INTRODUCTION
My experience as an Autonomous Nurse Practitioner (ANP) for a period of more than seven years in the Emergency Department (ED) has enabled me to be able to make correct assessments and interpretations of conditions of minor illnesses and injuries. In addition I am able to diagnose manage and make referrals of these patients who are presented to the Emergency Department. Successful management and discharge of the patients without reference to the doctor has been due to my understanding of the medicine’s concordance and knowledge that concordance is different from compliance.
According to Crow (2004), concordance recognizes sharing of decision making with patients when giving them therapy. Kaufman (2011) defines concordance as an agreement between a patient and a healthcare provider reached after negotiation with consideration of patient wishes which determines when and how the medicines are to be taken by the patient. Adherence on the other hand describes the freedom of the patient to follow recommendations of the health provider or ignore them; therefore a patient may be adherent or non-adherent. Compliance is the extent to which the behavior of the patient matches the recommendations of a health professional.
This essay aims at presenting the management of a medical case of lower back pain. The essay describes nurse preparation for patient consultation and the model used in the consultation. In addition a discussion of the pathophysiology of low back pain is presented in the essay. The assay also aims at describing the form of treatment that is chosen for low back pain and the monitoring of the patient until fully recovery from this condition.
BACKGROUND
As Kaufman, (2011) puts it, medical practitioners sometimes underestimate pain when they do not involve the patient in therapy. Chronic severe pain particularly may be underestimated if the concordance with the patient is not a consideration in the management of the sick. Underestimating what the patients are experiencing leads to poor patient management. Similarly, unnecessary medication may be given to patients who are experiencing pain if a medical professional overestimates the pain. It is therefore recommended that nurses and other health officers take patient consultation seriously as an important tool in any medical assessment and management.
The NICE clinical guideline 88, (2009) supports the idea of a health care professional partnering with the patient in assessment and management of the patient’s pain. The individual needs and preferences of patients must be taken care of during therapy. Their families may also be involved where it may be appropriate. The role of medical care professionals is to make informed decisions about patients taking into consideration their contribution into the treatment given to them.
Horne, (2005), confirms that medical treatment without concordance leads to inappropriate assessment, management and treatment of patients who are in pain hence leading to patients’ dissatisfaction with the health care provided to them.
The NICE clinical guideline 88, (2009) discusses the advantages of using the modern consultation models compared to the traditional models of adherence and compliance. Adherence provided the patient with the freedom of choosing whether to follow the advice of the health provider or not. This led to non-adherence to the prescribed medication. Compliance model measured the patient behavior against the recommendations of the health professional instead of the patient being involved in the discussion on the therapy provided.
CONSULTATION
The following describes the consultation between the patient and me with the medicine’s concordance principles being put into consideration. Using the decision making model which was offered by Wendy, (2007) the structure of the consultation is as follows. The concordance model is the preferred model that is gradually replacing the traditional model where the patient and the health provider negotiates and comes into an agreement on the medication the patient is to take, when and how to take the medicine. This model thus provides for patient participation in therapy unlike the traditional models such as Higgs and Jones.
The 35 year old male patient expressed his feelings and described the pain he was in with a clear indication that he understood the way he preferred to be handled. The clarity and extent to which the patient described all details of his pain and its cause and the fact that the patient seemed to understand that his opinion would determine therapy made me choose this case.
As Higgs, (2000) mentions, the treatment of patients with low back pain must take into consideration the patient’s needs and preferences in assessment, management and giving medication to the patient. The patient must therefore be accorded with the opportunity to make informed decisions with consultation with the nurse on how he or she would like to be treated.
I consulted with the patient on how he preferred his back pain managed and he suggested medication to relief the pain as the root of the problem is being managed. The patient was not ready for physiotherapy but I advised that it would be the solution to his pain and he was convinced to try it as long as he was handled with a lot of care.
Chapman, (2009), explains that proper communication between a nurse and a patient with lower back pain is very critical if care provided is to be safe and reliable. The strategies adopted in other industries in communicating with clients should be used in health care provision to ensure that the sick have a say in the kind of treatment that they receive from the medical care providers.
Shafer, (2007) on the other hand says that it should never be assumed that health care providers have good communication skills. He adds that these skills need to be learned. Medical malpractice suits result from lack of good communication. These suits would be avoided if the health professionals learned how to communicate with their patients. Learning these skills will be an advantage to both the patient and the health care provider.
