Practice Nurse in General Practice - Case Study Example

Reflective Exercise Introduction: I am a practice nurse in general practice. In practice, I come across many patients. While examining and treating patients, there are many situations where frustration looms large when I see that a patient is suffering despite my utmost attempt to provide him relief. The satisfaction of a general practitioner lies in her patients' cure or relief as may be applicable to the case. When I reflect on my experiences, I make sure that it serves as an opportunity of criticizing myself in my practice. Few questions asked and answered to self serve as an exercise to reorganize learning and education, and indeed, they help in developing strategies in future encounters with same patient or other in a different occasion (Barnes, P. J., 2007). Self-awareness: For ethical reasons, the identity of the patient that I am going to discuss now will remain confidential. I will call him Joe throughout this reflective exercise. He is a 25-year-old young man whom I have been treating. He is a university student, extremely pleasant, and severely irritated and impatient when in distress. He gets care in my practice for his bronchial asthma. He started having his attacks in adolescence, and suffering has imparted a stoic indifference to instructions to avoid an attack or on medications. As a practitioner, I am offering him treatments in my general practice surgery as an independent nurse prescriber for few years. In the beginning, his parents used to accompany him, specially when he used to have a severe attack. Medications in the form of steroids and bronchodilators had been routine. Despite this, he continues have attacks and flare-ups almost at seasonal intervals. Now, he is on inhaler therapy, since inhalers are treatments of choice in cases of bronchial asthma (Horiguchi, T. et al., 2006). Not only for NHS guidelines, current teaching suggests that aerosol inhalers taken regularly would prevent an attack of bronchial asthma and may be successful in achieving and maintaining a steady state for such patients. Initially, he was particular in using his inhaler schedule, but currently, it has been observed that he is having frequent attacks. On enquiry, it was revealed that he has not been using his inhalers. When I confronted him, he divulged that he thinks his inhalers are no longer acting; furthermore, he thinks inhaler is something habit forming. He would rather go for some oral medications or injectables for his problem. Honestly, I was first extremely irritated and desperately tried to stress on the fact that he will have to accept my prescription (Jantikar, A., et al., 2007). Description: When he presented to the clinic, there was audible wheezes; he was coughing incessantly. His accessory muscles of breathing were very prominent. There was nasal flare with a rapid breathing rate. Evidently, he was in distress. When I examined him, he was having no evidence of cyanosis in the nail beds, but his discomfort was evident from auscultation of his chest. The bronchospasm was evident from the wheeze and rhonchi. He was in distress; his blood pressure and heart rate were both little elevated, and psychologically, perhaps, this is called acute distress. He attended the clinic 2 weeks ago with almost an episode similar in intensity, and he was advised inhaler therapy with salbutamol and betamethsone. As far as my experience goes, 2 puffs twice daily of salbutamol and 2 puffs twice daily of betamethsone would be sufficient to provide and relief and continuing these in the same schedule would help maintain a symptom-free state in Joe. I was upset to see him back in the surgery because it was absolutely contrary to my expectations about the clinical outcome in case of Joe (Tatsis, G., Kotsifas, K., Filaditaki, V., Makrantoni, G., and Boulia, S., 2007). It was more frustrating to know that he has not use his inhalers due to misconception and unawareness, and as expected has entered into another episode. Critical Analysis: Inhalers, as per guidelines and on the basis of present knowledge are mainstays of therapy of bronchial asthma provided the patient is compliant. In fact, apart from the patients who are in the severe acute state at the time of presentation who need institutional management, all other patients presenting in the general practitioner setting can be treated with inhalers for both acute and chronic presentations. This means, the patients may be treated with more frequent inhalers up to 10 inhalations of each daily in the acute attack phase and then gradually tapering down to 4 inhalations of each daily as maintenance therapy to maintain a symptom-free state (Micheletto, C., Guerriero, M., Tognella, S., and Dal Negro, R.W., 2005). In case of Joe, a look and probe into his more than expected frequency of acute presentation led to the question whether