According to Luker et al (1997), in 1985 the Royal College of Nursing (RCN) made a case for the prescribing rights for nurse. The Cumberledge Report (1986) acknowledged that the government recognised that nurses should be eligible to prescribe. Nurse prescribing has an important contribution to make in the service to patients and clients and the advantages were acknowledged in the Crown Report 1 (1989). Thomas (2000) informs us that in this review, it recommended that nurses with either a Health Visitor or a District Nurse qualification should be allowed to prescribe from a limited nurses prescribers’ formulary (NPF).
In 1999 following a review of prescribing, it was suggested that prescribing right extend to include other groups of nurses and healthcare professionals (Crown Report 2 1999). The government endorses this in the National Health Service Plan (NHS) (2000). With reference to clinical practice, a referral was received from the GP to assess a patient whom he had seen at home and had diagnosed a chest infection and prescribed antibiotics. Whilst assessing the patient Katherine, she complained that she had tenderness in the sacral area.
On examination the GP found she was suffering with a sacral pressure sore, but she was unsure of how long she had the pressure sore for. Katherine is a seventy two year old lady who lives with her husband and prior to feeling unwell had been fairly fit. Unfortunately a constant cough meant that her sleep was disturbed, so she had taken to resting in bed for long periods of time. Due to increased production of phlegm Katherine’s appetite had been reduced eating only minimal amounts of food.
Nutritional supplement drinks had been prescribed by her GP. European Pressure Ulcer Advisory Panel (EPUAP) (2005) advice nutritional intervention through supplements should be considered where it is not possible to enhance the patient’s own consumption of food and fluids. The importance of increased fluid intake and nutritional input were discussed, informing Katherine that due to having a exuding wound it was essential to replace the loss of fluid and proteins to ensure effective wound healing.
Following a holistic assessment of Katherine which took into account her physical, psychological and social needs, it was found that she suffered with osteoarthritis and due to staying in bed this condition was exacerbated. Osteoarthritis is a fairly common complaint that affects joints making them painful, in Katherine’s case her knees and hips were affected. (Medinfo 2004) As for most part the best treatment is keeping mobile, as Katherine had been in bed for a number of days she was now suffering with increased pain.
Normally Katherine would only suffer with a mild ache, which did not interfere in her usual activities of daily living. Following liaison with her GP, he decided to prescribe paracetamol and capsican topical cream to apply to her affected joints, which would be appropriate at this time. She normally takes paracetamol one gram when required but her GP advised her to take the same amount four to six hourly. Katherine is not on any other medication. It is acknowledged that the effects of a wound can impinge upon a patient’s psychological, social health and body image (Bentley 2001).
A pressure sore is defined by EPUAP (2005) as “an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and or a combination of these. ” It is essential that a baseline holistic nursing assessment be undertaken to identify actual and potential problems. According to the National Institute for Clinical Excellence (NICE) (2003) risk assessment should be undertaken by appropriately trained personnel and the use of risk assessment tools should only be used as an “aide memoir” (page 5) and not replace clinical judgement.
To assess Katherine’s risk the Waterlow Pressure Sore Prevention Policy (1995) was used. It was found her risk assessment score was 13 that, due to her age, acute illness, nutritional status and reduction in mobility put her at risk of further deterioration if no intervention was established. It was decided that in order to minimise the pressure in Katherine’s sacral area and other bony prominences such as the heels and elbows, a pressure-relieving mattress and cushion were needed. Further advice on the importance of moving around in bed was discussed with Katherine.
The information leaflet produced by NICE (2003) giving advice, to patients and carers on pressure relief was given to Katherine to enhance the verbal information. A full assessment of the wound should be carried out prior to selection of dressings. Any allergies should also be noted. The wound should be traced, photographed and measured providing data for comparison throughout the treatment. Consent should be gained prior to photographing the wound and the patient should not be identifiable from the photograph (Benbow 2004). All information should be documented in patients’ records, using the wound assessment tool.
The pressure sore was identified as grade two which according to EPUAP (2005) is a partial thickness skin loss and presents as either an abrasion, blister or in this case a shallow crater. On further examination it was found to have 65% slough present, 35% granulating tissue evident and was exuding moderate amounts of exudate. The surrounding skin was reddened but no signs of maceration. The pressure ulcer measured 6cm by 7cm and was 1. 5 cm deep. It was decided a dressing was required to provide a moist, warm environment to promote healing.
Most modern wound care products are designed to provide these conditions but according to the National Prescribing Centre (NPC) (1999a) choice of dressing should based on the most effective dressing for the patient but also consider cost-effectiveness. According to the NPC (1999b) writing prescriptions has an effect on the patient, the prescriber and the NHS. The process can sometimes be intricate and it is therefore important to consider all aspects before deciding to prescribe or not. The prescriber should feel fully competent when prescribing and to enable effective prescribing the use of the prescribing pyramid (NPC 1999b) is endorsed.
It advises of a seven-principle approach to help appropriate prescribing, with each step needing careful consideration before the next is reached. The first step considers the holistic needs of the patient, with the patient’s medical and social history firstly being assessed. Factors surrounding age are important. Older people are often on multiple medications therefore; prescriber needs to be aware of contraindications before prescribing. Holistic assessment can establish whether a prescription is actually necessary or could alternative treatment be considered enabling the prescriber to make fully informed decisions.
