Our neighbourhood essay

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However, to the practitioners' knowledge, these have not been validated by a clinical study. Morris, (2008) found in his systematic review that antibiotics cure 50-100 of cases of cellulitis but did not find out which antibiotic regime was most successful. Kilburn et al, (2010) also could not find any definitive conclusions in their Cochrane review on the optimal antibiotics, duration or route of administration. Eron, (2000) devised a classification system for cellulitis and its treatment which crest used in their guidelines. This system divides people with cellulitis into four classes and can serve as a useful guide to admission and treatment decisions. However koerner johnson, (2011) found in their retrospective study, comparing the treatment received with the crest guidelines, that patients at the mildest end of the spectrum were over treated and at the more severe end undertreated.

The practitioner explained that she would like to discuss this with a senior Doctor to help decide on a treatment plan. The practitioner presented the patient to an ed registrar who agreed with the diagnosis. Diagnosis, treatment and prescribing options were then discussed to aid the practitioners learning. Cellulitis is a bacterial infection of the skin and subcutaneous tissue which is potentially serious (Epstein et al, 2008). It is caused by one or more types of bacteria, most commonly streptococci and staphylococcus aureus (nazarko, 2012). Cellulitis usually occurs on the lower legs, arms and face but can arise anywhere on the body (Bickley, grill 2008). Patients with cellulitis present with signs of inflammation, distinctively heat, redness, swelling and pain (nazarko, 2012). Inflammation is localised initially but increases as the infection progresses. Patients can be systemically unwell (pyrexial, tachycardic, hypotensive) and white cell count and C-reactive protein levels will be markedly raised (Beldon, 2011, wingfield, 2009, nazarko, 2012). It appears there is a general lack of evidence based literature surrounding the treatment of patients with cellulitis. The practitioner could only find one national guideline on the management of cellulitis in adults, which was published in 2005 by the Clinical Resource Efficiency support team (crest, 2005).

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All were within normal parameters except her temperature which was.2 degrees Celsius. Venous blood was taken to check haematological, biochemical and coagulation status. Mrs A white cell count (WCC) and C-reactive protein (CRP) levels were raised, all other blood results were normal. Handing over, before making a final diagnosis, it is important that differential diagnoses are excluded (nazarko, 2012). The practitioners' differential diagnoses were deep vein thrombosis (DVT) or venous eczema. However, Mrs A had a straightforward history (insect bite) that together with her observations (raised temperature examination findings (redness, heat, swelling and pain) and blood results (raised wcc and crp) indicated an alternative diagnosis, so dvt and venous eczema were ruled out. The practitioners working diagnosis essay was cellulitis. This was discussed with Mrs a and she appeared reassured that a diagnosis had been made.

our neighbourhood essay

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Upon examination there was obvious erythema. Light palpation revealed that the area was very warm and tender. Neurovascular assessment was performed and was unremarkable. Mrs A's chest was clear, heart sounds normal and her abdomen was soft, non tender. Physical examination is important as it is used to detect physical signs that the patient may not be aware of and can be used to confirm or disprove a possible diagnosis. It also suggests to the patient that their illness is being taken seriously. (Bickley, 2008, Charlton, 2006). Observations were taken including blood pressure, heart rate, temperature, respiratory shakespeare rate and oxygen saturations.

She had been managing to eat and drink as normal. Mrs A lived with her husband, was a non smoker and drank alcohol occasionally. She had no past medical history and took no prescribed or over the counter (otc) medications. It was also elicited that she was allergic to penicillin which she had an anaphylaxis reaction. Taking a medical, social, medication and allergy history is important as it can be relevant to the presenting complaint, makes sure key information has not been overlooked and is essential in preventing prescribing errors (Bickley, 2008; young et al, 2009). The practitioner actively listened to what Mrs A was saying by maintaining eye contact, using open questions and by summarising the history back to clarify points and to make sure nothing was missed. On reflection the practitioner feels this also gave the opportunity for Mrs A to add any further information not disclosed so far. Closed questions were then used to gain specific information related to the initial information given, this is advised by young et al, (2009) and moulton, (2007). Effective communication is important as Epstein et al, (2008) explains that a precise history can supply at least 80 of the information necessary for a diagnosis.

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During this time eye contact was maintained and the practitioner also asked Mrs A how she would like to be addressed. This was done to try and build up a rapport with Mrs a, to help her feel at ease and reassure her. Simon, (2009) and moulton, (2007) agree and state that rapport is essential to effective communication and consultation. Mrs A was also offered a trolley to sit on to make herself comfortable and the curtains pulled around for privacy and dignity. On reflection the practitioner was aware that the environment was a busy and noisy assessment area and this can have a negative impact on the consultation (Silverman et al, 2005). Identifying this with Mrs a and apologising may have re-assured her further and gained trust and respect. Summarising, the practitioner began with an open ended question and did not interrupt the patients' response.

Neighbour, (2005) and moulton, (2007) advise this to open the consultation. Gask usherwood, (2002) found that if a practitioner interrupts, patients then rarely disclose new information, which could lead to not finding out the real reason for the consultation. Mrs A revealed that she received an insect bite to her right lower leg 5 days ago, since then the surrounding skin had become swollen, increasingly red, painful and hot to touch. She explained that the redness was spreading up her leg and the pain was getting worse. Mrs a explained that she was concerned that it was not going to get better and was very worried that it had got worse writers during the last 3 days. Upon questioning Mrs a also complained of malaise and that she had been feeling very hot and cold and at times.

