Neighbourhood Nursing Essays

Neighbourhood Nursing Essays Neighbourhood Nursing Essay Neighbourhood Nursing Essay The ethos of a report by Cumberledge, Neighbourhood Nursing A Focus for Care (DOH, 1986), was to introduce nurse prescribing from a limited formulary to improve the care of patients in their own homes, and it identified that district nurses wasted valuable time requesting prescriptions from general practitioners (GPs) when they had seen and assessed the patient themselves with no medical involvement (Baird, 2003). Nurses as prescribers need to be aware of the influences on prescribing and the need for bias to be controlled in the information sources that they use, as patients receiving prescriptions from nurse prescribers will assume the product prescribed is safe and appropriate for them (Parker, 2000). In order to demonstrate the principles of safe, effective, appropriate and cost-efficient prescribing, the author will analyse the critical incident described in Appendix 1, and using the prescribing pyramid (NPC, 1999) to assist decision-making, explore the most appropriate course of action in terms of treatment. Consider the Patient Before prescribing, a thorough assessment of the patients medical and social history should be taken (NPC, 1999). A leg ulcer has been defined as the loss of skin below the knee, which takes more than six weeks to heal (Dale et al, 1983). Mr X had injured his leg six weeks prior to his referral to the DNs, therefore a leg ulcer assessment was conducted that incorporated a Doppler ultrasound, assessment of previous medical history and assessment of the limb and wound to determine the underlying cause of the ulcer and any associated diseases. This assessment will influence decisions about prognosis, referral, investigation and management (RCN, 1998). Lack of appropriate clinical assessment of patients with limb ulceration has often led to long periods of ineffective or inappropriate treatment (Stevens et al, 1997). The Doppler ultrasound revealed an ankle-brachial pressure index (ABPI) of 1.1 and 1.0 in the left. This gave an indication that Mr X had a vascular problem rather than arterial. The wound bed was sloughy, with slight inflammation around the edge, indicating a localised infection, which could delay healing; the wound was also malodorous again indicating infection was present. Chronic venous insufficiency of the lower extremities is a complicated disorder, affecting the productivity and wellbeing of millions of people worldwide (Donaldson, 2000; de Araujo et al, 2003). It is also a major cause of morbidity among patients in hospital and community settings (Nelson, 2001) Venous disease is the most common cause of leg ulcers. Identification of the risks of venous ulceration is important, as is optimal therapy, which requires control of abnormal venous physiology combined with adjunctive treatments to correct secondary skin ulceration, infection and lymphoedema (Donaldson, 2000). Which Strategy? Having established that the reason the ulcer was not showing signs of healing was due to venous insufficiency to the affected limbs and a localised infection to the wounds, the options for treatment needed to be considered. Liaison with his GP was essential to discuss pain management strategies with Mr X to control any pain he was suffering along with any anti-biotic therapy regarding the localized infection. However, the role of bacteria in chronic ulcers is a matter of debate and many authors have contradictory views regarding the use of antibiotic therapy (Tammelin et al, 1998). Within the local trust, guidelines suggest that if the patient is not showing signs of clinical infection such as pyrexia, friable, bleeding granulation tissue or cellulitis, antibiotics are not indicated. Furthermore, routine swabbing is not recommended as this is thought to be neither helpful nor cost-effective (Gilchrist, 2002). All chronic wounds contain bacteria and often represent either secondary colonisation or merely contamination, therefore not actually causing clinical infection (Morison et al, 1999). Consider the Choice of Product Short-stretch compression bandaging has been shown to be equally efficacious when compared to other compression systems in healing venous ulcers independent of associated factors (Scriven et al, 1998; Nelson, 1996; Vowden, 1998). This has directed a trend towards the use of short-stretch bandaging as a cost-effective and proven method of reversing venous hypertension and enhancing the wound repair process in some patients (Charles, 1998). Short-stretch compression bandages are fairly inelastic because the weave allows for minimal stretch and recoil (Charles, 1998). When applied to a leg at 90-100% stretch with a 50% overlap the inelastic nature of the bandage allows it to form a firm tube. When the muscle of the calf contracts, it reflects or rebounds from the wall of the tube, which increases the action of the calf muscle pump, thereby promoting venous return to the heart. It also has an effect on the microcirculation with an overall improvement in the function of the skin (Klyscz et al, 1997; Coleridge-Smith, 1997). The combination of increased calf muscle pump activity and an improved microcirculation as a result of short-stretch compression therapy therefore has the potential to correct venous incompetence and promote healing in venous