Comprehensive OSCE Scenario

The OSCE will introduce itself with the backdrop knowledge about Chronic Obstructive Pulmonary Disease (COPD), followed by the physiological features of the disease along with the pharmacological information about the drug salbutamol. Throughout the assignment, the medication error and the propositions will be discussed in a detailed manner. Moreover, it will also focus on the role of nurses as per the guidelines of NMC concerning prescribing of medication, and thereafter a care plan of nursing will be developed for the given case-patient using the Roper Logan model.

Following the study highlights of author Wang, et al, (2014), COPD is considered a respiratory difficulty that impacts the airflow of the patient. Moreover, the study of Kochanek et al, (2019) reported that above five percent of the population suffers from COPD and it is considered as a cause for high suffering and death among the individuals. The disease is a prolonged condition that progresses with time and impacts adversely on the individual with severe health complications. The usual symptoms of complications of COPD are extreme cough along with or without mucus, shortness of breath, loss in weight, tiredness, and anorexia (Gundry, 2019). The most important pathophysiological feature of COPD is the exacerbation which should be considered as a potential sign of caution (England, N.H.S., 2014). WHO informed that smoking plays a critical role in the succession of the disease (WHO, 2020).

The airflow within the passage gets diminished extremely during the acute condition of the disease, and the causes behind this condition may be that the air passage and the little air sacs within the lungs may show a reduced amount of flexibility, the passage walls might have undergone severe forms of destruction or inflammation due to the accumulation of a lot of mucus that results in the blocking of the air passage and airflow (Gold, 2013). The pathophysiological condition is marked by the presence of conditions persistent bronchitis and emphysema. During the condition of emphysema, the minute air sacs named alveoli to get damaged thereby disrupting the flow of oxygen to the blood circulation. Moreover, during this condition, the formation of the alveoli within the lungs also being referred to as bullae gets hampered due to the destruction. Within the bullae, the replacement of gases of carbon dioxide and oxygen is changed in comparison to the normal tissues of the lungs (Wang, et al, 2016). It is evident that during the condition of chronic bronchitis the gaseous exchange gets hampered due to the inflammation of the air passage and with the accumulation of phlegm, the clogging of the passage occurs which in turn diminishes the entry of oxygen-containing air into the lungs and carbon dioxide discharged from the lungs (Wang, et al, 2016). This is the reason that breathing becomes a difficult task for the patient. Moreover, with the elevated concentration of carbon dioxide and diminished level of oxygen within the blood of the patient, the muscles involved in the process of breathing contracts much more sturdily and speedily (Gregory et al, 2019). The neuro signaling process involved in the process is that the signals are transmitted to the brain of the present condition of the patient and resultant the patient feels a shortage of breath.

The study findings of the author Ullmann et al, (2015) highlighted the success of utilization of oxygen treatment along with the administration of β2 agonists for the treatment management of COPD. As per the suggestions of the Lung Institute, (2016) the following bronchodilators medications for instance the vilanterol, salbutamol, salmeterol, and formoterol, anticholinergics, for example, glycopyrronium, aclidinium, ipratropium and tiotropium, and theophylline should be administered. Anticholinergics and the β2 agonist are available in both the rapid and extended acting medication whereas the theophylline is only available in the extended-release form (Kaufman, 2013). Moreover, the β2 agonist class of medications is administered both in the cases of COPD and asthma, although a few forms of medications are available only for the cases of COPD. This class of medication shows their function within the muscle which lines up the air passage by acting like the β2 receptors that cause the air passage to enlarge (Louie, et al, 2012).

