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Reflective Summary On Prescribing Practice Learning Nursing Essay

The author, a nurse practitioner based in an Emergency Department (ED), from here on in will be referred to as ‘the practitioner’. The practitioner is currently employed in a development role with the view, following training, of becoming an acute care practitioner. This will entail working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. This plan of care could well include a number of prescribed medications. Hence it is in the practitioners job description (as it is increasingly in many specialist/autonomous nursing roles) to become a Nurse Independent and Supplementary Prescriber (NISP).

The Cumberlege Report (1986) suggested that nurses should be able to prescribe independently and highlighted that patient care could be improved and resources used more effectively by doing so. It identified that nurses were wasting their time requesting prescriptions from Doctors. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (DoH 1989, 1999, 2006 & 2008; Luker et al 1994; Latter et al 2011) and is still under constant review.

The aim of this portfolio is to:

Reflect on practice as a means of on-going personal and professional development.

Demonstrate a capability of integrating learning into practice.

Submit a range of material mapped against the module learning outcomes, NMC 2006 prescribing standards, domains of practice and core competencies.

Establish an evidence-based approach to practice competence as a safe independent & supplementary prescriber.

This prescribing practice portfolio will be a reflective portfolio using Rolfe et al (2001) model of reflection to aid learning from experience and close the gap between theory and practice. This model has been chosen as it is something the practitioner is familiar with and has used before.

The portfolio will conclude with a reflective summary on prescribing practice learning which will draw together the evidence used to support achievement of the competences identified.

After discussing with colleagues who have already completed the NISP course, the practitioner is aware of the complex nature and volume of work that is required over the duration of it. There is a feeling of nervousness due to this but also a feeling excitement over what will be learnt. If successful the practitioner believes her practice will be enhanced significantly as she will have the ability to give patients seamless care.

References

Department of Health. (1986) Neighbourhood Nursing: A Focus for Care. (Cumberlege Report). London: HMSO

Department of Health. (1989) Report of the Advisory Group on Nurse Prescribing. The Crown Report). London: HMSO

Department of Health. (1999) Review Of Prescribing, Supply And Administration Of Medicines. (The Crown Report Two) London: HMSO.

Department of Health. (2006) Medicines Matters. London: HMSO

Department of Health. (2008) Making Connections: Using Healthcare Professionals to Deliver Organisational Improvements. London: HMSO

Latter, S. Blenkinsopp, A. Smith, A. Chapman, S. Tinelli, M. Gerard, K. Little, P. Celino, N. Granby, T. Nicholls, P. Dorer, G. (2011) Evaluation of nurse and pharmacist independent prescribing. Faculty of Health Sciences, University of Southampton; School of Pharmacy, Keele University on behalf of Department of Health [Online] Available at http://eprints.soton.ac.uk/184777/ [Accessed 15th Sept 2012]

Luker, K. Austin, L. Hogg, C. Ferguson, B. Smith, K. (1998) Nurse-Patient Relationships: The context of Nurse Prescribing. Journal of Advanced Nursing. (28) 2: 235-242

Rolfe, G. Freshwater, D. Jasper, M. (2001) Critical Reflection in Nursing and the Helping Professions: a User’s Guide. Basingstoke: Palgrave Macmillan.

Consultation

Holistic Assessment Case Study

In this case study the consultation, diagnosis, prescribing options and decisions of a 35 year old female seen in the ED will be discussed. This case study will aim to improve the practitioners’ knowledge of conducting a consultation and its relationship with making a diagnosis and treatment options. To maintain confidentiality, in line with the code of professional conduct, the patient will be referred to as Mrs A (Nursing and Midwifery Council (NMC), 2008).

Consultation

Examining the holistic needs of the patient is the first of seven principles of good prescribing (National Prescribing Centre (NPC), 1999) and must be undertaken before making a decision to prescribe (NMC Practice Standard 3, 2006). Holistic assessment takes into consideration the mind, body and spirit of the patient (Jarvis, 2008). Traditionally consultation and making a diagnosis has been completed by Doctors. However, nurse diagnosis would appear to have been formally acknowledged since The Crown Two Report (DoH, 1999) as part of the independent prescriber role. Horrocks et al, (2002), found greater patient satisfaction with nurse consultations than with GP consultations. Jennings et al, (2009) and Wilson & Shifaza, (2008) also found this to be true of nurse practitioners working in emergency departments. Importantly, they also found no significant variation in other health outcomes. Most of these studies found that consultations with nurses were to some extent longer, they offered more advice on self-care and self-management and that nurses gave more information to patients.

Although there are various consultation models that have been described (Byrne & Long, 1976; Pendleton et al, 1984; Neighbour, 2005; Kurtz et al, 2003; Stott & Davis, 1979), these are based upon observation of doctor, not nurse consultations. Nevertheless, the consultation models and skills described in the medical literature are relevant to all practitioners (Baird, 2004). Consultation models help the practitioner centre the consultation around successful information exchange and try to provide a theoretical structure. Consultation models can also be used to help make maximum use of the time available at each consultation (Simon, 2009). Traditionally the medical model is used to assess patients however; it does not take into account the social, psychological, and other external factors of the patient. The model also overlooks that the diagnosis (that will affect treatment of the patient) is a result of negotiation between doctor and patient (Frankel et al, 2003)

In this case study, the practitioner has used Roger Neighbour’s model of consultation. This was found by the practitioner to be simple and easy to remember, whilst covering all areas needed to make an effective consultation and assessment. He describes a 5 stage model which he refers to as a journey with ‘checkpoints’ along the way:

Connecting - establishing a relationship and rapport with the patient.

