Medicine Management

Introduction

The assignment discussed medicine management and the role of nurses concerning the topic. It highlighted the guidelines and the factors that would determine the scope of practice for the nurses in medication management. The drug aspirin was chosen for the assignment as it is widely used for the patients of acute coronary problems, stroke patients and as antiplatelet therapy. However, the daily usage of the drug is associated with several problems such as gastrointestinal bleeding, peptic ulcers, severe nausea, vomiting and rapid breathing associated problems. Therefore, the assignment discussed all the aspects of medicine management such as pharmacokinetics, pharmacodynamics, legal and ethical framework of medicine management, advantages and disadvantages of self-administration of medication and the patient group directions particularly for this drug by the nurses. The term “medicine management” describes the safe and the cost-effective application of medicines within the clinical practice which will provide the patients with maximum benefits along with the reduction of the probable harm. According to the standards for the Medicine Management (NMC, 2007), it provides the nurses with the framework for effective medicine management and safe practice. Therefore, the nurses should amend the following guidelines while prescribing the medication such as: .

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  • The nurses or the midwives should be registered to a healthcare setting or organisation
  • The medication should be prescribed within the standard course of service of the healthcare facility or organisation by the registered nurses only (BRADY, et al, 2009; Choo, et al, 2010). The major factors that are considered for determining the scope of practice of medication management by the nurses include the following:
  • The competency of the nurses involved in the process
  • The application depends upon the autonomy of practice and accountability of the nurses. Therefore, the registered nurses should have a duty of the legal liability and care to provide towards their patients (NMC, 2007).
  • The nurses should show continuous development in their profession so that they can widen their practice and can develop the ability to provide quality care to their patients.
  • The professional standard is very significant for the development of competency of the care provided to the patient in the practice of nursing. Therefore, support should be provided to the nurses to maintain these standards for safe and competent clinical practice.
  • The nurses should follow the 5 rights of delegation while providing care to patients namely: The right person; right task; right circumstances; right directions and communication and right supervision and evaluation.
  • Emergency nursing is considered to be the special field in the professional practice of nursing. It demands the prompt action regarding the care offered to the patient to prevent the long term disability or death (ABA, 2000; BRADY, et al, 2009).

The principle for Pharmacology for Nurse

When the nurses administer medication, they must follow the five rights: the right patient, right drug, right dose, right route and the right time (Deans, et al, 2005). Pharmacodynamics is the branch of science that concentrates on the molecular, biochemical and physiological effects of the concerned drug on the body and it also includes the concept of receptor binding and sensitivity, the chemical interactions and the post-receptor effects. Pharmacokinetics can be described as what the body does to a drug which also involves the movement of the drug into and throughout the body. It involves the following parameters such as the bioavailability, absorption, distribution, metabolism and excretion of the concerned drug. This should also include the beginning, duration and the intensity of the effect of the drug (Leonards, et al, 1965). Aspirin belongs to the category of nonsteroidal anti-inflammatory drug (NSAID), also known as acetylsalicylic acid (ASA) and the drug is administered for the treatment of pain, for the inhibition of platelet aggregation and fever as it has got both the antipyretic and anti-inflammatory effects. It is considered as the non-selective cyclooxygenase (COX) inhibitor. It hinders the production of prostaglandins throughout the body by the target-specific mechanism of cyclooxygenase-1 and 2 (COX-1 &2). With the application of this mechanism during inflammation, the drug alleviates the symptoms of pain. The drug aspirin gets rapidly absorbed within the body from the stomach and the intestine via the mechanism of passive diffusion. When the pH of the stomach is 1.5 and that of the small intestine is approximately 6, the aspirin gets readily absorbed within the bloodstream, stomach and intestine. Aspirin is a prodrug that gets transformed into salicylate within the stomach, intestinal mucosa, blood, and specifically within the liver. Salicylate, in turn, gets further metabolized by the liver. The plasma concentration of the salicylic acid should be maintained at very low levels to obtain the optimal level of anti-inflammatory effect along with the reduction of systemic adverse effects. The two chief pathways involved with the elimination of the salicylate involve the formation of salicyluric acid and salicyl phenolic glucuronide. These two becomes saturated at a relative low concentration within the body and eventually, the plateau level of salicylate rises constantly with the daily dosage. The peak level of the salicylate is reached within 1-2 hours of post-administration. About 50-90% of the normal concentration of salicylate binds to the protein in the plasma especially the albumin. The bioavailability of the drug is 80 -100%. After the absorption of the drug, it gets distributed to all the tissues of the body (Leonards, et al, 1965). The excretion rate of salicyclic acid rises noticeably with the increase in pH level of urine and it takes about 48 hours for the entire dose to get eliminated from the kidney via the glomerular filtration and tubular excretion pathway. The clearance rate of ASA is extremely variable and it depends on several factors. For administering to patients of renal impairment, adjustment of dosage is required. Patients with the eGFR value > 10ml/min, extended-release tablet should be administered. It has been mentioned that regular use of aspirin is not associated with increased risk of kidney disease among normal adults. Individuals suffering from chronic kidney disease (CKD) are not advised with NSAID with exception to aspirin. ASA is slightly soluble in water and remains in the fat-soluble condition

