Introduction (200 Words)

In this project a medical case is going to be studied deeply with literature support as a case study. My topic is about an anaphylactic shock that happened to patient in hospital while I was doing my clinical placement it is a very interesting case to be considered. An evidence-based information will be provided and identified such as: the definition, the symptoms, the diagnostic features and tests, the progress and the treatment and alternatives. The benefits behind studying a case is effectiveness of delivering the information. As stated by Davis and Wilcock, 2014 that it allows the application of theoretical concepts to be demonstrated and will encourage an active learning, increasing the student enjoyment and interest of the topic and their desire to learn and it also provide a developmental key in learning skills such as problem solving, communication and team work. It is an enjoyable and challenging way of studying filled with evidence-based practice that will enhance the level of doing researches and studies that will help in future studies.

Nursing Assessment (300 words)

The patient has been received in Accident & Emergency in resuscitation room (RR). J.A.M 52 years old Bahraini female. The patient had an insect bite in that day while she was walking in public walking area, she stopped walking and itching occurred all over the body. While driving home after the insect bite the patient felt drowsy and hit another car near her house and loss consciousness. J.A.M was brought to the unit by 999 ambulance fully awake, well oriented, alert, afebrile, no respiratory difficulties, no complains of pain, skin is warm and dry, pallor and shivering with rash on the face gave history of feeling nauseated and vomited 4 times. Vital signs Checked and recorded Temperature 37.4C, Spo2 98%, Pulse 118/Minute, BP 145/43, HGT 7.6 Mmol/L. The skin was mainly involved representing pale colour and rash on the face, the cardiovascular system represents tachycardia, and the immune system is responsible for this reaction against the insect bite. The patient denies any chest pain, denies shortness of breath, the patient is known case of dyslipidemia on tablet Lipitor, no other history of other illness, no history of surgery and no history of any allergy. The patient can handle the basics of activity daily living such as eating, bathing, toileting, dressing and she is able walk and get out of the bed but she is not able to perform certain activities such as food preparation, housekeeping and driving a car. After the acute symptoms have been treated the family should be given health education about how to prevent possible future allergic reaction and the importance of seeking help as quick as possible if they do not know how to deal with the situation. Physical examination was done for cardiovascular system representing chest is equal in shape, no bounding or heaving, no lifting with heartbeat. Upper & lower extremities are normal in color and capillary refill within 3 seconds, skin is warm periphery with no edema. S1 is heard in all sites and S2 is heard all sites but louder at base and tachycardia observed. Skin is pale, dry, soft, warm. No edema, lesions or odor, good turgor, no signs of insect bite, rashes on face.

Medical Diagnosis and other pertinent medical information (500 words)

When received the patient the physician has requested ECG, blood tests as following: Full blood count, Cardiac enzymes, Liver function test, Electrolytes, serum, PT + APTT, ESR. Some of the results was not approved but most of the results were normal, this table shows the most important values and abnormal findings:

The patient was diagnosed as having an anaphylactic shock, the case was chosen because it is very common and could happen to anyone by exposure to an allergen of any kind which is in this case an insect bite. The community may not be aware about how dangerous is developing a serious reaction from a small allergen such as insect bite. The statistics was not specified in Bahrain but in some countries worldwide: “Systemic allergic reactions to insect stings are reported by 0.3% to 7.5% of persons in the United States and Europe’’. (Ruëff et al., 2009) An anaphylactic reaction is an acute systematic hypersensitivity that occurs within seconds or minutes after exposure to an allergen or foreign substance. It is a result of the relationship between Antigen and Antibody, The immunoglobin E is the responsible for human allergic reaction. The person may have a hypersensitivity to the venoms of insects (hymenoptera), stings in any part of the body can trigger anaphylaxis. The signs and symptoms includes Itching, nasal congestion, chest tightness, wheezing, cyanosis, dyspnea, generalized itching over the body, urticarial, tacky or bradycardia, pallor, decreased blood pressure, circulatory failure leading to coma and death, nausea, vomiting and diarrhoea. (Brunner and Smeltzer, 2010) All the required tests has been done to the patient in RR except antibody screening which refers to a special protein that is found on the surface of RBC to check for RH positive or negative. (Mayoclinic.org, 2014) IV cannula inserted once received the patient, Injection Hydrocortisone 300mg IV given, Injection promethazine 50mg IV given, Injection adrenaline 0.5mg s/c given, Injection Ranitidine 50mg IV given. Patient put on Cardiac monitor, Dexamethasone 10mg IV given, old file requested, chest x-ray requested, Paracetamol 1g IV, changed the patient and kept clean, Injection rocephin 2g given on Right Arm. The physician advised to be kept on 1.5 litres of Normal Saline for 12 hours, 2-4 litres of Oxygen on nasal cannula, kept the patient covered with necessary blanket to keep her warm and comfortable.

