A structured approach to prescribing

Independent prescribers need to be able to demonstrate a structured and safe approach to prescribing. One approach for newly qualified nurse prescribers is to use the seven-step structured guide devised by the National Prescribing Centre

Prescribing carries a range of legal and ethical responsibilities that necessitate a structured approach to assessment and diagnosis.¹ The needs of the patient must be holistically considered to determine a genuine requirement for a prescription drug to safeguard both the patient and the health professional (Figure 1).² The decision to prescribe must also meet the requirements of the NMC Standards of proficiency for nurse prescribers.³

Sound clinical decision-making for prescribing is based on thorough history taking and patient assessment, which may include a physical examination.⁴ Taking a good history is one of the most important aspects of the consultation, and is essential in formulating a differential or definitive diagnosis.⁵ It is also important to take into account that prescribing errors are often because of a result of poor history taking4 - one reason why this process should be as accurate and precise as possible. Box 1 shows one approach to constructive history-taking.⁵

CASE STUDY

History

My patient is a 22 year-old marketing assistant who lives with her long-term partner. She has a past medical history of recurrent bacterial vaginosis (BV) and has been taking the combined oral contraceptive pill (COCP), microgynon for two years. She is compliant in attending her three-monthly pill checks and her last blood pressure reading was stable at 120/80 mmHg, she is a non-smoker, consumes 10 units of alcohol a week, has a body mass index of 25.⁷ and has no menstruation irregularities or problems. Her last cervical smear (within the last three years) was normal. In general, her concordance with her medication appears good.

It is important to ask the patient whether they are taking any over the counter (OTC) medicines, vitamins or herbal remedies before prescribing a drug to avoid adverse effects, drug-drug interactions or decreased efficacy.⁶ In addition, nurses must always check whether a patient has an allergy to any medication. Given that this information is not always volunteered, it is crucial to enquire specifically about possible drug allergies with each patient at every consultation. My patient does not have any allergies as far as she is aware.

Presenting complaint

The patient was complaining of more vaginal discharge than normal with an onset of around five days as well as a change in colour with an unpleasant odour that she described as 'lingering'. The SOCRATES mnemonic5 is a logical way of clarifying the presenting problem. (Box 2)

When taking a history in a patient with abnormal discharge, is important to assess whether it is of physiological or pathological origin.⁷ Questions should include:

• duration
• amount
• colour
• consistency
• blood staining
• malodour
• cyclical pattern
• previous episodes, and
• associated symptoms (dysuria, itching, soreness, intermenstrual or postcoital bleeding, superficial or deep dyspareunia or lower abdominal and pelvic pain).

Due to the gynaecological nature of the complaint, a sexual history was also taken and the use of perfumed products, detergents and feminine sprays was noted.

It is important to consider that some patients will worry about being 'abnormal', having cancer or having 'caught' something from their partner when presenting with gynaecological symptoms. Patients may fail to voice actual concerns about relationship or sexual problems and it is only examination of the patient, knowledge of her lifestyle and the appearance of the discharge that will lead to the formulation of a likely diagnosis.⁸

Communication is the key to effective assessment and consultation skills. One of the barriers in communication in a patient presenting with personal physical symptoms involving the genitalia is embarrassment, so it is important to put the patient at ease and this should extend to the examination. Most patient-nurse interactions should demonstrate the nurse's proficiency in communication and effective consulting,9 and the nurse should help the patient to have the confidence to express concerns or fears.⁸

Examination

The following signs were noted on the speculum vaginal examination: thin, white homogenous discharge coating the vaginal walls with offensive odour. No vulvitis, vaginitis, cervical discharge, contact bleeding or cervicitis was observed. Vaginal pH >4.⁵ may be indicative of BV.¹⁰ However, this test alone is not sufficient for a definitive diagnosis. A high vaginal swab (HVS) for culture and sensitivities and endocervical swab was taken to exclude gonorrhoea and Chlamydia trachomatis.

WHICH STRATEGY?

A diagnosis of BV was confirmed post-vaginal examination.

BV is not sexually transmitted. It is caused by a change in the normal bacterial balance in the vagina with an overgrowth of anaerobic bacteria such as gardnerella and bacteroides.¹⁰

A prescription should only be given where there is a genuine need.¹ BV in pregnant women can be associated with late miscarriage, preterm birth, preterm rupture of membranes and postpartum endometriosis. BV is common in women with pelvic inflammatory disease (PID) although it is not clear whether it is predictive of PID. It has, however, been linked to an increased risk of HIV acquisition.¹⁰ Thus there is ample justification for prescribing antibiotics to treat the condition and to protect against problems in pregnancy should the patient become pregnant.

Having decided to prescribe, the next question is what to prescribe, taking into consideration the effectiveness, appropriateness, safety and cost-effectiveness of the prescription drug to be prescribed. (Box 3)

The British Association for Sexual Health and HIV (BASSH) 2012 draft guideline10 for the management of BV recommends:

• Metronidazole 400mg twice daily for 5-7 days, or
• Metronidazole 2g single dose

OR

• Intravaginal metronidazole gel (0.75%) once daily for 5 days, or
• Intravaginal clindamycin vaginal cream (2%) once daily for 7 days (product weakens condoms - advise against condom use during treatment)

Alternative regimens include tinidazole 2g single dose or clindamycin 300mg twice daily for 7 days.