within the stomach. The half-life of aspirin in the blood circulation is 13 -19 minutes and the concentration quickly drops down after getting absorbed completely. The half-life of salicylate form lies within 3.5 -4.5 hours (Ittaman, et al, 2014; Levy, et al, 1978). Therefore based on the evidence of best practice, the nurse should prepare and administer the drug and should also retain the accountability for the administration of medicine. Double-checking is mandatory for the drugs of high alertness as the process reduces the chances of medication errors and enhances safe medication practice. Moreover, the nurses should monitor the laboratory findings and the vital signs of the patient before the administration of the drug. The drug can be administered with food or with a glass of water. This reduces medicine induced irritation. Salicylate toxicity is the associated problem that develops due to the chronic exposure and it may affect the multiple organ systems which includes the central nervous system, pulmonary and gastrointestinal system. The adverse reactions include severe bleeding, severe gastroenteritis, hepatitis, pulmonary oedema, nephritis, encephalopathy and shock symptoms on some other organs (Leonards, et al, 1965; Patrono, et al, 2003; Zimmerman, et al, 1981). The above-mentioned information should be recorded by maintaining the local health guidelines and the patient or their relatives should be educated about the usage, adverse reaction and the dosage of medication in an all-inclusive manner. The role of nurses concerning the medication management includes the information about the action mechanism of the drug, the associated adverse reactions, probable interaction of the medicines with the other drugs (impact of polypharmacy) and with the intake of food, guidelines and precautions that has to be followed regarding the route, time and method of administration of medicines, significance of adherence to the prescribed therapy and reporting and documenting after every follow-up. It is also part of the role of nurses to inform about the discontinuation of medication to the concerned clinician in case of any reported adverse effects and also if the patient refuses to take the medication (NMC, 2007; Stawicki, et al, 2009).

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The Legal and Ethical Framework for Medication Management