Summarising - taking a history from the patient including their ideas, expectations, concerns and summarising back to the patient to ensure there are no misunderstandings.

Handing over - negotiating between the practitioners and patients agenda and agreeing on a management plan.

Safety netting - the consideration of ‘what if?’ and what the practitioner might do in each case.

Housekeeping - reflecting on the consultation.

(Neighbour, 2005)

Connecting

Mrs A was called through to the Rapid Assessment and Treatment area in the ED. It was apparent from Mrs A’s facial expression and limp that walking caused her pain. Silverman & Kinnersley, (2010) state that non-verbal communication is extremely important and can often provide clues to underlying concerns or emotions. The practitioner had never met the patient before so had no previous ‘relationship’ with her but was aware that she may have pre-conceived ideas about the ED which may have caused her anxiety. The practitioner introduced herself to Mrs A, explained her job role, the process that was about to be undertook and consent obtained. During this time eye contact was maintained and the practitioner also asked Mrs A how she would like to be addressed. This was done to try and build up a rapport with Mrs A, to help her feel at ease and reassure her. Simon, (2009) and Moulton, (2007) agree and state that rapport is essential to effective communication and consultation. Mrs A was also offered a trolley to sit on to make herself comfortable and the curtains pulled around for privacy and dignity. On reflection the practitioner was aware that the environment was a busy and noisy assessment area and this can have a negative impact on the consultation (Silverman et al, 2005). Identifying this with Mrs A and apologising may have re-assured her further and gained trust and respect.

Summarising

The practitioner began with an open ended question and did not interrupt the patients’ response. Neighbour, (2005) and Moulton, (2007) advise this to open the consultation. Gask & Usherwood, (2002) found that if a practitioner interrupts, patients then rarely disclose new information, which could lead to not finding out the real reason for the consultation.

Mrs A revealed that she received an insect bite to her right lower leg 5 days ago, since then the surrounding skin had become swollen, increasingly red, painful and hot to touch. She explained that the redness was spreading up her leg and the pain was getting worse. Mrs A explained that she was concerned that it was not going to get better and was very worried that it had got worse during the last 3 days. Upon questioning Mrs A also complained of malaise and that she had been feeling very hot and cold and at times. She had been managing to eat and drink as normal. Mrs A lived with her husband, was a non smoker and drank alcohol occasionally. She had no past medical history and took no prescribed or over the counter (otc) medications. It was also elicited that she was allergic to Penicillin which she had an anaphylaxis reaction to. Taking a medical, social, medication and allergy history is important as it can be relevant to the presenting complaint, makes sure key information has not been overlooked and is essential in preventing prescribing errors (Bickley, 2008; Young et al, 2009).

The practitioner actively listened to what Mrs A was saying by maintaining eye contact, using open questions and by summarising the history back to clarify points and to make sure nothing was missed. On reflection the practitioner feels this also gave the opportunity for Mrs A to add any further information not disclosed so far. Closed questions were then used to gain specific information related to the initial information given, this is advised by Young et al, (2009) and Moulton, (2007). Effective communication is important as Epstein et al, (2008) explains that a precise history can supply at least 80% of the information necessary for a diagnosis.

Upon examination there was obvious erythema. Light palpation revealed that the area was very warm and tender. Neurovascular assessment was performed and was unremarkable. Mrs A’s chest was clear, heart sounds normal and her abdomen was soft, non tender. Physical examination is important as it is used to detect physical signs that the patient may not be aware of and can be used to confirm or disprove a possible diagnosis. It also suggests to the patient that their illness is being taken seriously. (Bickley, 2008, Charlton, 2006). Observations were taken including blood pressure, heart rate, temperature, respiratory rate and oxygen saturations. All were within normal parameters except her temperature which was 38.2 degrees Celsius. Venous blood was taken to check haematological, biochemical and coagulation status. Mrs A white cell count (WCC) and C-reactive protein (CRP) levels were raised, all other blood results were normal.

Handing Over

Before making a final diagnosis, it is important that differential diagnoses are excluded (Nazarko, 2012). The practitioners’ differential diagnoses were deep vein thrombosis (DVT) or venous eczema. However, Mrs A had a straightforward history (insect bite) that together with her observations (raised temperature), examination findings (redness, heat, swelling and pain) and blood results (raised WCC and CRP) indicated an alternative diagnosis, so DVT and venous eczema were ruled out.

The practitioners working diagnosis was cellulitis. This was discussed with Mrs A and she appeared reassured that a diagnosis had been made. The practitioner explained that she would like to discuss this with a senior Doctor to help decide on a treatment plan. The practitioner presented the patient to an ED Registrar who agreed with the diagnosis. Diagnosis, treatment and prescribing options were then discussed to aid the practitioners learning.

Cellulitis is a bacterial infection of the skin and subcutaneous tissue which is potentially serious (Epstein et al, 2008). It is caused by one or more types of bacteria, most commonly streptococci and staphylococcus aureus (Nazarko, 2012). Cellulitis usually occurs on the lower legs, arms and face but can arise anywhere on the body (Bickley, 2008). Patients with cellulitis present with signs of inflammation, distinctively heat, redness, swelling and pain (Nazarko, 2012). Inflammation is localised initially but increases as the infection progresses. Patients can be systemically unwell (pyrexial, tachycardic, hypotensive) and white cell count and C-reactive protein levels will be markedly raised (Beldon, 2011, Wingfield, 2009, Nazarko, 2012).

