The Nurse Who Recommends an Over the Counter Product in Her Professional Role Remains

Evidence for competencies: 2.9 Prescribes safely, appropriately and cost effectively, 3.1 Knows the code of conduct and can apply the principles of accountability to prescribing practice, 3.2 Is able to account for the cost and effects of prescribing practice, 3.4 Writed and maintains coherent records of prescribing practice

Elsie is a 75yr old lady who has recently experienced worsening headaches. She is otherwise healthy apart from suffering lifelong asthma, which has been broadly controlled with regular inhaled steroids, and bronchodilators as necessary. She has recently had to increase her bronchodilators as her breathlessness has increased. A friend advised her to try Nurofen for her head pain, as it had worked very well for her similar symptoms, and Elsie has now been taking this for just over a week.

I recommended Elsie stop taking the Nurofen as NSAIDs are contraindicated in asthma, and may possibly exacerbate her symptoms (BNF, 2005). As she is over 65 and therefore exempt from prescription charges, I wrote her a prescription for regular paracetamol 1000mg four times a day. Had she been under 65 I would have recommended purchasing generic paracetamol from her local pharmacy, as this would be a considerably cheaper option for all. The nurse who recommends an over the counter product in her professional role remains accountable for that recommendation however, because of the therapeutic relationship which exists, and which thus brings about the duty of care to the patient (Gibson, 2001).

I then arranged to visit Elsie in a further week to assess the efficacy of my intervention. It is my hope that her breathlessness may decrease, resulting in less use of the bronchodilator, which may have exacerbated the headache initially, as headache is a side effect of salbutamol (BNF, 2005).

On review I would check Elsie’s LFTs and Urea and Electrolytes, as kidey and liver function in the elderly can be impaired, and the paracetamol dosage is the maximum recommended in any age group (BNF, 2005). Regular blood tests are a contentious area, and guidelines are hard to find. They may indicate underlying untreated pathology, but may also increase cost, take time, cause discomfort, and even cause false positives (Levy, 2005).

I would record my interventions in my case notes, and write to Elsie’s GP in specific regard to my prescription for paracetamol, in order to align databases, communicate and evidence that communication.

The nurse in this situation has the ability to make a real difference to someone’s well being, both physical and psychological. However, I am personally aware that my knowledge in this area is limited, and have sought to remedy this since the consultation by reading around the subject of asthma and pain relief, discussing it with my mentor and studying closely those treatments nurses will be able to prescribe. Benner (1984) comments that the expert nurse entering a new area of practice may be reduced to the level of novice if the area is sufficiently unfamiliar. I am experienced enough to be aware of my limitations, and though this is hard, do not practice outwith the scope of my competence (NMC, 2005). I thus remain accountable for my prescribing practice.
Nurses from the original nurse prescribing scheme have commented that they felt vulnerable when writing their first prescriptions, despite that fact that many had previously written prescriptions for GPs to sign (Luker, 1998). I expect to experience similar feelings of anxiety when I first sign a prescription and am able, for the first time, to take full responsibility for my decision. As a profession, nursing has tended to “avoid responsibility through deference to doctors” (Wainwright, 1994). For the nurse prescriber working within their scope of practice, this will no longer be an option.

References

Benner, P. (1984) From Novice to Expert. Excellence and power in clinical nursing. Wesley, California.

Levy, S (2005) Buffalo Centre for Integrative medicine [23.03.05]
Luker, K. Hogg, C. Austin, L et al (1998). Decision making: the context of nurse prescribing. Journal of Advanced nursing 27: 657-665.
Gibson, B (2001). Legal and professional accountability for nurse prescribing. IN: Courtney, M. (Ed). Current issues in nurse prescribing. Greenwich Medical Media

Wainright, P (1994). Professionalism and the Concept of Role Extension. In: Hunt, G and Wainright, P (Eds). Expanding the role of the nurse. Blackwell Science, Oxford.