Impact of the condition on the patient’s Quality of Life (200 words)

The patient may move on to anaphylaxis which is dangerous fatal stage thus the treatment did a great job in reducing this effect by using drugs such as: epinephrine (Adrenaline) which inhibits the mediator release from mast cell and basophils and protect the patient from upgrading to anaphylaxis. The hydrocortisone prevented relapse or protracted anaphylaxis. Lockey, 2014 states that the oxygen therapy will deliver the required oxygen to the patient which makes her comfortable. Promethazine will act on receptor as antihistamine which will reduce the itching and has a sedation effect will put the patient into more comfort. Ranitidine will prevent gastric acid secretion which reduces the nausea and vomiting. Rocephin is an antibiotic which inhibits the bacterial cell wall synthesis and will lead to cell death (Skidmore-Roth, 2012). Normal saline to maintain hydration of the patient. After receiving the treatment patient is feeling better, nausea and vomiting reduced, itching reduced, the patient is comfortable with the treatment.

Discussion (700 words)

The patient treatment started with requesting blood tests which shows any abnormal values to be treated. Brunner and Smeltzer, 2010 advised that treatment starts with removing the causative agent which is the insect venom but the patient did not know the exact site of the bite thus physical examination clarified that there is no proof of an insect bite. Brunner and Smeltzer, 2010 admits that the patient should be given the necessary emergency support of basic life functions which was given already to the patient, Epinephrine was given as vasoconstrictive. Brunner and Smeltzer, 2010 states another drug named Diphenhydramine (Benadryl) included in treatment of this condition to reverse the effect of histamine and reducing the capillary permeability but replacement alternative was given which were Promethazine and Ranitidine that acts on H1 and H2 receptors (Antihistamine) (Skidmore-Roth, 2012). Another medication which was stated by Brunner and Smeltzer, 2010 albuterol through nebulization to reverse the histamine bronchospasm if occurred. Brunner and Smeltzer, 2010 recommended that IV lines should be inserted to provide access to administer fluids and medication, IV cannula was inserted to the patient. They also state that respiratory status is measured by monitoring respiratory rate and if there is any abnormal lung sound and pulse rate any rhythm to be monitored regularly, cardiac monitor was put on the patient to assess the respiratory status and vital signs of the patient. The physical examination of the chest clarify that lung sounds are normal. Oxygen was applied to the patient to help compensate breathing pattern. The patient was assessed for previous allergies or exposure to such antigens and the understanding of the patient about this condition to prevent any future complications. Locky, R. 2014 recommended that the family should be educated about how to avoid the allergen and know the underlying causes of any allergy. Lockey, 2014 recommends that the patient should be given an auto injector which is a syringe that automatically injects single dose of medication when triggered and to be educated about it and the necessary information such as: dose, expiry date, route of administration. Such device is given to many people that are at high risk of developing anaphylaxis only during an anaphylactic emergency. The patient and the family should be also educated about prevention of exposing to the allergen by wearing protective clothes that is covering all the skin when needed to do such sport in public area and the onset symptoms that occurs when already exposed to such allergen. As stated in Brunner and Smeltzer, 2010 there is early simple management that could be done by the patient or the relative by removing the venom or stinger of the insect when found, wound care to be done using water and soap, scratching to be avoided to prevent histamine, to apply ice on the bite site as it will reduce the swelling and decreases the venom absorption by the body. In my opinion, the patient should be identified by wearing an allergy warning band that contains emergency information in case if the patient fainted or lose consciousness. The allergy should be documented in the patient file to avoid any further exposure to allergy and to avoid using the venom immunotherapy (VIT) which treats certain medical conditions. The patient should be monitored carefully during hospitalization because any adverse complication may occur suddenly. The patient should be referred to an allergist or immunologist to follow up regularly to maximize the quality of life.