The drug Salbutamol is a β2 receptor agonist and short action medication that is employed for the healing of both asthma and COPD patients. This particular drug shows several times more specificity for the β2 adrenergic receptor in comparison to the β1 adrenergic receptor which is present at the muscles of the heart (Kerstjens, et al, 2015). The drug salbutamol is formulated as the amalgamation of the isomeric forms S and R. The isomer R shows several times more affinity towards the β2 receptor in comparison to the S – isomer. Moreover, the S – isomeric form is considered to be harmful for health (Chong, 2003). This problem led to the formulation of the form levalbuterol which is composed of the only R isomeric form of the drug salbutamol. However, it must be noted that the extreme cost of the drug levalbuterol in comparison to the drug salbutamol hindered the broad usage of this unmodified isomeric form of the drug (Barisione, et al, 2010). The drug salbutamol is administered during the emergency of bronchospasm that gets augmented at the times of bronchial asthma, persistent bronchitis, and other related prolonged bronchopulmonary syndromes such as COPD. Moreover, it is also administered as prophylactic medication during the emergency condition of asthma (NHS 2018). The drug salbutamol provides comfort after administration during the emergency of COPD and asthma such as at the time of coughing and panting due to a shortage of breath. The action mechanism of the drug involves the expanding of the muscles of air passage to the lungs that result in the calming down of the process of inhalation and exhalation. The drug salbutamol is available in the form of the inhaler (puffer) which is usually blue in color (Ullmann et al, 2015). Patients who are suffering from the extreme forms of asthma and COPD are prescribed with drug salbutamol puffer. Puffer is a device that offers the medicine in the form of mist with the aid of a mask or a mouthpiece. The medicine salbutamol is also available in varied other forms such as syrup tablets, and capsules that are prescribed for those patients who are unable to use the inhaler appropriately (Yamanishi, 2003).

However, similar to the other drugs, medicine salbutamol also has certain associated adverse reactions but it is considered to be secure and effectual for the patients when administered in the prescribed form. The inhaler salbutamol is categorized as the "reliever" medication as they offer rapid improvement from the breathing difficulty state. The associated usual adverse reactions are cramps in the muscles, pain in the head, anxiety, and shaky feelings that demands the examination of the pulse rate (Drug bank, 2020).

In the following part of the assignment, the job functioning of the nurses will be discussed concerning prescription. In accordance with the guidelines formulated by the NMC code, 2018 the prescriber healthcare professional should at first need to successfully qualify the necessary course before prescribing. It is considered to be extremely demanding for the prescriber healthcare professional to be conversant about the health details of the patients, must possess the required knowledge to prescribe, to give suggestions, and should be able to administer medications. There are 5 steps in association with the process of prescription of medication for instances: recommend, transcribe, validate, administration, and transport along with supervision and detailing.

The dynamic association of healthcare professionals while prescribing drugs has demonstrated to achieve persistent access and continue with the process of perfect therapy as per the research background (Manojlovich, 2007; Fleming et al 2014). Healthcare professionals such as nurses have a cozy understanding relationship with the patients in comparison to the specialists because nurses spend maximum part of the time with patients and offer quality care services to them in terms of monitoring and even approaches to the physicians at the time of requirements. During these times give and take of the information occurs between the clinicians and the nurses and more quality services are offered by the nurses in terms of monitoring and appraisal. This teamwork between the nurses and the physicians allows more detailing of the knowledge and technical skills which have a strong influence over the care services offered to the patients in synergy (Nelson, 2008). It is also evident that a potentially skilled nurse also has a job functioning in the diagnosis and accurate therapy of the patients (Hornor, 2007). The nurses also have a pivotal role during the follow-up treatment of the patients. However, this progress occurs with the required clinical appraisal for the evaluation of the associated negative outcomes (Mahlknecht et al, 2017).