Consultation models can also be used to help make maximum use of the time available at each consultation (Simon, 2009). Traditionally the medical model is used to assess patients however; it does not take into account the social, psychological, and other external factors of the patient. The model also overlooks that the diagnosis (that will affect treatment of the patient) is a result of negotiation between doctor and patient (Frankel et al, 2003). In this case study, the practitioner has used Roger neighbour's model of consultation. This was found by the practitioner to be simple and easy to remember, whilst covering all areas needed to make an effective consultation and assessment. He describes a 5 stage model which he refers to as a journey with 'checkpoints' along the way: Connecting - establishing a relationship and rapport with the patient.


Summarising - taking a history from the patient including their ideas, expectations, concerns and summarising back to the patient to ensure there are no misunderstandings. Handing over - negotiating between the practitioners and patients agenda and agreeing on a management plan. Safety netting - the consideration of 'what if?' and what the practitioner might do in each case. Housekeeping - reflecting on the consultation. (Neighbour, 2005 connecting, mrs A was called through to the rapid Assessment and Treatment area in the. It was apparent from Mrs A's facial expression and limp that walking caused her pain. Silverman kinnersley, (2010) state that non-verbal communication is extremely important and can often provide clues to underlying concerns or emotions. The practitioner had never met the patient before so had no previous 'relationship' with her but was aware that she may have pre-conceived ideas about the ed which may have caused her anxiety. The practitioner introduced herself to Mrs a, explained her job role, the process that was about to be undertook and consent obtained.

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However, nurse diagnosis would appear to have been formally acknowledged since The Crown Two report (doh, 1999) as part of the independent prescriber role. Horrocks et help al, (2002 found greater patient satisfaction with nurse consultations than with gp consultations. Jennings et al, (2009) and Wilson shifaza, (2008) also found this to be true of nurse practitioners working in emergency departments. Importantly, they also found no significant variation in other health outcomes. Most of these studies found that consultations with nurses were to some extent longer, they offered more advice on self-care and self-management and that nurses gave more information to patients. Although there are various consultation models that have been described (Byrne long, 1976; Pendleton et al, 1984; neighbour, 2005; Kurtz et al, 2003; Stott davis, 1979 these are based upon observation of doctor, report not nurse consultations. Nevertheless, the consultation models and skills described in the medical literature are relevant to all practitioners (Baird, 2004). Consultation models help the practitioner centre the consultation around successful information exchange and try to provide a theoretical structure.

our neighbourhood essay

(2001) Critical Reflection halimbawa in Nursing and the helping Professions: a user's guide. Consultation, holistic Assessment Case Study, in this case study the consultation, diagnosis, prescribing options and decisions of a 35 year old female seen in the ed will be discussed. This case study will aim to improve the practitioners' knowledge of conducting a consultation and its relationship with making a diagnosis and treatment options. To maintain confidentiality, in line with the code of professional conduct, the patient will be referred to as Mrs A (Nursing and Midwifery council (nmc 2008). Consultation, examining the holistic needs of the patient is the first of seven principles of good prescribing (National Prescribing Centre (npc 1999) and must be undertaken before making a decision to prescribe (nmc practice Standard 3, 2006). Holistic assessment takes into consideration the mind, body and spirit of the patient (Jarvis, 2008). Traditionally consultation and making a diagnosis has been completed by doctors.

Of Prescribing, supply And Administration Of Medicines. (The Crown Report Two) London: hmso. (2008) making Connections: Using healthcare Professionals to deliver Organisational Improvements. (2011) evaluation of nurse and pharmacist independent prescribing. Faculty of health Sciences, University of southampton; School of Pharmacy, keele University on behalf of Department of health Online available at /184777/ Accessed 15th Sept 2012. (1998) Nurse-patient Relationships: The context of Nurse Prescribing. Journal of Advanced Nursing.

Demonstrate a capability of integrating learning into practice. Submit a range of material mapped against the dissertation module learning outcomes, nmc 2006 prescribing standards, domains of practice and core competencies. Establish an evidence-based approach to practice competence as a safe independent supplementary prescriber. This prescribing practice portfolio will be a reflective portfolio using Rolfe et al (2001) model of reflection to aid learning from experience and close the gap between theory and practice. This model has been chosen as it is something the practitioner is familiar with and has used before. The portfolio will conclude with a reflective summary on prescribing practice learning which will draw together the evidence used to support achievement of the competences identified. After discussing with colleagues who have already completed the nisp course, the practitioner is aware of the complex nature and volume of work that is required over the duration. There is a feeling of nervousness due to this but also a feeling excitement over what will be learnt.

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Print, reference this, published: 23rd March, 2015, the author, a nurse practitioner based in an Emergency department (ed from here on in will be referred to as 'the practitioner'. The practitioner is currently employed in a development role with the view, following training, of becoming an acute care practitioner. This will entail working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. This plan of care could well include a number of prescribed medications. Hence it is in the practitioners job description (as it is increasingly in many specialist/autonomous nursing roles) to become a nurse Independent and Supplementary Prescriber (nisp). The cumberlege report (1986) suggested that nurses should be able to prescribe independently and highlighted that patient care could be improved and resources used more effectively by doing. It identified that nurses were wasting their time requesting prescriptions from Doctors. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (doh 1989, 1999, 2006 2008; luker et al 1994; Latter et al 2011) and is still under constant review. The aim of this portfolio is to: Reflect on practice as a means of on-going personal and professional development.


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Edition used: Adam Ferguson, An Essay on the history of civil Society, 5th. For years we've heard how our economic and accounting systems are flawed because they fail to take into account the resources and services we get "free" from nature.

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