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Patient’s outcomes and the impact of appropriate consultation carried out by an aesthetic nurse.
Aesthetics is one of the fastest growing specialties of medical practice. Aesthetic nurses play a significant role in delivering aesthetic non-surgical treatments. They administer around 70 per cent of all non-surgical treatment. They typically work in a range of roles within the NHS and the private sector. Aesthetic nurses practise in clinical settings. Their roles span a broad range of task including systematic problem solving and the management of patient requirements. Aesthetic nurses play a key role in patient care pathway and are responsible for the provision of the right information about treatment and products, making diagnoses, creating a care plan and ensuring that patients receive the best treatment. Aesthetic nurses are also accountable for evaluation of patient’s treatment outcomes and progress towards achieving well-being and health (Fry et al., 2011).
The management of health problems poses several challenges including having the right skills, attitude, expertise and knowledge to manage patient’s needs. Aesthetic nurses need to possess the right knowledge, communicative and ethical skills to minimise the risk of clinical errors. These aspects are crucial to delivering effective and positive outcomes during the management of patient’s needs.
The general patient pathway comprises of an assessment that is carried out by the nurse during a consultation. This step is key to the management of patient risk, health and choices. Ineffective assessment and consultation could result in the wrong treatment prescription with the potential emotional, physical and psychological harm of the patient’s health.
In this case study, I will apply Gibb’s reflective model (Jasper, 2003) to describe and present how lack of communication and incorrect treatment could lead to patient’s distress caused by the development of adverse effects following an aesthetic treatment.
Case description using Gibb’s approach
A 35-year-old woman came in to the clinic complaining of painful, irritated skin on both the right and left side of her face and the forehead. In particular, she reported signs of inflammation around the nasal-labial fold and perioral area, and in the buccal and frontal area. She noticed the problem within a day after receiving an aesthetic treatment at the clinic. She underwent a course of dermal filler injections containing Restylene to reduce the signs of lines and wrinkles in the frontal, buccal and nasal-labial areas. Although she was warned, she may experience some soreness and redness the patient was not aware of the type of active substances in her dermal fillers. She also has not been given a range of options of treatment and she did not receive any leaflets about the after care. She was presented with red, swollen and painful skin in particular during smiling or speaking. The patient came in to the clinic three days after her treatment and she was assessed by her aesthetic nurse. The nurse examined her face and prescribed her 1% hydrocortisone cream with the application of three times a day to the patient’s face for the duration of 7 days. Unfortunately, her symptoms worsened within three days of this treatment and the unhappy and distressed patient went to see a doctor. After careful examination and consultation with the doctor, the patient was diagnosed with a skin infection caused by the treatment she had at the aesthetic clinic. The patient’s skin presented with even greater inflammation characterised by pustules and yellow crusts in the area where the dermal filler injections took place. The doctor prescribed the patient a course of antibiotics taken externally as a cream in the form of Bactroban three times daily and Clarithromycin 200 mg 4 times a day. The course of antibiotic treatment lasted 7 days resulting in positive outcomes for the patient. During the patient’s visit to the doctor, I took part in the consultation, examination and medical history assessment. I reflected on my practice trying to identify the signs and symptoms that I missed to correctly diagnose this patient. I realised that perhaps I did not understand fully what the patient was feeling and therefore, misdiagnosed the risk of her signs and symptoms. I realised that effective risk assessment is crucial to correct diagnosis and treatment prescription as well as management of quality patient care. What is more, I did not give the patient enough information about the after care and did not ask to pay attention to possible signs of possible adverse effects.
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The case study described above shows an example of negligence in clinical aesthetic practice. It underlies common mistakes health care practitioners make when consulting and prescribing products and treatments. To avoid negative practice it is crucial to identify the cause of the problem, how the symptoms developed and what steps can be taken to avoid the problem.
Reflective practice and the right consultation between patients and health care professionals are valuable tools for effective treatment management and provision of high quality care (PMETB, 2008). It is evident that in the case study described above the aesthetic nurse failed to inform the patient about the choice of products and their possible side effects. Today’s patients need to be fully informed about the chemical composition of the products and their effects on their physical health. This is very important especially that today’s health care aims to address patient’s physical, emotional, psychological and well-being needs. As the patient was not presented with options followed by informed instructions, the patient was not able to make the right decision concerning which products she should have chosen. Whilst dermal fillers are not legally regulated and are accepted as harmless (MHRA, 2009), evidence suggests they may lead to health complications (Funt and Pavicic, 2013). For example, intra-arterial dermal filler injection with hyaluronic acid might lead to extensive injury of the tissue and necrosis (Delorenzi, 2014). Other products such as Juvederm Ultra may also lead to local inflammation, formation of nodules, tissue damage, and necrosis and other adverse reactions (Allergan, 2010). Common clinical symptoms following hyaluronic acid injections include skin blanching, delayed refilling of the capillaries, discolouration of the skin, livedo reticularis that might be followed by more adverse symptoms such as formation of blisters and tissues damage (Delorenzi, 2014). Prompt recognition of these signs and symptoms by the aesthetic nurse are the mainstays of effective treatment. The effective treatment at an early stage would involve prescription of hyaluronidase, administration of anti-inflammatories such as oral acetylsalicyclic acid (aspirin) and topical occlusion with nitropaste. Warm compresses and vigorous massage to affected area can also help to minimise stress (Delorezni, 2014). Meticulous technique during the dermal filler injection could prevent the above adverse effects. Therefore, patients should be informed about the types of products and their respective composition and possible adverse reactions. Aesthetic nurse plays a key role in the provision of this information and after care. In particular, patients can be empowered by receiving the right information about the after care and should be alarmed to keep an eye on any possible adverse effects (Cohen, 2008). Early identification of any adverse effects generally results in lower negative health impacts. All nurses should follow the guidelines set out by the Nursing and Midwifery Council as described in Standards for medicine management (NMC, 2011). This highlights that communication between the nurse and the patient is extremely important in minimising risk following aesthetic treatments as well as provision of high quality patient care and lawful practice.