It appears there is a general lack of evidence based literature surrounding the treatment of patients with cellulitis. The practitioner could only find one national guideline on the management of cellulitis in adults, which was published in 2005 by the Clinical Resource Efficiency Support Team (CREST, 2005). However, to the practitioners’ knowledge, these have not been validated by a clinical study. Morris, (2008) found in his systematic review that antibiotics cure 50-100% of cases of cellulitis but did not find out which antibiotic regime was most successful. Kilburn et al, (2010) also could not find any definitive conclusions in their Cochrane review on the optimal antibiotics, duration or route of administration.

Eron, (2000) devised a classification system for cellulitis and its treatment which CREST used in their guidelines. This system divides people with cellulitis into four classes and can serve as a useful guide to admission and treatment decisions. However Koerner & Johnson, (2011) found in their retrospective study, comparing the treatment received with the CREST guidelines, that patients at the mildest end of the spectrum were over treated and at the more severe end undertreated. They also found a significant variation in antibiotic regimes prescribed for patients with cellulitis. Marwick et al, (2011) questioned whether classes I and II could actually be merged to improve treatment.

The practitioners trust has antibiotic guidelines (updated yearly) which also include a classification system. This aids the prescriber in choosing the correct antibiotic, dose, route and duration for certain conditions, cellulitis being one of them. After discussion with the Registrar it was determined that Mrs A was in Class I or non-severe which meant she could be managed with oral antibiotics on an outpatient basis.

The practitioners trust and CREST, (2005) guidelines advise first line treatment for non-severe or class I cellulitis as oral Flucloxacillin 500mg, three times a day. Flucloxacillin is a moderately narrow-spectrum antibiotic licensed for the treatment of cellulitis. However, Flucloxacillin was contra-indicated for Mrs A as she had a severe penicillin allergy (British National Formulary, (BNF) 2012).

Clarithromycin is a macrolide which has an antibacterial spectrum that is similar but not identical to that of penicillin; they are thus an alternative in penicillin-allergic patients (BNF, 2012). Clarithromycin is licensed and recommended by CREST, (2005), and by the practitioners’ trust, as an alternative to Flucloxacillin in cellulitis for patients with a Penicillin allergy. It is indicated in the BNF, (2012) for the treatment of mild to moderate skin and soft-tissue infections. It demonstrates suitable pharmacokinetics, with good distribution into skin and soft tissues, and is effective against the large majority of staphylococcal and streptococcal bacteria that cause cellulitis (Accord Healthcare Limited, 2012), (See drug monologue page 21-28). There were no contraindications in prescribing Clarithromycin for Mrs A.

The option of not having any medication was discussed with Mrs A however, she wanted treatment so the benefits and side effects of Clarithromycin was explained, and consent obtained from Mrs A to prescribe the antibiotics and to be discharged, (NMC Practice Standard 5, 2006). Dose and duration were then also clarified and the importance of taking the antibiotics as prescribed and to complete the full course. On reflection, by discussing and deciding on the best treatment together this would hopefully promote concordance. Negotiating with patients and agreeing on a management plan is very important aspect of reaching patient centred care (Neighbour, 2005). Using an FP10 Clarithromycin tablets 500mg twice a day was prescribed by the Registrar (as the practitioner was not a licensed prescriber, NMC Practice Standard 1, 2006), as per trust guidelines, for 7 days. Paracetamol tablets 1g four times a day was also prescribed for its analgesic and anti-pyretic properties (BNF, 2012). A stat dose of both were prescribed and the practitioner asked the nurse to administer the first dose (NMC Practice Standard 9 & 14, 2006), and was aware that by delegating this task the prescriber remained accountable. The FP10 was given to the patient to take to the pharmacy of her choice for them to dispense (NMC Practice Standard 10, 2006), (See mock prescription page 29).

The practitioner did not initially contemplate cost effectiveness but on reflection it has been recognised that this needs to be taken into consideration when prescribing (NPC, 1999). Intravenous antibiotics may have been prescribed, which may have meant an admission into hospital or administration by nurses on an outpatient basis; thus would have increased the cost of treatment significantly. Admission to hospital can also be overwhelming and can put the patient at risk of hospital acquired infections and increased risk of antibiotic resistance (Wingfield, 2008).

Safety Netting

The erythematous border was marked, with the patient’s consent, with permanent pen to monitor for any improvement or additional spread of infection (CREST, 2005, Beldon, 2011). The practitioner advised Mrs A that she should return or see her GP if she had worsening symptoms or if by the completion of the course of antibiotics symptoms had failed to resolve. Mrs A was also advised that, if a similar incident occurred, she should seek medical assistance early so that treatment could begin as soon as possible to reduce the risk of severe and long-term complications. In addition it was recommended that she should drink plenty of fluids to prevent dehydration, elevate the leg for comfort and to help reduce the swelling (CREST, 2005, Beldon, 2011). Mrs A was warned that there could be an increase in erythema in the first 24-48 hours of treatment (CREST, 2005). This advice and information empowered Mrs A and made sure that her discharge was as safe as possible.

The practitioner brought the consultation to a close by asking Mrs A if she had any questions or if there was anything else she would like to discuss. This gave Mrs A the opportunity of clarifying any information given by the practitioner and the opportunity to divulge any information or concerns not previously mentioned. This re-assured the practitioner that she had addressed her problem appropriately.

