The Prescribing PyramidKimberley Tordoff
Aim of the session
• To appraise the use of the prescribing pyramid in relation to non medical prescribing decisions
Learning Outcomes
By the end of the session learners will be able to
Knowledge• Describe the seven principles of good prescribing• Describe the concept of the prescribing pyramidSkills• practice using the prescribing pyramid• challenge other members of the multi-disciplinary group on
decisions
Attitudes• Continue to build up relationships with their peers through group
work
The prescribing pyramid
1. Consider the patient… The Consultation
• Prepare as much as you can & establish rapport• Identify reasons for consult• Explore the patients Ideas, Concerns and Expectations of the problem (ICE)• Obtain essential information• Impact of problem of the problem• Differential diagnoses• Re evaluate information, ensure shared understanding,
consider more tests, and interpret results for diagnosis• Decide treatment options discuss with patient, Q&A• Summarising, terminating the consultation, writing-up
1. Consider the patient
• WWHAM!
What's Wham got to do with it?Who is it forWhat are the symptomsHow long have the symptoms been presentAny action takenMedication
What information would you want to know about the patient/symptoms
The determinants of Health
• Age, sex, hereditary factors
• Lifestyle factors
• Social & community networks
• Living & working conditions
• Socio-economic, cultural & environmental conditions
Dahlgren & Whitehead 1991
Medications Drug History and Allergies
• Ask patient to list medications they are on, or show their repeat prescription, or bring in their meds.
• Ensure you have a written record in your notes of the name, dose, frequency and route.
• Are they actually taking them as prescribed?• Enquire about Over The Counter (OTC), herbal
and illicit…you may be shocked!• Any allergies or reactions to meds or foods or
environmental factors and record them and any treatment given.
2. Strategy
• Is diagnosis established?
• Is there a need to prescribe?
• Is referral elsewhere indicated?
• What does the patient expect?
3. Choice
• Appropriate
• Effective
• Safe
• Cost
• Acceptable“Sign," © 2011 Adam Williams, Used under a Creative Commons Attribution-Non-commercial-ShareAlike 2.0 Generic license: http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en_GB
Safety Issues
• For any given therapeutic intervention, the potential benefits of the treatment must always be balanced against the known safety concerns.
Avoiding Adverse Drug Reactions
• Use as few concurrent drugs as possible• Use the lowest effective dose• Check if patient pregnant or breast feeding• Is the patient at extremes of life?• Do you know all of the drugs that the patient
is taking• Check for Over The Counter medicines• Drug allergies or previous reactions to
medications
4. Negotiate
• Concordance
• Compliance
• Medicines adherence
Review
• Where
• When
• How
• Who
Record
• Why is it important
• What are the barriers to this in practise
Record Keeping Guidelines
• Accurate• Legible• Unambiguous• Contemporaneous • Relevant• Enough to enable other professionals to provide
effective care• Dated, timed and signed • Practitioners must not tamper with original records in
any way• Electronic records are clearly attributable• Kept securely (NMC,2008)
Reflect
• On your prescribing decision
• On the episode as a whole
• Discuss with colleagues
References
Dahlgren & Whitehead (1991) Social Model of Health www.nwci.ie/download/pdf/determnants_health_diagram.pdf
Nursing & Midwifery Council ( NMC) (2008)
The code: Standards of conduct, performance and ethics for nurses and midwives May London NMC www.nmc.org.uk
Note for facilitator
• Divide the class into inter-professional groups
• Now proceed to Activity on prescribing pyramid
This work was produced as part of the TIGER project and funded by JISC and the HEA in 2011. For further information see: http://www.northampton.ac.uk/tiger.
This work by TIGER Project is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. Based on a work at tiger.library.dmu.ac.uk.
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