This case study highlights an example of aesthetic nurse negligence, where firstly, she failed to inform the patient about the possible consequences of the products and treatment she had, secondly, she did not provide the right after care and thirdly, failed to diagnose her symptoms correctly after the treatment. She misdiagnosed patient’s symptoms as an inflammatory reaction rather than infection and therefore, prescribed the wrong treatment of 1% hydrocortisone cream to treat the symptoms. The nurse failed to carry out a correct assessment and examination and failed to address the health symptoms adequately according to the guidelines developed by National Prescribing Centre (Courtney and Griffiths, 2010). The guidelines follow principles of good practice recommending considerations for the patient including a thorough medical examination, choice of appropriate treatment, and prescription of correct drugs for the respective symptoms. 1 % hydrocortisone cream was inadequately prescribed because it is not the right treatment to alleviate symptoms of infection. What is more, its immunosuppressing properties could worsen the symptoms and increase the predisposition to infection (JFC, 2011). The right treatment should have been prescription of antibiotics according to the guidelines for the treatment of skin infections set out by the British Association of Dermatologists (BAD, 2008). The treatment of a topical cream in the form of Bactroban three times daily and Clarithromycin 200 mg 4 times a day was confirmed by the doctor at a later stage and resulted in improved outcomes for the patient’s symptoms. If the symptoms were identified and diagnoses at an earlier stage, the patient could have been just treated with the topical form of antibiotics. However, due to the advanced form of inflammation oral administration of antibiotics was also prescribed. Effective consultation and accurate diagnosis by the aesthetic nurse could have prevented unnecessary distress to the patient. A meticulous technique used by the aesthetic clinician during dermal filler injections could have prevented development of the adverse effects all together.
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Conclusion and action plan
The rapidly growing range of non-surgical treatments and products including dermal fillers for the use in aesthetic soft tissue augmentation has benefits to both patients and physicians, but as indicated in this case study, as the number of products grows, the number of complications is also likely to expand. There are a number of steps that can be taken to avoid errors in aesthetic nursing practice. Communication at the right time with the patient as well as written advice may help empower patinet’s choices over the types of products and treatments that are most suitable to them. Today, patients have access to information through the means of internet and expect to be well informed about all possible complications associated with the use of aesthetic products. It is the role of the nurse to make sure patients have the right information at the right time. The information about the side effects and adverse reactions of the aesthetic products is available on many of the pharmaceutical companies’ websites. Companies such as Allergan, Merz and Galderma usually provide detailed protocols and guidelines to practitioners about their products. They even provide templates for taking demographic and medical history notes, treatment guidelines, and flyers containing all the information patient needs to know about pre and post-care and possible adverse reactions. It is recommended that aesthetic centres develop their own standards of care so that their patients can be informed well. The above strategies can be easily deployed to minimise the incidence and impact of complications associated with dermal filler injections. Knowledge about the products and potential adverse effects and their risk management will enhance the use of the products and influence good aesthetic nursing practice. For optimum outcomes, aesthetic clinical practitioners should have good knowledge of the anatomy of facial structures; the prospective characteristics of the wide range of dermal fillers; their implications, contraindications, beneficial effects and setbacks; and strategies to prevent and avoid possible complications.
Continuing professional development is a good way to keep up-to-date with the latest scientific findings and allows engagement with other professionals in the field to develop optimum treatment options and management. Poor practice should always be reported to ensure best outcomes for the patients in the future (NMC, 2011).
Overall, quality care that patients receive depends on accurate diagnosis and prescription of drugs and treatment that involves communication skills, compassion, and care from healthcare professionals as well as knowledge, experience and expertise that is necessary to make correct diagnoses. Effective management of patient clinical risk and learning from reflective practice leads to the provision of high quality care to patients at the right time in the right place and satisfied patients.
Allergan (2010). Juvederm Ultra 4. Summary of Product Characteristics. Pringy: Allergan.
Cohen, J., L., (2008) Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 34 Suppl 1:S92-9. .
Courtney, M., Griffiths, M., (2010) Independent and supplementary prescribing. An essential Guide. 2nd Ed. Cambrdige. Cambridge University Press.
Delorenzi, C., (2014) Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 4(4):584-600.
Fry, S., T., Veatch, R., M., Taylor, C., R., (2011) Case Studies in Nursing Ethics, Jones and Bartlett Learning, 4th Ed.
Funt, D., Pavicic, T., (2013) Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 12;6:295-316.
Jasper, M., (2003). Beginning Reflective Practice. Cheltenham. Nelson Thornes.
Joint Formulary Committee (2011). British National Formulary 61. London. British Medical Journal Group and Pharmaceutical Press.
Medicines and Healthcare product regulatory agency (MHPRA) (2009). Borderlines with Medical Devices. London. MHRA.
Nursing and Midwifery Council (2011) Remote prescribing and injectable cosmetic medicinal products. London, NMC.
Postgraduate Medical Education and Training Board (PMETB), (2008), Patient’s role in healthcare. The future relationship between patient and doctor. General Medical Council.
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