CONTEXT
In preparing to consult with the patient, I read through the brief triage notes on the patient beforehand. I organized for a private consultation room. In the consultation room, first I introduced myself to the patient and briefly talked to him by getting to know him a little better and making him feel comfortable as a measure creating rapport. I then explained to him my role in managing his case as I was seeking for his consent to go ahead in managing his back pain. I further explained that I was accountable for his treatment and explained my limits, the aims of the consultation to make the patient understand that he was free to communicate and express his feelings about the whole treatment exercise. As Malone, (2001), a positive relationship must be fostered by nurses and create a conducive environment during health care experiences. This is necessary because of the big impact the health providers have on perceptions of patients, there safety and well being.
In accordance to the Nursing and Midwifery Council, (2009), the written consent forms may be signed by the patient but what matters is the communication between the health care provider and the patient that causes the patient to authorize the physician to make the patient to undergo a specific medical intervention. Therefore I took personal accountability to discuss the details of the sickness with the patient. I explained my limits to the patient before obtaining his consent by explaining that the aim of the consultation was to promote the patient’s health and finally full recovery with the patient participating in the manner in which the therapy was to be conducted
As an Autonomous Nurse Practitioner who is guided by the oxford handbook of accident and emergency medicine I have the ability to make correct assessment, diagnosis and provide treatment for patients suffering from lower back pain presenter at the Emergence Department. I am also able to follow the NICE guidelines and the hospital policies in managing patients with lower back pain. I understand my limitations and with the support of the senior medical colleagues, I am able to apply evidence based practice and concordance values in making my medical decisions.
Jonathan, (2004), describes Accident and Emergency Medicine as a specialty that is expanding rapidly. Nurses and doctors in the Emergence Department face many challenges and problems. They need to make rapid decisions. The Oxford Handbook of Accident and Emergency Medicine also provides a series of capabilities nurses and doctors need in order to manage patients presented to the Emergency Department and advice on the range of problems and conditions that patients in this department have and how to manage them successfully to ensure patient satisfaction.
UNDERSTANDING
The National Prescribing Center (NPC) (2010) explains that obtaining accurate history is very important. It is necessary to come up with a clinical assessment based on the patient history that is taken. With my experience I was able to determine that the patient had none of the red flag symptoms. This is an indication that his pathology was not very serious.
I adopted the Bates History taking model in taking the patient history; consulting and assessing him. Bickley, (2004) on the Bates’ Guide to Physical Examination and History Taking describes the guide as best foundation for nurses who take patient history and perform physical examination. The guide provides step by step techniques of patient examination with detailed information on assessing pain and also the psychosocial aspects of health care.
To my advantage the patient was a good historian and was very open to questioning. In addition, the patient was able to provide the needed information and data during the consultation which led to accurate history as I ensured precise record keeping in accordance to the requirements of the Nursing and Midwifery Council, (2009).
EXPLORING
Since the patient had already tried paracetamol whose effect was little, he had very high expectations and what he wanted was immediate remedy to enable him resume his duties. During the consultation, the patient’s dislike of taking pills was noted. The pathophysiology of low back pain as describe below enabled me to understand the cause of his pain that assisted me in managing the patient’s condition.
NICE clinical guideline 88, (2009) defines low back pain as tension in the lower back region that causes pain soreness or stiffness in the region. Sometimes it is not possible to the actual or specific cause of such pain hence calling for accurate taking of patient history. The symptoms of low back pain can be aggravated by the structures in the lower back such as connective tissue, discs and joints. The specific cause of pain in the lower back includes fractures infection, tumors, inflammatory disorders and Ankylosing spondylitis.
Sullivan, (2011), on evaluating patients with lower back pain explains that the medical literature helps the health care provider to determine whether there are red flags in the case. These red flags symbolize a serious condition that presents fever, metabolic disorders, muscle weakness, bladder dysfunction, and history of cancer.
Airaksinen, (2006) describes low back pain as pain in the lower back that usually starts after you have a traumatic injury, move suddenly, lift a heavy object or sit in one position for a long period of time. This pain may vary from irregular to severe pain that is continuous. This pain may be sharp or dull.
As illustrated by Morone, (2007), low back pain can either be acute or chronic: Acute lower back pain lasts for a few days while chronic lower back pain is that pain that persists for three months or more.
Carragee, (2005), shows that low back pain is commonly associated with disk degeneration. Poor peripheral blood supply to the inter-vertebral disk is a possible cause of the degeneration that results to severe pain in the lower back.
As Bogduk, (2007) explains, the pathophysiology of lower back pain is usually a nonspecific etiology. Tearing and stretching of tendons, fascia, vertebral column and the spine’s surrounding muscles may occur if sudden force is applied to the spine. This usually results from actions such as torsion of the spine and heavy lifting.