It is also important to be aware if the patient is taking any over the counter medication as they too could have detrimental effects on what the nurse is prescribing. A simple linctus was bought for Katherine but was found to have no effect on the prescription for the wound. (Nurse Prescribers’ Formulary (NPF) 2003-2005) Katherine was taking the antibiotics for her chest infection prescribed by her GP, but she had not bought anything for her pressure sore. The second step considers the appropriate strategy, which in this case was found to be a prescription for wound dressings, in order to commence the healing of the pressure sore.
Initially a wound dressing from the first dressing pack would be used, prior to prescription being collected. The third step of the prescribing pyramid (NPC 1999b) is the consideration of which product to prescribe. It looks at the effectiveness and suitability of the product whilst considering the safety and cost-effectiveness. (NPC 1999b) It was decided that an alginate would be most effective; these are indicated for moist sloughy wounds with moderate to heavy exudate, which are used in the management of pressure sores and cavity wounds. Benbow 2004) According to NPC (1999a) “alginates act via an ion exchange mechanism, absorbing serous fluid or exudate that forms a hydrophilic gel and conforms to the shape of the wound” (page 2). Alginates have also been found to be significantly easier to remove and caused less pain at dressing change. (Hollinworth and Collier 2000) Although if the exudate reduces an alginate could possibly dry, so a change in treatment would become appropriate, possibly the use of a hydrocolloid dressing such as Aquacel. (Benbow 2004) Alginates are found to be more absorbent than hydrocolloid dressings.
A prescription for Sorbsan 10cm x 10cm along with a secondary dressing Allevyn Adhesive 12. 5cm x 12. 5cm and non-woven fabric swabs to clean the wound, was issued. (NPF 2003-2005) Initially Seasorb was considered but was found to be more expensive than Sorbsan. Alginate dressings can be changed every 2 – 7 days, depending on the wound requirements. Changing the outer dressing further depends on the need of the wound, such as how effective it is in containing the exudate. Allevyn adhesive is a hydrocellular outer dressing in which exudate is absorbed into its cells. Williams and Young 1996) In addition to choosing suitable products the dose, formulation and the duration of the treatment should be considered for each individual patient. Any contraindications were taken into account. (NPC 1999b) The prescription was for a box of 10 on each product, allowing reassessment of effectiveness of the product without over prescribing. According to NPC (1999b) the nurse prescriber should provide one months’ treatment or a shorter duration if indicated. The fourth step of the prescribing pyramid considers the negotiation and concordance with the patient.
Prescribing situations can be considered as a contract between the patient and the prescriber, this being known as concordance. This is viewed as more of a positive step as it allows the patient to be central to any decision making which results in less non-compliance. (NPC 1999b) Ethical issues surrounding prescribing should be addressed, as it can be considered negligent not to inform patients regarding proposed treatment. (Nursing and Midwifery Council (NMC) 2002) This considers the patients’ understanding of what the treatment is for and any possible side effects.
The treatment was discussed with Katherine, giving her an informed choice, visits were negotiated and storage of the wound products, in a dry area away from direct sunlight, was also discussed. Contact numbers for the District Nursing Service were given to Katherine on an information leaflet, in case she had any problems, such as exudate leaking around the dressing. The fifth step discusses the importance of regular reviewing of the patient to establish whether the treatment is safe, effective and suitable.
It should be noted on the wound assessment if the dressing is to be changed by a qualified nurse or any team member, especially if the wound is fragile or complex in nature. The dressing would be changed every three days and the appropriateness of it would be reviewed at each visit. The dressing needs to be appropriate to use in the community otherwise visits will need increasing. Any side effects such as maceration around the wound would be observed. If maceration became a problem a skin barrier such as Cavilon 1ml applicator (NPF 2003-2005) would be prescribed to protect the wound edges and surrounding skin.
Sowerby (1998) reports that no more than six repeat prescriptions should be issued without the prescriber themselves reviewing the patient. According to the NMC (2002) proficient record keeping is crucial in protecting the well being of patients. In step six record keeping is examined. Details of the nurses’ prescription should be recorded in the patients’ records and a copy should be given to the GP as per local policy. (NPC 1999b) It is not professionally appropriate or acceptable to rely on the patient regarding previous prescribed items or any previous reactions that may of occurred.
The accurate recording enables all professionals to access the information required thus ensuring continuity of care and will avoid negligence in a prescribing situation. (Preece 2002) The final step of the prescribing pyramid (NPC 1999b) discusses reflection, which helps nurses to improve their prescribing knowledge and practice through using reflection when making prescribing decisions. Lowe and Hurst (2002) suggest that as more practitioners are able to prescribe, a more critical approach will be needed and assisted through reflection.
From the issues raised within this assignment it is clear that prescribing is a complex and intricate issue. Whilst reflecting on practice it could be argued that the care for Katherine was holistically assessed, health promotion and concordance being considered important attributes to ensure quality of care. The prescribing of wound products seemed applicable, cost-effective and safe whilst proving successful. Nurse prescribing is a fairly new initiative but one which is developing to meet the current climate of changing health care needs of the population.