Housekeeping

The practitioner made sure there was clear concise documentation of the consultation and choice of prescription in Mrs A notes (NMC Practice Standard 7, 2006). A discharge letter was also produced to send to her GP NMC Practice Standard 6, 2006). Once the prescription was ready, Mrs A was discharged.

This case study has shown the practitioner the importance of effective communication in consultation. By following Neighbours consultation ‘checkpoints’ it gave structure to the consultation and will be used by the practitioner in future practice. It has also helped the practitioner to gain an understanding of different prescribing options and how to explore these further. For example, the practitioner did find when reading around the subject that there has been some research on the use of corticosteroids in cellulitis to increase resolution, however, to the practitioners’ knowledge, this is not currently advised in any guidelines and further research is needed. The practitioner would also like to be involved in the development of a cellulitis pathway at her place of work. This could include an algorithm to aid practitioners to differential diagnosis so patients can receive appropriate treatment and reduce the incorrect prescribing of antibiotics.

As there are no National Institute for Health and Clinical Excellence (NICE) guidelines on the treatment and management of cellulitis, treatment of patients is not standardised and consequently quality of care could be affected. The optimal choice for antimicrobial therapy requires review and definitive study in clinical trials.

References

Accord Healthcare Limited (2012) Summary of Product Characteristics for Clarithromycin Capsules 500mg. [online]. Electronic Medicines Compendium. Datapharm Communications Ltd. Available from: http://www.medicines.org.uk/EMC/medicine/25914/SPC/Clarithromycin+500mg+Tablets/ [Accessed 21ST September 2012]

Byrne, P. Long, B. (1976) Doctors Talking to Patients. London, HMSO.

Baird, A. (2004) The Consultation. Nurse Prescriber. (1) 3: 1-4

British National Formulary: No. 64 (2012) London: BMJ Group and Pharmaceutical Press.

Bickley, L. (2008) Bates’ Guide to Physical Examination and History Taking. 6th Ed. London: Lippincott, Williams and Wilkins.

Beldon, P. (2011) The Assessment, Diagnosis and Treatment of Cellulitis. Wound Essentials. (6): 60-68.

Clinical Research Efficiency Support Team (2005) Guidelines on the Management of Cellulitis in Adults. Belfast: Clinical Research Efficiency Support Team.

Charlton, R. (2006) Learning to Consult. Abingdon: Radcliffe.

Department of Health (1999) Review Of Prescribing, Supply And Administration Of Medicines. (The Crown Report) London: HMSO.

Epstein, O. Perkin, G. Cookson, J. De Bono, D. (2008) Clinical Examination. 4th Ed. London: Mosby.

Eron, L. (2000) Infections of Skin and Soft Tissues: Outcome of A Classification Scheme. Clinical Infectious Diseases. (31) 287

Frankel, R. Quill, T. McDaniel, S. (2003) The Biopsychosocial Approach: Past, Present, and Future. Rochester: University Of Rochester Press.

Gask L, Usherwood, T. (2002) ABC of Psychological Medicine: The Consultation. British Medical Journal (324) 7353: 1567-1569.

Horrocks, S. Anderson, E. Salisbury, C. (2002) Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors. British Medical Journal. (324) 7341: 819-823.

Jarvis, C. (2008) Physical Examination and Health Assessment. 5th Ed. Missouri: Saunders Elsevier.

Jennings, N., Lee, G., Chao, K., Keating, S. (2009) A Survey of Patient Satisfaction in a Metropolitan Emergency Department: Comparing Nurse Practitioners to Emergency Physicians. International Journal of Nursing Practice (15) 213-218.

Kilburn, S., Featherstone, P., Higgins, B., Brindle, R. Interventions for Cellulitis and Erysipelas. Cochrane Database Systematic Reviews. 2010 Issue 6, Art. No. CD004299. DOI: 10.1002/14651858.

Koerner, R. Johnson, A. (2011) Changes in the classification and management of Skin and Soft Tissue Infections. Journal of Antimicrobial Chemotherapy. (66) 232-234.

Kurtz S, Silverman J, Benson J, Draper J. (2003) Marrying Content and Process in Clinical Method Teaching; Enhancing the Calgary-Cambridge Guides. Academic Medicine (78) 8: 802-809.

Marwick, C. Broomhall, J. McCoowan, C. Phillips, G. Gonzalez-McQuire, S. Akhras, K. Merchant, S. Nathwani. Davey, P. (2011) Severity Assessment of Skin and Soft Tissue Infections: Cohort Study of Management and Outcomes for Hospitalised patients. Journal of Antimicrobial Chemotherapy. (66): 387-397

Morris, A. (2008) Cellulitis and Erysipelas. Clinical Evidence. [online] BMJ Publishing Group Ltd. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907977/ [Accessed 10th September 2012]

Moulton L. (2007) The Naked Consultation: A practical Guide to Primary Care Consultation skills. Abingdon: Radcliffe.

National Prescribing Centre. (1999) Signposts for Prescribing Nurses – General Principles of Good Prescribing. Prescribing Nurse Bulletin. (1): 1-4.

Nazarko, L. (2012) An Evidence-Based Approach to Diagnosis and Management of Cellulitis. British Journal of Community Nursing. (17) 1: 6-12.

Neighbour, R. (2005) The Inner Consultation. How to Develop an Effective and Intuitive Consulting Style. 2nd Ed. Oxford: Oxford-Radcliffe.

