards of practice and

Nursing and Midwifery Council, 2018. The NMC register.

Nuttall, D. and Rutt-Howard, J. (2015). The textbook of non-medical prescribing. 2nd ed.

Pendleton, D., 1984. The consultation: an approach to learning and teaching (No. 6). Oxford University Press.

Prinzmetal, M., Kennamer, R., Merliss, R., Wada, T. and Bor, N., 1959. Angina pectoris I. A variant form of angina pectoris: preliminary report. The American journal of medicine, 27(3), pp.375-388.

Prüller, F., Milke, O.L., Bis, L., Fruhwald, F., Scherr, D., Eller, P., Pätzold, S., Altmanninger-Sock, S., Rainer, P., Siller-Matula, J. and von Lewinski, D., 2018. Impaired aspirin-mediated platelet function inhibition in resuscitated patients with acute myocardial infarction treated with therapeutic hypothermia: a prospective, observational, non-randomized single-centre study. Annals of intensive care, 8(1), p.28.

Roberts, D., 1998. Nurses' perceptions of the role of liaison mental health nurse. Nursing times, 94(43), pp.56-57.

Saloheimo, P., Ahonen, M., Juvela, S., Pyhtinen, J., Savolainen, E.R. and Hillbom, M., 2006. Regular aspirin-use preceding the onset of primary intracerebral hemorrhage is an independent predictor for death. Stroke, 37(1), pp.129-133.

Siller-Matula, J.M., Delle-Karth, G., Christ, G., Neunteufl, T., Maurer, G., Huber, K., Tolios, A., Drucker, C. and Jilma, B., 2013. Dual non-responsiveness to antiplatelet treatment is a stronger predictor of cardiac adverse events than isolated non-responsiveness to clopidogrel or aspirin. International journal of cardiology, 167(2), pp.430-435.

Siller‐Matula, J.M., Krumphuber, J. and Jilma, B., 2010. Pharmacokinetic, pharmacodynamic and clinical profile of novel antiplatelet drugs targeting vascular diseases. British journal of pharmacology, 159(3), pp.502-517.

Smeeth, L., Skinner, J.S., Ashcroft, J., Hemingway, H. and Timmis, A., 2010. NICE clinical guideline: chest pain of recent onset. Br J Gen Pract, 60(577), pp.607-610.

Vernooij, M.W., Haag, M.D., van der Lugt, A., Hofman, A., Krestin, G.P., Stricker, B.H. and Breteler, M.M., 2009. Use of antithrombotic drugs and the presence of cerebral microbleeds: the Rotterdam Scan Study. Archives of neurology, 66(6), pp.714-720.

Wiley-Blackwell.

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