Nursing. 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,

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Introduction

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 nurse’s wasted valuable time requesting prescriptions from general practitioners (GP’s) 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 patient’s 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 DN’s, 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).

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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 ...

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