The patients are advised with necessary medicines by the nurses and also supervise their impact upon the patient following the drug administration which is considered a pivotal role of the nurses (Edwards et al 2011; Castleldine, 2006). Moreover, the development of policies, regulations, and recording within documents are considered within the functioning part of the nurses concerning drug usage. Therefore the nurses have an immense role to play along with the clinicians for the multidisciplinary management of the medication within the setting of healthcare to improve the offered quality of the treatment (Guy et al 2003). However, it should be also mentioned that their role should not be exaggerated concerning about their correspondence with the physicians for prescribing drugs in certain situations where the prescriptions are not clear enough, their role while dealing with the errors in the prescription and supervising the patients following the administering of drugs for the identification of any adverse drug reactions. Therefore, it is very much clear that nurses have an central role in the recognition of errors within the prescription and proper management of those errors by working as a team with the physicians while offering their day to daycare service to their patients. In the literature background section, the maximum part of the functioning of the nurses concerning prescribing and dealing with drug errors have been discussed. Moreover, also according to the study highlights of Lim et al, 2014, physicians are also dependent on the nurses for the identification of medication errors and also to offer valuable information while prescribing medications. As per the definition proposed by the NCCMERP (2020), the drug error is considered to be any negative outcome that might have resulted due to the wrong usage of the medicines while it is still in the ownership of a healthcare professional for instance the physicians, nurses, and pharmacists. It is also evident that there can be varied factors which can contribute to drug errors such as mistakes during the professional rehearsal, errors at the time of prescription, due to improper packaging or labeling of the products, errors at the time of administration of medication, due to poor knowledge about medicines and improper monitoring of the adverse drug reactions (due to lack of proper supervision by the nurses of the patients following the administration of drugs) (Ferner 2006). There are seven rights of medicine prescription that offers safe prescribing by the nurses and avoid drug errors such as:

These rights help the nurses to provide the correct medicines to the patients. Concerning this, there are varied errors in the prescription or drug chart of the case-patient Mr. Smith. However, as per the highlights of Edwards et al 2018, maximum numbers of drug errors are due to the worse process of prescribing now and then, and most frequently these errors are performed by the inexpert healthcare staffs who are involved within the maximum part of the prescribing process at the hospital. Ibuprofen and ramipril were the drugs that were prescribed for Mr. Smith and as per the guidelines of NICE (2020) the administration of both these drugs results in the development (risk factors) of hyperkalaemia. In addition to this, as per the information available from the study of Hassan, et al, 2009, the amalgamation of the ramipril and ibuprofen might diminish the impact of drug ramipril that is prescribed to keep the blood pressure of the patients in control. Moreover, the prolonged use of these medications also impacts the functioning of the kidney of the patients and other negative outcomes on health. Therefore, it is advised that nurses should involve the multidisciplinary team (MDT) into action for the treatment of this patient.

As per the case patient's condition, the drug salbutamol should be administered when it is necessary (PRN), but on the contrary, the prescription indicated it to be as once only used medication and the year was also not found to be mentioned there which is considered to be an error within the prescription. There was also an error in the spelling noticed in the name of the drug salbutamol as "salbutamel''. However, it should be noted that the study findings of Edwards (2020) highlighted that these types of errors in prescribing can be diminished with the aid of the electronic category of prescribing that in turn diminishes the chances of any errors due to incorrigible handwriting. In addition to these the other errors that were noticed within the prescription are the presence of varied signatures for the administration of ibuprofen, no date of initiation was stated for the medication lactulose and mentioned with improper units, the hospital number appeared to be different and there was no prescription of the medicine tiotropium.

Calculation of IV fluid

One liter of intravenous fluid (IV) comprising of 0.9% of normal saline for more than 8 hours was administered to the patient, Mr. Smith, and the formula that was used for the calculation of fluid administration was –

IV volume (ml) / Time (Min) = Drop Factor.

Therefore the calculation would be 1 litre of normal saline administered for 8 hours

1litre = (1000) - 1000 divide by 8 hrs = 125 Drop Factor

As the disease is reported to have no cure treatment, therefore nurses must have a proper management guideline that could uplift the quality of life of the patients (Gundry, 2019). Therefore, the theory of Roper Logan had been utilized to explain the functioning of the nurses. This particular model was selected as it offers the patients with appropriate guidance to attain the comparative autonomy for the routine day to day activities (Roper et al 2003).

