Reflection of Role of Prescribing for Patient with Stroke

The World Health Organisation (1978) describes stroke as a disease of probable vascular origin, which is categorised by symptoms developing in a sudden nature, which due to the interruption of cerebral function can cause either localised or global symptoms. In my role as an Advanced Practitioner, my purpose is to advance the delivery of care utilising an understanding of both regional and national driver, ensuring a holistic and individualised assessment (Ryley et al, 2016). This aspect of care is enhanced by the oversight of both medical and non-medical consultants and through members of a Multi-Disciplined team.

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I will reflect up on a patient contact of a 69-year-old male patient under the care the care of the above team. The patient was undergoing a period of rehabilitation due a stroke had suffered some weeks previous, but now complaining pain in the affected upper limb, which normal analgesia was not affective.  To maintain patient confidentiality the patient will be call John For the purposes of this reflection, Nursing Midwifery Council guidance (NMC 2015).

The purpose of this refection is to investigate my understanding the practice of prescribing more importantly, contextualise the elements involved in the role of the prescriber. The role of reflection is conceptualised as the understanding how practise, specific interventions and evolving patient management develops individual practice (Rolfe, 2001), is understood to be an action of such influence that its role should not be underestimated (Cox et al 2013) and can be used a conduit between the notional gap of academia and practice (Johns, 2017). To allow me to provide structure to this piece of work I will use the reflective model as described by Driscoll (2000),

What happened?

The patient, who for the purpose of unanimity will be named John, was admitted to a local Stroke ward due an acute onset of Left sided sensory loss. Brain imaging established an ischaemic stroke, due to interrupted blood supply, leading to acute loss of neuronal function. (Kumar and Clarke 2012).

Treatment options for john followed national stroke guidelines (RCP 2016). John was moved from an acute setting to that more fitting of a rehabilitation patient (RCP 2016).

It was becoming evident that John was finding it difficult to fully integrate into the rehabilitation programme due to pain and fatigue in the L arm. This interruption in his rehabilitation programme was at odds with the personalised rehabilitation goals as prescribed by the AVERT trial (AVERT trial group 2015).

I began by gaining consent and making myself known to John ensuring that he know the reasoning behind our discussion (NMC 2015). Initially it was difficult to interact with John as his main objective was to get home and not to have any further interventions. It is import to recognise that there is a proportion of patients that will knowingly under report symptoms due to pain post stroke (Kumar et al 2017).

Obvious progress had been made with Johns rehabilitation (Colomer et al 2016) but the therapy teams working with John has identified further meaningful progress if John could interact fully with the program of therapy assigned to him.

With members of the MDTR I was able to identify the areas of concern with John and described to him how pain and then reduced interaction would mean a greater time in hospital. Through an integrative MDT approach, I was able to explain to the patient the potential barriers to his ongoing rehabilitation, including a delayed discharge. Taking this opportunity I was able to discuss further pain management options.

So What?

Accurate history taking can assist in many decisions that need to be made (Tyrrell et al 2015), whilst supplementing action choices around practical and pharmacological discourses to achieve optimal management. Research has demonstrated that a number of a common cause to post stroke pain (Harrison et al 2015, Seifert et al 2016, Bethoux 2015,).

There is a correlated link between stroke and depression leading to rehabilitation goals not being achieved, so it was appropriate to ask if John was being affected in this way. (Stanton-Hicks et al 2018, Graig et al 2013). It is explicitly understood that pain such as John was experiencing has multiple complications (Harrison and Field 2015; Gamble et al 2000) and how this concept can affect a large number of patients.

Due to changes in the brain post stroke, pain can be experienced in the affected side, although no such injury has occurred (Finnerup et al 2016). The hypothetical conclusion is uncertain, but pain may be caused by neuronal activity being uncontrolled or the hypersensitivity to stimulus as the potential pathophysiological reasons for this condition (De Vloo et al 2016).

As demonstrated the causes for post stroke pain are defined, but it must also be understood that reduced limb activity, increases muscular tone/contracture, thereby increasing pain within that limb, this cyclical action of pain and reduction in movement, leads to further complications (Liza et al 2019).

Pharmacological treatment of neuropathic pain consists of either antidepressants such as tricyclics or serotonin-norepinephrine reuptake inhibitors and anticonvulsants such as Gabapentin and Pregabalin in the first instance (Royal College of Physicians 2016). The use of anticonvulsants in this patient group is seen as being the best option. Banerjee et al (2013) appear to conclude that although cost of anticonvulsants is greater that antidepressants there is some evidence to suggest that anticonvulsants appear to have less potential variance, with Kamerman et al (2016) suggesting that Gabapentin should be considered as the first line treatment option.