According to Ashok, (2004), the pathophysiology of low back pain is more obvious. Compression by spinal disk of the spinal nerves is the explanation for the back pain especially that which results from an acute disk herniation.
DECIDING
According to the NICE clinical guidelines (2009), the treatment for mechanical back pain is to make sure that the patient is given adequate analgesia so that they can be able to go back to their daily activities as quickly as possible. In this case, the patient had already tried paracetamol but it did not give the desired analgesic effect. From the patient history, the patient had no allergies or medical problems hence I chose codeine & ibuprofen as the analgesics of choice. My choice was in line with the British National Formulary (BNF) and the NICE guidelines.
Response to NSAID’s may vary and in addition some patients respond well to one drug as compared to another. Because the patient received poor analgesic effect from paracetamol alone I prescribed a combination of ibuprofen 600mg along with paracetamol (1 gram) and codeine (60mg). This combination is recommended for moderate to severe pain by the British National Formulary (BNF). The 60mg of codeine was prescribed as the Clinical Knowledge Summaries (2010) state that when a low dose of codeine is used in some preparation it is no more effective than paracetamol when used alone. Ibuprofen was preferred because of its potency in relief of pain minimal side effects and because the patient needed therapy that will relief the pain as soon as possible. In addition Ibuprofen is less costly compared to other analgesics hence affordable to the patient.
Atul, (2000), provides the pharmacologic treatment for simple low back pain as nonsteroidal anti-inflammatory drug (NSAID). If there are no contraindications, the medication should be provided in a two to four week period. In case of acute pain, narcotics may be considered but for a short term use. The possible side effects of using the anti-inflammatory drugs include allergies and nausea.
MONITORING
Deshpande, (2006), shows the benefits of taking a combination of Co-codamol and Ibuprofen as it attains a higher efficacy as compared to taking paracetamol alone hence enabling the patient be able relieve his pain and return to his normal activities as soon as possible.
In monitoring the patient, I recommended him to the physiotherapist whom I advised to return the patients to the Emergency department if the red flag symptoms were experienced. Jordan, (2005), recommends that massage can be used to relief lower back pain. The massage should be done by a physiotherapist who is experienced in treatment of lower back pain. This is because an untrained person my harm the patient.
The physiotherapy referral was made and since the physiotherapist did not report worsening of the pain, it was concluded that the therapy was working. There was successful closure of the case after concise documentation of the patient management process as per the NMC requirements (2009).
REFLECTION
As an experienced ANP my listening and communication skills enabled ne to interact and give him the opportunity to contribute to his therapy by asking questions and suggesting the manner in which he preferred to be treated. The information I gave the patient was based on my knowledge and experience in the ED hence it was adequate. I applied reflective practice in this case as I examined practical values in managing the pain in the patient using actions based on skills, experience, medical guidelines and guides and my insight.
As provided in the National Institute for Health and Clinical Excellency guidelines, (2009), reflection enabled me to work within a legislative framework of the medical profession, as I recognized my boundaries as a student nurse prescriber and also the importance of the medicines concordance principles as a way of recognizing the role of the patient and my colleagues in effective management of the patient.
This case has added more experience to my nursing practice because now I have a better understanding of the medicines concordance and shared decision making and how it relates to my practice as a student nurse prescriber. However the consultation was rushed a little because of the busy nature of the Emergency Department but the care given to the patient was satisfactory.
CONCLUSION
As a nurse in the Emergency Department, my experience and the adherence to the medicine concordance enables me be able to manage a case of low back pain effectively. The case presented here was not serious as the patient did not exhibit any of the red flag symptoms that demonstrate a serious underlying condition to the back pain. With the NICE clinical guidelines on low back pain and medicines concordance, I was able to manage the patient with his approval and contribution to the therapy given a consideration. The use of the patient history and the proper diagnosis of the conditions enabled me to provide the required medication as provided by the British National Formulary. The main objective of the treatment was to successfully follow the treatment procedures of lower back pain and provide medication that would enable the patient return to his normal activities as early as possible.
In treatment of any condition the laid down policies of medical treatment must be followed and proper consultations and referrals done to ensure that there is patient satisfaction in the health care provided. Above all the patient must be given the opportunity to contribute to the therapy prescribed. This is possible through proper communication between patients and health providers. This case provided me with a better understanding of the shared decision making model and importance of medicines concordance in my practice as a student nurse prescriber.
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