Conclusion and recommendations (100 words)

An allergic reaction could develop anywhere in the nursing practice such as administering certain drug that the patient allergic to or using and device that has an allergen element. Nurses must highly prioritize the general assessment done when receiving patients specially asking for allergy for any medication or substance or any allergic reaction that occurred in the past, because we held such responsibilities to prevent any fatal complications that occurs because of anaphylactic reaction, shock or anaphylaxis. Nurses must be aware of such symptoms to detect an early reaction which could be preventable as soon as possible. This will be beneficial to the patients and nurses to deliver the maximum health outcomes.

References

Brunner, L. and Smeltzer, S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Davis, C. and Wilcock, E. (2014). Teaching Materials Using Case Studies. [Online] Materials.ac.uk. Available at:

http://www.materials.ac.uk/guides/casestudies.asp

[Accessed 30 Nov. 2014].

Kozier, B. and Berman, A. (2012). Kozier & Erb’s fundamentals of nursing. Boston: Pearson.

Lockey, R. (2014). Anaphylaxis. [Online] Mayoclinic.org. Available at:

http://www.mayoclinic.org/diseases-conditions/anaphylaxis/basics/treatment/con-20014324

[Accessed 30 Nov. 2014].

Lockey, R. (2014). Anaphylaxis: Synopsis. [Online] Worldallergy.org. Available at:

http://www.worldallergy.org/professional/allergic_diseases_center/anaphylaxis/anaphylaxissynopsis.php

[Accessed 30 Nov. 2014].

Mayoclinic.org, (2014). Rh factor blood test Why it’s done. [Online] Available at:

http://www.mayoclinic.org/tests-procedures/rh-factor/basics/why-its-done/prc-20013476

[Accessed 30 Nov. 2014].

Ruëff, F., Przybilla, B., Biló, M., Müller, U., Scheipl, F., Aberer, W., Birnbaum, J., Bodzenta-Lukaszyk, A., Bonifazi, F. and Bucher, C. (2009). Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: Importance of baseline serum tryptase—a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. Journal of Allergy and Clinical Immunology, 124(5), pp.1047-1054.

Skidmore-Roth, L. (2012). Mosby’s 2012 nursing drug reference. St. Louis, Mo.: Elsevier/Mosby.

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Chronic Obstructive Pulmonary Disease (COPD) is a treatable condition that is defined as being “a disease characterised by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases” (Fabbri, 2003). One in every four acute admissions to hospital is due to respiratory difficulties, and 50 per-cent of these are caused by the complications of COPD (Roberts, et al., 2001). In the United Kingdom, it is the third most common cause of overall adult morbidity and mortality, especially among smokers, (Barnes, 1999), and it is a significant burden to the NHS.

In recent years, nurse-led primary care interventions have become more widespread. Although there has so far been insufficient evidence to support their implementation, there appears to be no difference in quality of care between doctor-led and nurse-led COPD programmes (Pye, 2008), and they may offer a cost effective and holistic solution to both the NHS and patients respectively. This essay will use a case based discussion to illustrate the role of the Nurse Practitioner (NP), and nurse prescribing issues for a patient with COPD.