disease. Non-compliance is a recognised problem in the use of compression therapy (Mayberry et al, 1991; Taylor, 1992). There are a number of reasons why this is the case, including factors such as forgetting instructions, difficulty managing the bandages and discomfort caused by the bandages for example, finding them too hot (Samson and Showalter, 1996). Mr X had experienced leg ulcer in the past and had not felt happy with four layer bandaging as he had complained of them making his legs too hot and also they felt bulky. Negotiate a Contract To ensure concordance it is important that the patient plays a central role in the decision-making process (NPC, 1999). If the patient is not consulted and does not understand the rationale for dressing choice, compliance with the treatment may be affected (Cole, 2004). A nurse prescriber has to balance dressing cost with nursing time, together with patient acceptability and concordance (Edwards, 2000). Mr X had experience of other wound care products used on his leg in the past, and had strong opinions about which ones he was willing to accept the use of. It is important to be aware of influences that may affect the way treatments are prescribed however, such as patient pressure or drug companies promotional advertising (Brew, 1994). Autonomy is grounded in respect for patients ability to choose, decide and take responsibility for their own lives (Randers and Mattiasson, 2004), but had his decisions been inappropriate, unsafe or not based on best evidence, agreeing to prescribe them could be deemed maleficent (Pridmore, 1998). Providing information on the benefits of the treatment proposed, in addition to the drawbacks enabled him to make an informed choice. Ultimately, negotiation ensures that the patient receives the most appropriate evidence-based care, which is safe, and which he agrees on. Review the Patient Twice weekly visits were agreed with Mr X to monitor the effectiveness of the bandaging and ensure that it was not causing a reaction, was helping to debride the slough, reduce the localised infection and absorb the exudate. Mr X was informed of the signs of an adverse reaction to the dressing, such as itching, increased localised pain and irritation at the site of the dressing, and advised to ring the DN if at all concerned. If the dressing used caused a reaction to Mr Xs leg and it was not picked up soon enough and the dressing removed, the effects could be deemed maleficent (Pridmore, 1998). Ongoing evaluation of the prescribed treatment should always be undertaken, as modifications may need to be made if conditions change (Morison et al, 1999). Once the primary objective has been achieved, the assessment process needs to be repeated in order to identify the next treatment objective until the wound has healed (Collier, 2002). After one week the inflammation surrounding the ulcer had gone and there was evidence that the slough was beginning to lift. Mr X had not reported any discomfort or irritation to the ulcer or surrounding tissue, which suggests that the dressing prescribed, was suitable for him. Record Keeping As a registered nurse one has both a professional and legal duty of care, therefore all nurses have a responsibility to keep accurate and up-to-date records that should be an accurate account of treatment, care planning and delivery that provides clear evidence of the decisions made (NMC, 2002a). This form of communication ensures that all members of the healthcare team involved in the care of the patient are fully informed, and ensures changes in the patients condition are detected at an early stage (NMC, 2000b). Details of the prescribed treatment were entered into Mr Xs assessment notes with a clear rationale for the choice of treatment. The trust has a specific form to complete that informs the GP of the treatment prescribed, which was completed and handed to Mr Xs doctor. Reflection Utilising a structured model of reflection by Driscoll (2000) has provided a useful means of reflecting on the incident described and analysing the decisions made. Although Mr X had expressed strong opinions about the choice of treatment he was willing to accept on his ulcer, negotiation had enabled a decision to be made that was safe, appropriate and cost-effective, in addition to being acceptable by him, thus ensuring concordance. Using the prescribing pyramid (NPC, 1999) provided a systematic, structured method of decision-making in relation to the choice of treatment, therefore ensuring that all essential aspects that needed to be considered were included. Conclusion Many district nurses have expertise in the different causes and manifestations of leg ulceration and wound care, thus most GPs tend not to interfere in the treatment, preferring to take advice from the experts in this field. So it makes sense that district nurses should be able to prescribe the most appropriate choice of dressing themselves. A good knowledge of wound healing mechanisms in relation to venous ulcers, in addition to a knowledge of treatment choices that reflect local policy, their suitability, contradictions and adverse reactions based on evidence not influence, ensured that Mr X received a dressing that proved successful in reducing the bacterial load, healing of the ulcer and comfort. The dressing did not cause any reaction or deterioration, therefore was safe and effective.