Nursing and Midwifery Council (2006) Standards of Proficiency for Nurse and Midwife prescribers. London: Nursing and Midwifery Council.

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council.

Pendleton, D. Schofield, T. Tate, P. Havelock, P. (1984) The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press.

Silverman, J. Kurtz, S. Draper, J. (2005) Skills for Communicating with Patients. 2ND Ed. Oxford: Radcliffe.

Silverman, J. Kinnersley, P. (2010) Doctors Non-Verbal Behaviour in Consultations: Look at the Patient Before You Look at The Computer. British Journal of General Practice. (60): 76-8.

Simon, C. (2009) The Consultation. InnovAiT (2) 2: 113-121. [online] Available at http://rcgp-innovait.oxfordjournals.org/content/2/2/113.full. [Accessed 13th September 2012]

Stott, N. Davis, R. (1979) The Exceptional Potential in Each Primary Care Consultation. Journal of the Royal College of General Practitioners. (29): 201-5.

Wingfield, C. (2009) Lower Limb Cellulitis: A Dermatological Perspective. Wounds UK. (5) 2: 26-36.

Wingfield, C. (2008) Cellulitis: Reduction of Associated Hospital Admissions. Dermatological Nurse 7(2): 44–50.

Wilson, A. Shifaza, F. (2008) An Evaluation of the Effectiveness and Acceptability of Nurse Practitioners in an Adult Emergency Department. International Journal of Nursing Practice. (14): 149-156.

Young, K. Duggan, L. Franklin, P. (2009) Effective Consulting and History-Taking Skills for Prescribing Practice. British Journal of Nursing. (18) 17: 1056-1061.

Drug Monologue.

Name of Drug

Clarithromycin

Drug Classification

Macrolide

Therapeutic Uses(s)

Clarithromycin film-coated tablets are indicated in adults and adolescents 12 years and older for the treatment of the following bacterial infections, when caused by clarithromycin-susceptible bacteria.

• Acute bacterial exacerbation of chronic bronchitis

• Mild to moderate community acquired pneumonia.

• Acute bacterial sinusitis

• Bacterial pharyngitis.

• Skin infections and soft tissue infections of mild to moderate severity, such as folliculitis, cellulitis and erysipelas

Clarithromycin film-coated tablets can also be used in appropriate combination with antibacterial therapeutic regimens and an appropriate ulcer healing agent for the eradication of Helicobacter pylori in patients with Helicobacter pylori associated ulcers

Dose range and route(s) of administration

Adults and adolescents (12 years and older)

• Standard dosage: The usual dose is 250 mg twice daily.

• High dosage treatment (severe infections): The usual dose may be increased to 500 mg twice daily in severe infections.

Children younger than 12 years:

Use of Clarithromycin film-coated tablets is not recommended for children younger than 12 years. Use Clarithromycin paediatric suspensions. Clinical trials have been conducted using clarithromycin pediatric suspension in children 6 months to 12 years of age.

Elderly:

As for adults

Dosage in renal functional impairment:

The maximum recommended dosages should be reduced proportionately to renal impairment. In patients with renal impairment with creatinine clearance less than 30 mL/min, the dosage of clarithromycin should be reduced by one-half, i.e. 250 mg once daily, or 250 mg twice daily in more severe infections. Treatment should not be continued beyond 14 days in these patients.

Patients with hepatic impairment:

Caution should be exercised when administrating clarithromycin in patients with hepatic impairment

Administered orally.

Pharmacodynamics

Mode of Action

Clarithromycin is a semi-synthetic derivative of erythromycin A. It exerts its antibacterial action by binding to the 50s ribosomal sub-unit of susceptible bacteria and suppresses protein synthesis. It is highly potent against a wide variety of aerobic and anaerobic gram-positive and gram-negative organisms.

The 14-hydroxy metabolite of clarithromycin also has antimicrobial activity. The MICs of this metabolite are equal or two-fold higher than the MICs of the parent compound, except for H. influenzae where the 14-hydroxy metabolite is two-fold more active than the parent compound.

Side Effects

Dyspepsia, tooth and tongue discoloration, smell and taste disturbances, stomatitis, glossitis, and headache; less commonly: arthralgia and myalgia; rarely: tinnitus; very rarely: dizziness, insomnia, nightmares, anxiety, confusion, psychosis, paraesthesia, convulsions, hypoglycemia, renal failure, interstitial nephritis, leucopenia, and thrombocytopenia

Interactions

Aprepitant

Clarithromycin possibly increases plasma concentration of aprepitant

Atazanavir

Plasma concentration of both drugs increased when Clarithromycin given with atazanavir.

Atorvastatin

Clarithromycin increases plasma concentration of atorvastatin.

Cabazitaxel

Avoidance of clarithromycin advised by manufacturer of cabazitaxel.

Calcium-channel Blockers

Clarithromycin possibly inhibits metabolism of calcium-channel blockers (increased risk of side-effects).

Carbamazepine

Clarithromycin increases plasma concentration of carbamazepine.

Ciclosporin

Clarithromycin inhibits metabolism of ciclosporin (increased plasma concentration).

Colchicine

Clarithromycin possibly increases risk of colchicine toxicity—suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment).

Coumarins

Clarithromycin enhances anticoagulant effect of coumarins.

Disopyramide

Clarithromycin possibly increases plasma concentration of disopyramide (increased risk of toxicity).

Dronedarone

Avoidance of clarithromycin advised by manufacturer of dronedarone (risk of ventricular arrhythmias).