Case study

The patient is a 62-year-old married Caucasian female who attended for a routine primary care nurse-led COPD evaluation during 2010. The patient had no other past medical history, apart from moderate COPD. This was diagnosed three years ago, following recurrent respiratory infections, two of which had necessitated hospitalisation.

The NP had not seen this patient before and after familiarising herself with the notes and establishing a rapport with the patient took a medical history asking important questions about the history of the presenting complaint, the COPD, the patients past medical and surgical history, medication lists, allergies to medications, social history and smoking habits. The NP used a template questionnaire that was part of the COPD care pathway to identify how the COPD impacted on the patient’s quality of life. She herself had introduced this questionnaire herself as a result of her own reflective learning and had based it on one from a paper by Vandevoorde, et al., (2007) that included aspects about patient symptoms that patients do not always volunteer to medical professionals, such as side effects from medication and qualitative measures of fatigue and mental well-being (Vandevoorde, et al., 2007).

Three months earlier, the patient had one exacerbation, which resulted in admission to the local hospital’s medical assessment unit, and she recovered well. She occasionally had “moments of shortness of breath”, but these were typically on exertion and doing other strenuous activities.

During this visit, she reported that her condition was stable. Her sputum production was approximately ¼ – ½ a cup/ day, and she needed to use 2.5l of oxygen at night. The patient continued to smoke six cigarettes/ day, and being a much heavier smoker previously she had a history of 60 pack years. She was compliant with her regular inhalers and had no problems with side effects, apart from a bad “almost metallic” taste in her mouth that she had occasionally recently started if she had forgotten to wash her mouth after using her inhalers. She had also been started on a Corticosteroid inhaler by the hospital respiratory team following her last exacerbation, but she mentioned that she had not noticed any difference in her COPD symptoms in using this. On direct questioning, she remembered that she also did have an unpleasantly sore mouth and voice was becoming hoarser since she had commenced using this steroid inhaler, but she didn’t know if this was the effect of the steroid inhaler, the drying effects on mucous membranes of using oxygen therapy, or something else. She had noticed these symptoms for at least three weeks, and two weeks ago she had noticed “white patches” on her tongue.

Apart from oxygen, and the newly introduced Corticosteroid inhaler that she was using; in terms of her other medication, she was taking the long acting beta 2-agonist Salmeterol twice a day, and the anti-cholinergic bronchodilator, Ipratropium Bromide. She had been using both Salmeterol and Ipratropium Bromide for several years, and she had no side effects with either of these medications. Antibiotics had been stopped for some time since her last exacerbation, and she had finished her Prednisolone some time ago. Overall, from a medical perspective she felt well in herself apart from the mouth problem.

On examination, the patient spoke in short sentences, and occasionally her wording was stifled by shortness of breathe, but she did not appear to be in distress, and she was alert. Her skin was pink in colour and she appeared to be breathing with pursed lips, which is a characteristic feature of being a “pink puffer” and having the diagnosis of emphysema (Flenley, 1990). The NP then examined the patient’s vital signs, checking her pulse, which was 96 beats/ min and regular. Blood pressure, was 140/ 78 mmHg, and she was apyrexial. The NP then looked for signs of peripheral and central cyanosis by checking the colour of the patient’s hands and asking the patient to show the underside of her tongue. There were none, but the patient appeared to have oral candidiasis.

The patient’s hands had a fine tremor, a side effect of her taking the long acting beta 2-agonists (Rossi, et al., 2008), but when questioned, she reported that it was not a problem as she was “still able to write housework instructions to her husband”. The patient’s respiratory rate was slightly higher than normal at 18/ min, but this was satisfactory. The NP listened to the patient’s chest and bilateral breath sounds were equal, but with a few polyphonic wheezes. There were no crackles and no crepitations were present. Heart sounds were normal. Spirometry was done, after explaination to the patient how to do the test in detail beforehand, giving the opportunity to ask questions. The patient had done the test many times beforehand, but expressed appreciation. The results showed airway obstruction and ventilatory impairment, consistent with the diagnosis of moderate COPD. A blood gas analysis was not taken, but the oxygen saturation on air was 96%. Inhaler technique was checked and this was satisfactory.