For prescribing the medication the guidelines of NICE and national policies of Medicine and Healthcare Product Regulatory Agency (MHRA) are followed. In 1964 MHRA and the Commissions on Human Medicines inaugurated the yellow card scheme to report any side effects of medications. Moreover, the National Reporting and Learning System (NRLS) was organised in 2010 by the National Patient Safety Agency for monitoring the aspect of patient safety in England and Wales. In the year, 2014 NHS, England and MHRA jointly issued an alert namely the Patient Safety alert improving medication error reporting and learning to improve the quality of the reported data and also to minimize the medication error. The drug aspirin should not be administered with blood-thinning agents such as clopidogrel or warfarin as this might result in bleeding problems. Consultation with the physician is advised before the administration of aspirin with medication for pain and inflammation such as prednisolone and ibuprofen. According to NIH, consultation should be made with the physician before the administration of aspirin in case of elderly and peptic ulcer patients. Moreover, updates had been observed from the legal bodies as mentioned by the Irish Medicines Board Act, Act No. 3, 2006 and Medicinal Products Regulations 2007 (SI 201 of 2007) for granting the permission to nurses concerning the prescription of medicines. According to the 2007 regulation guidelines, Personal Identification Number (PIN) should be provided within the prescription. The legal guidelines for the prescription and administration of medicine were formulated by the Medicine Act, 1968 by following the NMC code, 2007. Aspirin is an over the counter medication in the UK. The best practice guidelines by MHRA for sales regulation of the pain relief medicines should be controlled for a maximum of two packs per transaction. Training should be conducted on staff regarding the restrictions and the way of dealing with customers who want to buy more quantities of drugs. These restrictions are implemented as there is evidence that people sometimes use large quantities of medicines in an impulsive manner. Therefore, restrictions on the availability of the medication will eventually reduce the number of hospital admissions and death associated with accidental or impulsive overdose. As per law the maximum pack size of pain relief medications in the general sales outlet consist of 16 tablets. More than 32 tablets can be prescribed after consulting a pharmacist and it is considered to be illegal to sell 100 tablets of aspirin at one retail transaction. According to the UK Medicine Control Agency, aspirin use is banned under the age of 16 years because it is associated with Reye's syndrome which is a rare but fatal disorder among children and adolescents (ABA, 2000; ABA et al, 2005; Bulechek, et al, 1999; Nursing Board, 2000; Alexis, et al, 2013). The trade name of the drug is aspirin and the generic name is acetylsalicyclic acid (ASA). According to NIH, aspirin was recommended by the clinician for the cardiovascular-related disease at a low dosage on everyday basis. It is evident that the use of drug aspirin can prevent recurrent stroke or heart attack. However, recently few researches have reported that the daily use of aspirin is associated with increased risk of bleeding. In the United Kingdom, aspirin is used as a pain killer and is available as the over the counter medication. It is also used to treat the symptoms of flu and to control the fever. Therefore, aspirin was considered as the chosen drug for the present study (Leonards, et al, 1965). Aspirin can be stored at room temperature (20 C to 25 C) and in a sealed container to avoid excess heat and moisture. The medication should be kept beyond the reach of children. According to the guidelines of the UK, unnecessary medication should be returned to the chemist or pharmacy for safe disposal. It should not be flushed down the toilet and also should be disposed of into the dustbins as pets, children and other people can access the medicines and can also accidentally consume the product. Therefore, the most preferred way of disposal of medicine is through medicine take-back programme (Leonards, et al, 1965). The preferred route of administration of aspirin is via the oral route as a short-acting tablets or delayed-release tablets. However, it should also be noted that the drug aspirin should not be chewed as it increases the chances of stomach upset. For the antiplatelet therapy, 75 -100mg of aspirin is recommended after the myocardial infarction. For the acute ischaemic stroke patients, an initial 300mg dose of aspirin is administered for 2 weeks. Similarly for the patients of transient ischaemic attacks 75 -100mg of aspirin is administered as a replacement of clopidogrel. On the contrary, it is also stated that aspirin should not be administered longer than 10 days if it is self-prescribed (Ramsay, 1999). The most common associated side effects of aspirin is severe nausea, vomiting, pain in the stomach, blood with cough or vomiting, rapid breathing and seizures. The daily dose of aspirin may increase the chance of bleeding stroke, gastrointestinal bleeding and other medication-induced allergies. The nurses also have certain roles to play before the administration of aspirin. They should evaluate pyrexia and pain one hour prior to the administration of the aspirin. If the drug is applied for a long term, then nurses should monitor the functioning status of liver and kidney along with ototoxicity. The list of other medication should also be considered before the administration of aspirin as ibuprofen and other NSAIDs such as naproxen or diclofenac cannot be administered together as it may cause intestinal bleeding and ulcers (Silagy, et al, 1993; Hochain, et al, 2000; Stevenson, et al, 1996). The Patient Group Directions (PGD) is a legal structure that permits some of the registered health professionals for supplying and administering certain medications to a specified group or a predefined group of patients without the consultation of a prescriber. It is a written instruction specifying the sale, supply and administration of the concerned drug in a clinical situation. As per the guidelines of NHS, the drug aspirin 300mg can be considered within PGD in case of the emergency treatment for the chest pain in acute coronary conditions. The PGD of aspirin 300mg excluded those patients, who are sensitive to aspirin, have active bleeding problems or major bleeding disorders such as Haemophilia, had a history of acute bronchospasm due to the use of aspirin and for the pregnant patients. The drugs that are excluded from PGD include all unlicensed medications and radiopharmaceuticals (Kaufman, et al, 2010). Self-administration of medication (SAM) is described as when the individual within home care can look after their condition and can administer their medicines. The nursing staff should consider the opinion of the person regarding the choice of the medicines and also the associated risk with it. The advantage associated with SAM is that the individual can receive the new drug therapy under the supervision of nursing and pharmacy staff who will provide the necessary required information to the patients and about the ways of taking drugs before the patient is discharged from the hospital. The disadvantages associated with SAM that the pharmacists have to dispense the medicines in different bottles which is a labour-intensive task. Moreover, some patients perform incorrect diagnosis, may miss their medication or sometimes impulsively administer an overdose of medicine which may result in the associated adverse reactions. The drug aspirin is suitable for the use in SAM scheme. Therefore the nurses should educate the patients and the families about the medication, adverse reactions, the significance of dosage and adherence to strictness to prescription. Written instructions should be provided with the verbal communications and the family or carers of the patient should also participate in the SAM (Manias, et al, 2004). .