Efavirenz

Increased risk of rash when clarithromycin given with efavirenz.

Eletriptan

Clarithromycin increases plasma concentration of eletriptan (risk of toxicity)—avoid concomitant use.

Eplerenone

Clarithromycin increases plasma concentration of eplerenone —avoid concomitant use.

Etravirine

Clarithromycin increases plasma concentration of etravirine , also plasma concentration of Clarithromycin reduced.

Everolimus

Clarithromycin possibly increases plasma concentration of everolimus —manufacturer of everolimus advises avoid concomitant use.

Fesoterodine

Manufacturer of fesoterodine advises dose reduction when Clarithromycin given with fesoterodine —consult fesoterodine product literature.

Fidaxomicin

Avoidance of clarithromycin advised by manufacturer of fidaxomicin.

Itraconazole

Clarithromycin increases plasma concentration of itraconazole.

Ivabradine

Clarithromycin possibly increases plasma concentration of ivabradine —avoid concomitant use.

Maraviroc

Clarithromycin possibly increases plasma concentration of maraviroc (consider reducing dose of maraviroc).

Methylprednisolone

Clarithromycin possibly increases plasma concentration of methylprednisolone.

Midazolam

Clarithromycin inhibits metabolism of midazolam (increased plasma concentration with increased sedation).

Nevirapine

Plasma concentration of clarithromycin reduced by nevirapine (but concentration of an active metabolite increased), also plasma concentration of nevirapine increased.

Nilotinib

Avoidance of clarithromycin advised by manufacturer of nilotinib.

Omeprazole

Plasma concentration of both drugs increased when clarithromycin given with omeprazole.

Pazopanib

Avoidance of clarithromycin advised by manufacturer of pazopanib.

Phenytoin

Clarithromycin inhibits metabolism of phenytoin (increased plasma concentration).

Pimozide

Increased risk of ventricular arrhythmias when clarithromycin given with pimozide —avoid concomitant use.

Pravastatin

Clarithromycin increases plasma concentration of pravastatin.

Quetiapine

Clarithromycin possibly increases plasma concentration of quetiapine —manufacturer of quetiapine advises avoid concomitant use.

Ranolazine

Clarithromycin possibly increases plasma concentration of ranolazine —manufacturer of ranolazine advises avoid concomitant use.

Repaglinide

Clarithromycin enhances effects of repaglinide.

Rifabutin

Clarithromycin increases plasma concentration of rifabutin (increased risk of toxicity—reduce rifabutin dose).

Rifamycins

Plasma concentration of clarithromycin reduced by rifamycins.

Rilpivirine

Avoidance of clarithromycin advised by manufacturer of rilpivirine (plasma concentration of rilpivirine possibly increased).

Ritonavir

Plasma concentration of Clarithromycin increased by ritonavir (reduce dose of Clarithromycin in renal impairment).

Saquinavir

Increased risk of ventricular arrhythmias when clarithromycin given with saquinavir —avoid concomitant use.

Sildenafil

Clarithromycin possibly increases plasma concentration of sildenafil —reduce initial dose of sildenafil.

Simvastatin

Increased risk of myopathy when clarithromycin given with simvastatin (avoid concomitant use).

Sirolimus

Clarithromycin increases plasma concentration of sirolimus —avoid concomitant use.

Tacrolimus

Clarithromycin increases plasma concentration of tacrolimus.

Tadalafil

Clarithromycin possibly increases plasma concentration of tadalafil.

Telaprevir

Plasma concentration of both drugs possibly increased when clarithromycin given with telaprevir (increased risk of ventricular arrhythmias).

Theophylline

Clarithromycin possibly increases plasma concentration of theophylline.

Ticagrelor

Clarithromycin possibly increases plasma concentration of ticagrelor —manufacturer of ticagrelor advises avoid concomitant use.

Tipranavir

Plasma concentration of Clarithromycin increased by tipranavir (reduce dose of clarithromycin in renal impairment), also clarithromycin increases plasma concentration of tipranavir.

Tolterodine

Avoidance of Clarithromycin advised by manufacturer of tolterodine.

Trazodone

Clarithromycin possibly increases plasma concentration of trazodone.

Vinorelbine

Possible increased risk of neutropenia when clarithromycin given with vinorelbine.

Zidovudine

Clarithromycin tablets reduce absorption of zidovudine (give at least 2 hours apart).

Pharmacokinetics

Absorption

Clarithromycin is rapidly and well absorbed from the gastrointestinal tract – primarily in the jejunum – but undergoes extensive first-pass metabolism after oral administration. The absolute bioavailability of a 250-mg clarithromycin tablet is approximately 50%. Food slightly delays the absorption but does not affect the extent of bioavailability. Therefore, clarithromycin tablets may be given without regard to food. Due to its chemical structure (6-O-Methylerythromycin) clarithromycin is quite resistant to degradation by stomach acid. Peak plasma levels of 1 – 2 µg/ml clarithromycin were observed in adults after oral administration of 250 mg twice daily. After administration of 500 mg clarithromycin twice daily the peak plasma level was 2.8 µg/ml.

After administration of 250 mg clarithromycin twice daily the microbiologically active 14-hydroxy metabolite attains peak plasma concentrations of 0.6 µg/ml. Steady state is attained within 2 days of dosing.

Distribution

Clarithromycin penetrates well into different compartments with an estimated volume of distribution of 200-400 l. Clarithromycin provides concentrations in some tissues that are several times higher than the circulating drug levels. Increased levels have been found in both tonsils and lung tissue. Clarithromycin also penetrates the gastric mucus.