She lived with her husband, although she mentioned he had recently had to stop work due to him having ill health, and this was causing her a lot of anxiety from both the worry over his health and also the potential impact of the loss of income to their household. He had previously worked in a factory that stored and distributed flour products, and he had over several years started to develop breathing problems himself, despite him being a lifetime non-smoker. He was under investigation by the respiratory physicians, and this was causing a significant amount of tension to both of them. She reported that when she had her last exacerbation, he had become ill at that time, and she had to help him with personal care at home for a period of time, and the increased workload caused her shortness of breath to increase. She felt that her “energy levels had been depleted” for several weeks in the run up to her last admission to hospital, and that she “did not even have time to smoke”.

Despite her COPD being relatively stable on this visit, the patient appeared depressed. When asked if she was depressed, she answered that she was and she was also having difficulty sleeping at night with financial issues caused by the ill-health retirement of her husband being the biggest stressor.

The NP explained to the patient that she had identified several areas that needed action and further discussion with the GP. One was on the appropriate use of the steroid inhaler, the second was the oral thrush – perhaps caused by the use of steroid inhaler (Ellepola, et al., 2001), the NP explained that there are treatments available for this that might be appropriate for her. Furthermore, she told the patient that the issue of depression needed further assessment by the GP. The patient’s medical records were updated with the findings of the assessment, as per good note keeping practice (NMC, 2009), and the patient was left in the room while the GP was consulted.

The NP presented the case to the patient’s GP and mentioned her concerns about both the depression, and also the appropriateness of using the Corticosteroid inhaler and the oral candida. The NP recalled a lecture she had received during her course on nurse prescribing for COPD and discussed this with the GP. The GP took the opportunity to do an informal teaching session and agreed with the NP reminding her about the findings from a paper in 2000, by Barnes, which suggested that inhaled corticosteroids are not indicated for the treatment of COPD anymore. Unlike in asthma, where inhaled Corticosteroids are the mainstay of treatment, they have been found to have a limited role in the maintenance of function in patients with COPD. It was observed that only 1 in 10 patients with COPD will show a significant improvement in lung function following treatment with inhaled corticosteroids (Barnes, 2000) and the reason is thought to be that different inflammatory mediators are accountable for the airway hyper reactivity that is present in asthma and COPD, and those that are responsible for COPD are less responsive to inhaled steroids (Barnes, 2000). Respiratory physicians will still use them, but usually only in cases where symptoms are not optimally controlled with bronchodilators alone (Fabbri, 2004), hence explaining why they were introduced when this patient had her last exacerbation.

It was thought very likely that the oral candida as well as the metallic taste and hoarse voice could be due to her use of the steroid inhaler. The NP showed to the GP that the patient’s pulmonary function, as demonstrated by the Spirometry taken that day, was no worse than on her previous visit, prior to the Corticosteroid inhaler being started. Since a significant clinical response had not been objectively observed, both the GP and the NP decided together that the steroids should be discontinued from the point of view of risk v benefit and also evidence-based best practice.

Both the GP and the NP then explained to the patient about the likelihood of the steroid inhaler not offering her that much benefit, instead causing her new symptoms. Her mouth was examined and it was confirmed that the patient had oral thrush, which is a known side effect of using steroid inhalers (Ellepola, et al., 2001).

It was decided to wean off the Corticosteroid inhaler over a couple of weeks before stopping completely, and see how things go. She was also advised by the GP to rinse her mouth thoroughly after using the steroid inhaler, as well as the others. If the situation became worse, with regards her breathing she was advised to call the surgery for an urgent appointment to review her medication. The NP then suggested that the patient was started on an antifungal medication for the Candida albicans infection, such as Fluconazole, a decision that had been made following consideration and reflection, in line with the steps of the prescribing pyramid (National Prescribing Centre, 1999). The NP had already consulted the British National Formulary online (BNF, 2010a) to check for contraindications. The patient had none and also there were no history of liver problems or cardiac arrhythmia where caution should be exercised. The decision was made to commence treatment using a course of oral Fluconazole. The patient was advised about this, and also she was told of the possible side effects such as headache, dizziness, nausea, vomiting, abdominal pain, diarrhoea and the small possibility of liver problems (BNF, 2010a). She understood the information given and found the decision acceptable and so agreed to commence treatment, and to report any side effects that she noticed.