Conclusion:

The study discussed the varied aspects of medicine management by the nurses for the drug aspirin. This drug is widely used over the UK as the pain relief medication and also against fever. However, the daily dosage of this drug can result in severe health conditions so the roles of nurses concerning medicine management have been descri.

References:

Leonards, J.R. and Levy, G., 1965. Absorption and metabolism of aspirin administered in enteric-coated tablets. JAMA, 193(2), pp.99-104. NICE, M. and Prescribing, C.U., 2015. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Ittaman, S.V., VanWormer, J.J. and Rezkalla, S.H., 2014. The role of aspirin in the prevention of cardiovascular disease. Clinical medicine & research, 12(3-4), pp.147-154. Levy, G., 1978. Clinical pharmacokinetics of aspirin. Pediatrics, 62(5s), pp.867-872. Patrono, C., 2003. Aspirin resistance: definition, mechanisms and clinical read‐outs. Journal of Thrombosis and Haemostasis, 1(8), pp.1710-1713. Zimmerman, H.J., 1981. Effects of aspirin and acetaminophen on the liver. Archives of Internal Medicine, 141(3), pp.333-342. Silagy, C.A., McNeil, J.J., Donnan, G.A., Tonkin, A.M., Worsam, B. and Campion, K., 1993. Adverse effects of low‐dose aspirin in a healthy elderly population. Clinical Pharmacology & Therapeutics, 54(1), pp.84-89. Hochain, P., Capet, C. and Colin, R., 2000. Digestive complications of aspirin. La Revue de medecine interne, 21, pp.50s-59s. Ireland. Nursing Board, 2000. Scope of Nursing and Midwifery Practice Framework: April 2000. An Bord Altranais. Stevenson, D.D., Hankammer, M.A., Mathison, D.A., Christiansen, S.C. and Simon, R.A., 1996. Aspirin desensitization treatment of aspirin-sensitive patients with rhinosinusitis-asthma: long-term outcomes. Journal of allergy and clinical immunology, 98(4), pp.751-758. Stawicki, S.P. and Gerlach, A.T., 2009. Polypharmacy and medication errors: Stop, listen, look, and analyze. Opus, 12, pp.6-10.

Ramsay, L.E., Williams, B., Johnston, G.D., MacGregor, G.A., Poston, L., Potter, J.F., Poulter, N.R. and Russell, G., 1999. British Hypertension Society guidelines for hypertension management 1999: summary. Bmj, 319(7210), pp.630-635. Deans, C., 2005. Medication errors and professional practice of registered nurses. Collegian, 12(1), pp.29-33 Kaufman, G. and Fernandes, T., 2010. Developing patient group directions for medicines management. Nursing Standard (through 2013), 24(48), p.50. Manias, E., 2015. Communication relating to family members' involvement and understandings about patients' medication management in hospital. Health Expectations, 18(5), pp.850-866. Nursing and Midwifery Council (Great Britain), 2007. Standards for Medicines Management: Safeguarding the Health and Wellbeing of the Public Through Professional Standards. Nursing & Midwifery Council. ABA, A.B.A., 2005. Review of nurses and midwives in the prescribing and administration of medicinal products: final report/[An Bord Altranais, National Council for the Professional Development of Nursing and Midwifery]. -3632. BRADY, A.M., MALONE, A.M. and Fleming, S., 2009. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of nursing management, 17(6), pp.679-697. Choo, J., Hutchinson, A. and Bucknall, T., 2010. Nurses' role in medication safety. Journal of nursing management, 18(7), pp.853-861. Alexis, O. and Caldwell, J., 2013. Administration of medicines–the nurse role in ensuring patient safety. British journal of nursing, 22(1), pp.32-35.


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