Clarithromycin is approximately 80% bound to plasma proteins at therapeutic levels.

Metabolism

Clarithromycin is rapidly and extensively metabolised in the liver.

Excretion

Elimination half-life increased from 2-4 hours following administration of 250 mg clarithromycin twice daily to 5 hours following administration of 500 mg clarithromycin twice daily.

Approximately 20 -30% of clarithromycin is collected as the unchanged active substance in the urine. This proportion is increased when the dose is increased. Renal insufficiency increases clarithromycin levels in plasma, if the dose is not decreased.

Notes

Cost

Tablets, Clarithromycin 250 mg, net price 14-tab pack = £2.52; 500 mg, 14-tab pack = £3.52.

Pharmacy Stamp

Please don’t stamp over age box

Age 35

D.o.B 01/01/1977

Title, Forename, Surname & Address

Mrs Andrea Another

1 Any Street

Anytown

AA1 2BB

NHS Number 111111

Number of days’ treatment

N.B. Ensure dose is stated

7days

Endorsements

S A M P L ENURSE INDPENDENT / SUPPLEMENTARY PRESCRIBER

Clarithromycin 500 mg [five hundred milligrams] Twice a day for seven days.

Paracetamol 1g [one gram] up to four times a day – max. For 7 days

No other medications on this prescription.

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CN

Signature of Prescriber Sally Hopeful

Date 01/09/2012

For

dispenser

No. of

Prescns.

on form

1

image31

Mrs Sally Hopeful 77Y1234E

Anywhere PCT 77V55

PATIENTS PRACTICE CODE ……………………………

TRUST HQ, HOSPITAL CAMPUS

ANYWHERE

PQ99 6PQ

01604 8912345

NURSE CONTACT TEL. NO …………………………….

FP10Q99999

1233445647978

Independent/Supplementary Nurse Prescribing

Practice Record Log

Type of Learning Environment:

ED

Status of Practitioner Visited:

Registrar

Personal learning objectives for visit and related competencies:

Prescribing for children, understanding the use of off-label medicines. Further learning on licensed and unlicensed medicines. Practice Standards: 2, 17, 18.

Hours in Practice 8 Hours

Date: 17th September 2012

What?

The practitioner has no experience working with children except as part of her nurse training. Now working in the ED there will be more contact with children and although this does not include assessment and diagnosis at present, this could change through the practitioners’ career so is something she must be aware of. This is a reflection of a witnessed consultation with a child, her parents and an ED Registrar.

Child A (4 years old) was brought in by her parents with a high temperature and productive cough. She had no PMH or allergies and took no prescribed or OTC medications. The assessment was very different to what the practitioner was used to as the questions were more directed at the parents than at the child, however the same style of consultation that the practitioner used herself was used to maintain structure. As advised by Dorp (2008) the registrar used non jargon to communicate with the child and sat down next to her to try and provide reassurance. Before asking questions he played with the child to try and gain trust. It is also advised to have a child friendly atmosphere when assessing children (Dorp 2008). Unfortunately at the time of writing the practitioners ED is for both adults and children; however there are plans to dedicate an area for children only to improve facilities and make it more child friendly. Following the consultation and examination, the registrar diagnosed a chest infection and decided to prescribe oral Paracetamol 240mg max QDS and Amoxicillin 125mg TDS. Consideration was taken to the formulation of the medicine – the Registrar prescribed suspension which came with oral syringes – to aid administration (NPC, 2000). The parents were advised of the dose and duration of the medication and to keep it out of the childs’ reach. Side effects were explained and what to do if the child did not improve or symptoms worsened.

So What?

Amoxicillin is indicated in the BNF for Children (BNFc) (2012) and licensed for infections and Paracetamol for pyrexia and pain. The BNFc advises oral Amoxicillin for children 1–5 years, 125 mg every 8 hours and oral Paracetamol for children 4–6 years 240 mg every 4–6 hours (max. 4 doses in 24 hours), however best practice would have been to use the childs weight to dose (RCN, 2010). The product literature for Amoxicillin states that the daily dosage for children is 40 - 90 mg/kg/day in two to three divided doses (not exceeding 3 g/day) depending on the indication, the severity of the disease and the susceptibility of the pathogen. Children weighing more than 40 kg should be given the usual adult dosage. Calculation by body-weight in an overweight child may result in much higher doses being administered than necessary; in such cases, the dose should be calculated from an ideal weight for height (BNFc, 2012). Product literature for Paracetamol advises doses for children based on age and the BNFc advises Paracetamol and Amoxicillin doses based on age, not weight, so in this instance the correct dose was calculated from the Childs’ age. On reflection this appears confusing and open to subjectivity and could lead to inconsistencies in prescribing.

Although not in this case, many medications prescribed for children are actually not licensed for use in children. Licensed medications that are prescribed outside of their licence are termed off–label prescribing as pharmaceutical companies do not usually test them on children. Once qualified as a NISP the practitioner will be able to prescribe off-label and/or for children as long as it is in her scope of competence (NMC 2006, Practice Standard 18).

When prescribing licensed drugs for unlicensed indications:

•Advice the child and/or carers of what is being done and why and gain consent for the drug's use.

•Explain that in these circumstances the patient information leaflet (PiL) will not have information about the use of the drug.

•Record in the patients notes the above and reasons for prescribing outside the licensed indications for the drug.