With regards the patient’s depression this was assessed by the GP, after taking a psychiatric history and risk assessment. Both the patient and GP together decided to try a short course of antidepressant medication, which would be kept under close review. She was also encouraged to pursue social service channels with regards to disability living allowance if she was finding it difficult to care for her husband, especially because she was also infirm. The NP provided her with relevant paperwork for local social services and offered to make some enquiries on her behalf to arrange a home assessment. Before the patient left the room, both the GP and the nurse reinforced the importance of smoking cessation on her COPD and the possibility of nicotine replacement. The patient smiled and said she will “give it some thought”. Influenza vaccination was also mentioned as a reminder for later in the year. A follow up telephone consultation had been arranged for two-weeks time with the NP. The notes were then completed by both the GP and nurse with regards this part of the consultation.

Two weeks the telephone consultation took place and the patient reported that she felt much better about her quality of life, her oral symptoms were “almost back to normal” and since taking the antidepressants, she had noticed a higher ability to perform day to day activities, and overall she seemed to have a more positive and bright outlook on life. The patient mentioned that she had also finally decided to stop smoking and wanted assistance with this in the form of nicotine patches that the nurse had previously mentioned. The NP arranged for the patient to attend a smoking cessation clinic, during which she made a mental note to apply the prescribing pyramid to this particular issue of nicotine replacement, and offered her congratulations on the patient’s progress. A further review appointment was also made with the GP to monitor the antidepressant treatment.

Discussion

This case illustrates the role of the COPD NP in primary care, and discusses prescribing issues. The nurse had taken a complete history and identified several medical, psychosocial issues and prescribing issues and taken appropriate action. From a medical and functional viewpoint, the examination and spirometry showed the patient had stable, moderate COPD, however holistic assessment revealed that she was taking steroid inhalers that were ineffective in her condition and were also causing her to develop an oral thrush infection. The NP also identified that the patient was depressed and there were social problems at home, caused by the patient’s husband being unwell.

The COPD NP correctly identified several issues that needed referral to her GP colleague, and she had worked through a prescribing pyramid to identify that both the steroid inhaler may not be needed anymore, and that the patient would benefit from using an antifungal medication for her thrush.

The prescribing pyramid

The prescribing pyramid (National Prescribing Centre, 1999) is a stepwise approach that has involves seven stages (1-7), and each stage should be considered carefully before climbing to the next:

Consider the patient.

Which strategy should be used?

Consider a choice of product

Negotiate a contract

Review the patient

Record keeping

Reflection

With regard the oral thrush infection, the patient had a full history taken and clinical examination. A holistic viewpoint that took into account the fact that the patient was experiencing unpleasant side effects led the nurse to conclude that GP referral was necessary to confirm the diagnosis and also to tackle the concurrent issue of the steroid inhalers and depression. When considering step four, the NP had reviewed the British National Formulary online (BNF, 2010a) and had decided that Fluconazole was the most effective product for this patient as the patient also had a dry mouth because of her oxygen therapy. Nystatin, another antifungal can be used for oral thrush, but it is less suitable for patients who have dry mouths (BNF, 2010b). The patient also had no contra-indications to Fluconazole, and she was not taking and other drugs that had known drug-drug interactions with this new agent. The patient was informed of all the possible side effects in a form that she could understand.

This patient had a central role in the decision making process in this consultation in line with stage four of the prescribing pyramid (National Prescribing Centre, 1999). Effective communication skills are an important part of good nursing practice, as originally outlined by the UKCC in 1996 (UKCC, 1996). In the context of nurse prescribing, this includes explaining what the prescription in for; how to take the medication; how long it takes to work and what the possible side effects may be. The nurse also referred to the BNF as reference when making this decision, which is an example of good, evidence-based reflective practice.

