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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