the therapy and prescription was right for him. It was revealed that he was not compliant with his inhalers. Despite irritation, I revisited my advice to him. I questioned myself if I had educated him appropriately on the previous visit. On reflection, I could understand, perhaps, I should have spent more time with Joe explaining the rationale and science behind inhaler use. Inhaler is standard therapy because it delivers the therapy directly in the inflamed bronchial tree. By avoiding oral or parenteral route, the adverse effects of these therapeutic agents are avoided effectively. Added to that aerosol administration employs the physiology of respiratory tract where air is deployed as the vehicle of the drugs to reach every corner of the bronchial tree to reduce inflammation and beta-adrenoceptor mediated bronchoconstriction in these patients. It is true that compliance is an issue with the patients suffering from bronchial asthma (Tomlinson, H.S., Corlett, S.A., Allen, M.B., and Chrystyn, H., 2005). This would, as expected, be more prominent in a patient like Joe who has been suffering from adolescence. Synthesis: I as a practitioner had perhaps been paying sole attention to therapy alone. In case of bronchial asthma patients environmental adjustments are important parameters for a successful therapy (Anderson, P., 2005). The patients often get frustrated with the cycle of suffering and symptom-free period, and they need psychological manipulation and motivation directed toward eliminating the idea that asthma is a disease where suffering is the rule, and cure and relief is an increasingly distant idea in the course of therapy (Belda, J. et al., 2007). The prescriber's role as provider is not only to prescribe inhalers, but also to increase awareness about inhaler therapy, and the key to achieve target therapeutic benefit is to continue therapy (Strek, M.E., 2006). In future practice, I have made it a point to stress this and explain this to the patients. I little more time spent in explaining the rationale would motivate the patients and would influence their decisions in the right track (Gillissen, A., Busch, K., and Juergens, U., 2007). Evaluation: In short, therapeutic prescriptions in bronchial asthma should come in a package, and the other counter part is education. Understanding the disease would alleviate the frustrating resistance for using inhaler therapy on the part of the patients. More importantly, the prescriber has a responsibility to highlight the importance of inhalers from the context of the pathophysiology of bronchial asthma. At least, the patient would be offered an informed choice to accept or reject therapy after all information is delivered. My learning from this experience had been extensive because the experience with Joe has taught me again that therapy for bronchial asthma is inhaler based, and patient's understanding in this regard is more important than the prescriber's choices. References Anderson, P., (2005). Patient preference for and satisfaction with inhaler devices. European Respiratory Review; 14: pp. 109 - 116. Barnes, P. J., (2007). Scientific Rationale For Using A Single Inhaler For Asthma Control. European Respiratory Journal; 29: pp. 587 - 595. Belda, J. et al., (2007). Anti-Inflammatory Effects Of High-Dose Inhaled Fluticasone Versush Oral Prednisone In Moderate Asthma Exacerbations. A Randomized Clinical Trial. European Respiratory Journal; 10.1183/09031936.00050306. Gillissen, A., Busch, K., and Juergens, U., (2007). Adherence to therapy in bronchial asthma. Dtsch Med Wochenschr; 132(23): pp. 1281-1286. Horiguchi, T. et al., (2006). Usefulness Of HFA-BDP For Adult Patients With Bronchial Asthma: Randomized Crossover Study With Fluticasone. Journal of Asthma; 43(7): pp. 509-512. Jantikar, A., et al., (2007). Comparison Of Bronchodilator Responses Of Levosalbutamol And Salbutamol Given Via A Pressurized Metered Dose Inhaler: A Randomized, Double Blind, Single-Dose, Crossover Study. Respiratory Medicine; 101(4): pp. 845-849. Micheletto, C., Guerriero, M., Tognella, S., and Dal Negro, R.W., (2005). Effects Of HFA- And CFC-Beclomethasone Dipropionate On The Bronchial Response To Methacholine (Mch) In Mild Asthma. Respiratory Medicine; 99(7): pp. 850-855. Strek, M.E., (2006). Difficult Asthma. Proceedings of the ATS; 3: pp. 116 - 123 Tatsis, G., Kotsifas, K., Filaditaki, V., Makrantoni, G., and Boulia, S., (2007). Efficacy Of Beclomethasone Dipropionate HFA 200 Microg Once Daily In Chronic Obstructive Pulmonary Disease And Bronchial Asthma. Journal of Internal Medicine and Respirology; 35(3): pp. 361-373. Tomlinson, H.S., Corlett, S.A., Allen, M.B., and Chrystyn, H., (2005). Assessment Of Different Methods Of Inhalation From Salbutamol Metered Dose Inhalers By Urinary Drug Excretion And Methacholine Challenge. British Journal of Clinical Pharmacology; 60(6): pp. 605-610. Read More