Among the 12 activities of the daily living of the model, 3 will be discussed for the case patient, Mr. Smith: breathing, correspondence, and elimination.

Breathing

Exacerbation in a COPD patient is considered to be a warning sign according to NICE, 2019 guidelines. It is considered to be the acute phase and the related symptoms are cough, dyspnoea, and enhanced production of the sputum (NHS, 2019). Mr. Smith also demonstrated the signs of dyspnoea and a diminished level of tolerance. He was utilizing his accessory muscles for breathing. The utilization of the accessory muscles for breathing was evaluated by the nurses and it indicated the extreme form of respiratory compromise that demanded early intervention. Due to this, a chart will be maintained for the supervision of the rhythm of the breathing, and the drug salbutamol had been prescribed via the nebulizer. Moreover, as per the guidelines of NICE, 2018 short-acting β2 receptor agonist (SABA) like salbutamol can be used to manage the symptoms of breathing difficulty whereas the long-acting β2 agonist (LABA) can be used for the in-progress therapy of the disease. Moreover, the drug salbutamol may eventually result in tachycardia, cramps in muscles and headaches so following the administration of the medicine to Mr. Smith nurses will monitor him concerning any adverse reactions and documentation will be maintained along with any alternative medicine in the presence of any negative outcome (NICE, 2018). Moreover, it is also recommended to prescribe antibiotics at the time of exacerbation in case of any suspected infection. As Mr. Smith was observed to be peripherally cyanosed therefore supplemental oxygen therapy will be offered and the blood examination of arterial blood gas shall be conducted. The other necessary detailing like the device category for oxygen supply, flow rate, respiratory exertion, the sound of breath, color of skin, and the psychological condition of the patient will be recorded. The patient will be checked after every one hour of interim.

Communication

As per the job functioning of the nurses they need to correspond effectively with the patient to comprehend the pre-medical background. As Mr. Smith was facing difficulty while speaking therefore communication was carried on with his relatives and related information about smoking, any past infections were documented. The pain scale will be used to measure the level of torment and suitable action will be taken. Informed consent was obtained from Mr. Smith prior to any procedures, and he was reassured about the treatment procedures as anxiety may further hamper his health condition. As per the recommendations of NICE, 2018 the significance of smoking abstinence for the quality improvement of life of COPD patients will be discussed with Mr. Smith and his relatives. As he had already stopped smoking so a persistent boosting will be offered to him to maintain the healthy habit. At the time of discharge, Mr. Smith will be educated about the signs of exacerbations and the potential triggers during which he should return to the hospital. He will be educated about the pulmonary rehabilitation on his follow up treatment session, as per the recommendations of NICE, 2016 for the COPD patients to improve the physical activity tolerance, signs and to reduce the psychological distress (Gundry, 2019).

Eliminating

Mr. Smith was found to be constipated which might be due to reduced intake of fluid and diet and also due to medication side effects. At the initial steps, the normal bowel and bladder symptoms will be evaluated to diagnose any problems. In this regard, it should be mentioned that the fluid administration chart assists in comprehending the intake pattern of fluid, the pattern of diet along with the bowel and urine output of the patients (Black, 2019).

Therefore, a fluid chart will be maintained for Mr. Smith along with the other required changes in the lifestyle and nutritional patterns. Varied medicines such as lactulose and other related medications will also be suggested.

Conclusion

As per the records of the British Lung Foundation, 2020 around 115000 individuals are diagnosed with COPD every year. NICE has already recommended the clinical advice for nurses and physicians to manage COPD patients. It is expected that nurses will offer evidence-based care based on a holistic approach and so the Roper- Logan Model has been utilized for nursing care. As per the NMC code, 2018 the safety of patients will be ensured by avoiding any kind of medication error while prescribing. Moreover, all the details will be appropriately documented along with the action prompted as per the guidelines of NMC code, 2018.

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