All these treatments have been shown to achieve cure rates of 70 - 80% after 4 weeks in controlled trials. Oral metronidazole treatment is established, usually well tolerated, and inexpensive. The 2g immediate dose may be slightly less effective at 4 week follow up. Intravaginal metronidazole gel and clindamycin cream have similar efficacy but the latter is more expensive. Theoretically, metronidazole has an advantage because it is less active against lactobacilli than clindamycin. Conversely, clindamycin is more active than metronidazole against most of the bacteria associated with BV. Tinidazole has similar antibacterial activity to metronidazole in vitro, and efficacy is equivalent but it is also more expensive.

Metronidazole at the dose recommended above can be used during pregnancy and breastfeeding, although it enters breast milk and may affect its taste. It may be preferable, therefore, to recommend an intravaginal treatment for lactating women.

It is at this stage of the consultation that the prescriber and patient need to negotiate choice of treatment - in this case, whether to use a systemic or topical preparation. In this case, we agreed to use oral metronidazole 400mg, twice daily. It is also important to explain the management strategy and signs of reoccurrence to the patient, as BV has a greater than 50% recurrence rate within the first twelve months after treatment.

Historically, it was advised that patients taking the COCP should always use additional precautions while taking oral metronidazole, but recent updated guidance from the Faculty of Sexual and Reproductive Healthcare confirms that this is not necessary with antibiotics that are not enzyme inducers.¹¹

Patients who are prescribed metronidazole should be advised to avoid alcohol for the duration, and for at least 48 hours after completing the course, of treatment because of the possibility of a disulfiram-like reaction.¹⁰ The most common side effects of metronidazole are gastrointestinal disturbances, nausea and vomiting, taste disturbance, furred tongue and oral mucositis.¹²

Prescribers should always be aware of the cost of drugs they are prescribing and should prescribe with budgeting in mind: a 21-pack of metronidazole 400mg is inexpensive, at lb1.35.

NEGOTIATING A CONTRACT

This part of the pyramid reflects concordance. Improving patients' adherence to medication regimens is essential for effective therapeutic intervention.¹³ The 'contract', when prescribing antibiotics, should include seeking the patient's commitment to completing the course of treatment, even if symptoms appear to have subsided, to avoid adding to the burden of antibiotic resistance.¹⁴

REVIEW

It is usual to advise patients to return if they experience problems, or if their symptoms persist after completing treatment. In BV, patients should be contacted if vaginal micro-culture and sensitivity indicate that a different antibiotic is required. Otherwise, a test of cure is not required if the symptoms resolve.¹⁰

KEEPING RECORDS

Record keeping is an essential part of nursing practice with clinical and legal significance. Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality care.¹

REFLECTION

Reflection is active, purposeful thought applied to an experience to understand the meaning of that experience.¹⁵ However, reflection on experience alone will not increase our knowledge or allow us to develop expertise.¹⁶

The aim of reflection is to improve practice and this can be done independently through reflective thinking and analysis, on paper, with peer groups or with the working team.

CONCLUSION

Using the prescribing pyramid has enabled a structured and logical approach to the prescribing consultation as well as rationalising the use of the prescribed drug of choice to benefit the patient while safeguarding both parties. It reflects and maintains the competencies outlined by the NMC. In addition it links theory to practice and vice versa while building on knowledge in preparation for the role of an independent nurse prescriber.

REFERENCES

1. While A. Medication errors: types, causes and impact on nursing practice British Journal of Nursing 2010; 19(6):380-385

2. NPC Signposts for prescribing nurses - general principles of good prescribing Prescribing Nurse Bulletin 1999;1(1):1-4

3. NMC (2006) Standards of Proficiency for Nurse and Midwife Prescribers NMC, London

4. While A. Practical skills: prescribing consultation in practice British Journal of Community Nursing 2002;7(9): 469 - 473

5. Young K, Duggen L, Franklin P (2009) Effective consulting and history-taking skills for prescribing practice British Journal of Nursing 2009;18(17):1056

6. Greener. Understanding the principles of drug metabolism Nurse Prescribing 2009;7(3):109-114

7. Brown M. Case study: Diagnosing BV Independent Nurse 2007. Available at: www.independentnurse.co.uk

8.Watkins J. BV Practice Nursing 2009; 20(4):192

9. Redsell. Nurse-led consultations: enhancing or diminishing the quality of primary care? Quality in Primary Care 2006;14(4): 203

10. British Association of Sexual Health and HIV. Clinical Effectiveness Group. UK National Guideline For The Management Of BV 2012 (Draft). Available at:

http://www.bashh.org

11. Faculty of Sexual and Reproductive Healthcare Drug interactions with hormonal contraceptives 2011. Available at: http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf

12. BNF 62. British National Formulary BMJ Group, London; 2011

13. Griffith R. Improving patients' adherence to medical regimens Practice Nurse 2006;31(4):21-26

14. Clark L. Antibiotic resistance: a growing and multifaceted problem British Journal of Nursing 2000;9(4):225

15. Ashby C. Models for reflective practice Practice Nurse 2006;32(10):28-3

16. Fowler J. The importance of reflective practice for nurse prescribers Nurse Prescribing 2006;4(3):103