Pregabalin is a ligand for alpha2-delta subunits of voltage gated calcium channels within central nervous tissue. It was originally conceived as a drug to help control epileptic seizures in patients (Ryu et al 2012). Subsequent evidence suggested that it also has a role to play in the control of neuropathic pain. It effects are not fully understood but are believed to be inline with the commendation of neuronal cells (Patel et al 2016).

Gabapentin acts in a similar way to Pregabalin, but in this context is a derivative of 1-(aminomethyl) cyclohexaeacetic acid and in a similar context little is known as to its pharmacodynamic process (Cruccuet et al 2017). Similarly, Gabapentin was established as an antiepileptic and has an effect of reducing the excitable cells within the brain. In the context of pain, it does not block the pain, but reduces the sensitivity of the neurons (Whita et al, 2010).

When considering the use of Gabapentin, it is excreted via the Kidneys and as such the renal function of a patient should be monitored (Brunton 2010; Kaufman et al 2013).

At the time of consultation, John was treated with the standard antiplatelet and lipid lowering treatment (RCP, 2016). Renal function demonstrated no chronic or acute injury Both antiepileptic medications mentioned  have been deemed safe for use with medications Jiohn wa already prescribed and in the context of atrial fibrillation are deemed safe for use when combined with (Joint Formulary Committee 2015).

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Patients previous experiences can alter the perceived benefit of a potential treatment option and although many unique alternatives, such as questionnaires have been developed, it is the consolation that still proves to be the best method of initiating medical pathways (Nielsen , 2018). Although the case, questionnaires can still prove to be beneficial. One such, validated questionnaire (Herrero et al 2017), the S-LANSS has demonstrated the correct pain class. During the consultation and subsequent assessment, it was noted that John was unable to use the right arm due to his stroke and consequential increased tone. John found it difficult to accurately define the type of pain he was experiencing but contextualised the pain as a stiffness. John, through discussion had not realised what affect the reduction in movement, due to pain was having on his ongoing rehabilitation. He did understand that during his therapy sessions he was having to reduce the amount of activity time due the pain he was experiencing.

Due to the fact that he now fully understood what affect the pain was having on his therapy sessions, he agreed that he would agree to starting Gabapentin in combination with paracetamol (RCP 2016; NICE guidance, 2013), this was prescribed by my DMP.

The dose of the medication left some room to be increased if the desired affect had not been achieved, enabling John to fully participate in his therapy session. By r.evisiting the use of the S-LANSS tool, John was able to adequately manage his ongoing pain, especially during his therapy

With a further few weeks therapy and due to his pain management being optimised, John was able to return home with the help of specialised community services. John progress and pain management was constantly assessed. On discharge, Johns GP was asked to monitor his pain, via the use of the S_LANSS tool. Due to another element of Johns stroke, he had become forgetful and he was rightly concerned that he would forget if he had taken his medications for that day. John was able to receive free prescriptions and his pharmacist was asked to dispense his medication in the form of a dosette box.

Now What?

This patient encounter has allowed me to bring together features of the Non-Medical Prescribing course. Developing some comprehension of pharmacology and pathophysiological methods, has demonstrated even further the need for a consultation that is patient centred, when considering the prescribing process.  Due to this reflection the standing of the consultation has been increased.

My preferred model of consultation is the Through Calgary-Cambridge model (Kurtz et al 2003), as was evident within this consultation. Keeping the patient central to the choices and decisions that need to be made is paramount, moving away from this approach can lead to a lack of consonance (Desai et al 2018; Cox et al 2004). With the change of the concept of an uninformed patient a two way conversation must be formed to allow the best treatment options prevail (Smith et al 2000; Bylund et al 2011; Couet et al 2013).

A practitioners role is to empower the patient through information and knowledge to ensure that the patient fully engages with their treatment management (Nicholson Thomas et al 2017).

Within the changing field of health and the public health agenda, reflection of the consultations I perform will allow for the most current treatment options to be delivered and also allowing the patient, in this case John, to fully engage and understand their treatment options available to them, allowing for shared decisions to be made and be able to fully participate with their individualised care. The patient contact and this reflection have enabled me to fully understand the concept of the centralisation of the patient within the consultation (Schoenthaler et al 2018).  Using validated tool as apparatuses to enabling decision making, may support ongoing management of patients to assess their treatment outcomes however, these tools must be validated and practitioners trained in their use (Cook et al, 2018). The manner through which I intend to achieve an ongoing renewal of skills and implementation of evidenced based practice is through observed prescribing activities.  Exposure to wider prescribers practice and a continually growing awareness of not only the biological, but the ethical and legal constraints of prescribing through attendance to medicine management forums and MDT working alongside pharmacy colleagues.

It is evident that the Non-Medical Prescribing programme has given me a foundation on which to build my practice. My continuing professional development and practice of my prescribing skills will allow me to effectively create diverse management plans based not only on best available evidence but, at the heart of practice, the patient, their biological and psycho-social well-being (Kinderman, 2014).

References

Appendices 1.

S-LANNS questionnaire.