(Dorp 2008)

NMC Practice Standard 17 was updated in 2009 and now allows a NISP to prescribed unlicenced medications on the same basis as Doctors, dentists and supplementary prescribers. The Medicines and Healthcare products Regulatory Agency (MHRA) operates a system of licensing before medicines are marketed/prescribed/sold. The MHRA confirm that medicines have met standards for safety, quality and efficacy (NPC, 2000)

Now What?

This reflection on a witnessed consultation with Child A has made the practitioner aware of many issues surrounding prescribing for children including consultation methods, calculating medication doses, medication licenses and off label prescribing. It has also highlighted to the practitioner the potential for inconsistencies in prescribing doses for children based on age or weight. At the time of writing the practitioner has highlighted this to the lead nurse and consultant in her area and has requested guidance for all prescribers in this.

At this point in the practitioners’ career, even on completion of the NISP, the practitioner would not feel it was in her scope of practice to prescribe for children. However, it maybe that her career changes and consultations with children may be part of the norm. This reflection has given the practitioner some basic knowledge and understanding to build upon if this were the case.

References

British National Formulary for Children No. 64 (2012) London: BMJ Group and Pharmaceutical Press.

Dorp, F. (2008) Consultations with Children. InnovAiT. (1) 1: 54-61

Nursing and Midwifery Council (2006) Standards of Proficiency for Nurse and Midwife Prescribers. London: Nursing and Midwifery Council

Royal College of Nursing (2010) Standards for the Weighing of Infants, Children and Young People in the Acute Healthcare Setting. London: Royal College of Nursing [online] Available at http://www.rcn.org.uk/__data/assets/pdf_file/0009/351972/003828.pdf [Accessed 10th October 2012]

National Prescribing Centre (2000) Prescribing for Children. MeReC Bulletin. (11) 2: 5-8

Independent/Supplementary Nurse Prescribing

Practice Record Log

Type of Learning Environment:

ED

Status of Practitioner Visited:

Consultant

Personal learning objectives for visit and related competencies:

Prescribing of Controlled Drugs. Misuse potential of drugs. Practice Standards 2, 4, 6, 16.

Hours in Practice 8 Hours

Date: 29th September 2012

What?

Mr A was a 35 year old male that came to the ED requesting sleeping tablets – specifically Temazepam - as he was unable to sleep. Mr A declined examination and did not want to answer specific questions asked by the practitioner to try and elict why he was not sleeping. He just wanted ‘a prescription for Temazepam’. At this point the practitioner referred to an ED Consultant for advice and help (NMC practice standard 6, 2006). The consultant reviewed the patient and advised him to go to his GP to have a discussion regarding sleeping tablets as he felt his GP would be more appropriate to do so.

So What?

This led the practitioner reflect on legal and ethical issues surrounding this consultation.

The legal ability to supply medicines is based on the classification of medicinal products, there are three classes:

Medicine subject to general sale

Prescription only medicine

Pharmacy medicine

The Human Medicines Regulations (2012).

The Misuse of Drugs Act (1971):

Controls substances because they are liable to misuse

Prohibits all activity with controlled substances unless it is specifically authorised by the Act or Regulations

Activity includes import, export, manufacture, supply and possession.

With effect from 23rd April 2012, it is legal for Nurse Independent Practitioners and Pharmacist Independent Practitioners to prescribe, administer and give directions for administration of Controlled Drugs for treating disease or injury, but not for treating addiction, (The Misuse of Drugs (Amendment No 2) Regulations 2012).

Hence, sleeping tablets could have been legally prescribed for Mr A by the Consultant, and by the practitioner after completing the NISP course, as long as it was for a legitimate medicinal purpose (NMC Practice Standard 16, 2006, amended 2012). However, due to the misuse potential the consultant did not prescribe as it was unclear the reasons for him needing the prescription. Referring him to his GP was the safest options as they would have his patient record to review, and could see if he had had them before, therefore reducing the misuse potential. Prescribers have a duty to ensure they are not creating or contributing to an addiction problem (NPC, 2005).

A letter was written to Mr A’s GP advising him of the reason for attendance in the ED and that no prescription was given (NMC Practice Standard 6, 2006).

Reflection of this consultation led the practitioner to consider ethical issues: what if Mr A genuinely needed the sleeping tablets? In ethical terms this would be described as respect for autonomy and beneficence – the duty to do good - (Beauchamp & Childress 2009). However the Consultant ‘safety netted’ by advising to see his GP and by communicating with his GP. It was believed that there was not a genuine need so the risks of prescribing outweighed the benefits; the ethical principle non-maleficence – to avoid causing harm (Beauchamp & Childress 2009)

Now What?

This reflection on a consultation with Mr A has increased the practitioners’ knowledge on the legal issues surrounding prescribing controlled drugs and the misuse potential of them. Once qualified as a NISP the practitioner will only prescribe controlled drugs, in fact any medication, when there is a legitimate medicinal purpose. This reflection has also re-iterated the importance of the use of the prescribing pyramid and specifically – which strategy? – to remind oneself that a prescription should only be given where there is genuine need. Pressure from patients can have the potential to result in inappropriate prescribing.

The practitioner believes to improve practice in the future GP patient records should be able to be accessed by hospital staff which is something her trust and PCT is looking into.

Sleeping tablets drugs not the only medications liable to misuse, opiates and antibiotics are other common medications liable to misuse. To develop learning the practitioner will read around the misuse of medicines further and makes up part of her EBL scenario. (?see page.....)

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