In accordance with step five, a review of the patient was organised to establish whether the treatment was effective, safe and acceptable. The patient was also advised to make contact if there were any problems, which is in line with guidance (National Prescribing Centre, 1999). For step six, the nurse practitioner made detailed notes in the medical records immediately after the consultation as per recommendations by the NMC (2009).

The NP reflected on her own practice in this situation and asked the GP to give her constructive feedback, which was useful for improving her own learning and practice. Her need for continuing professional development was acknowledged in the original planning of the service within that practice and as a specialist member of the team, having a good working relationship with all the GPs she had the clinical support to hand and was able to obtain medical advice, supervision and guidance when required. The department also had regular visits from pharmaceutical companies and teaching on local formulary practices. The NP’s own educational programme included critical appraisal training to enable her to be aware of the influences on prescribing.

Conclusion

Nurse-led COPD primary care assessment services where specialist NPs are responsible for performing assessment, investigation and are able to act as liaison officers for patients are becoming more widely implemented in the UK as an integrated medical-social and holistic approach to COPD management. Such nurses prescribe full treatment packages for patients and provide them with a point of contact for specialist advice should the patients have an exacerbation at home, as well as forming the link to the tertiary respiratory units should the need arise. Keeping the majority of COPD care in the community should offer better patient centred care as well as cost savings for the NHS. NPs have a crucial role in the management of COPD, and must be aware of prescribing issues reflective learning to give their patients the best possible care.

HIV, the Human Immunodeficiency Virus, infects and gradually destroys an infected person’s immune system, reducing their protection against infection and cancers (Terrence Higgins Trust, 2009a). The General Medical Council, GMC (2009), classifies HIV as a ‘serious communicable disease’ as it capable of causing significant harm and death. It has been estimated that 83,000 people are infected with HIV in the UK of whom 27% are unaware of their status (HPA, 2009, pp. 2). I had the opportunity to meet two community visitors to understand the implications of HIV. Dr. A, a healthcare professional works in a HIV clinic and Mr. Y was diagnosed as HIV positive in February, 2000 following a blood test. Firstly, I will explore the various social and health services available for HIV patients in London which are now more pertinent than ever before as the HPA (2009, pp. 7) report also noted that prevalence of HIV was highest in London. Secondly, I will discuss the range of socioeconomic and psychological barriers that might prevent people from using these services. Thirdly, I will consider methods to overcome these barriers.

Within London, there are many health and social support services available for people with HIV. Firstly, there are primary and tertiary NHS healthcare services. Some patients may use their general practitioner (primary care) as their first port of call who will then refer them to a sexual health clinic (tertiary care). However, people can visit a sexual health clinic or a GUM clinic (genito-urinary medicine) without a referral. There are over thirty GUM clinics in London for a wide variety of patients (GMFA, 2009). GUM clinics ‘deal with the male and female sexual organs’ and health conditions related to them such as HIV and other sexually transmitted infections. They offer advice, testing and treatment amongst other services (NHS choices, 2008). For instance, the Bloomsbury Clinic in central London is ‘open access’ and offers free outpatient services for people with HIV and ‘inpatient services at UCLH’ for specialist treatment. It even offers an emergency clinic for out of hours support (NHS Camden Provider Services, 2009).

Providing multiple health and social services is typical of some GUM clinics in London. For instance, Dr. A’s clinic offers HIV testing and treatment, psychiatry and counselling, social services to help patients with immigration and housing matters, the citizen’s advice bureau as well as specialist HIV pharmacists, nurses, reflexologists and dieticians. I believe this is an excellent model for patients as they have access to all the resources they may require in one location. GUM clinics may run special clinics at specific times for different sorts of people. Dr. A, for example, works mainly with thirteen to eighteen year old adolescents who acquired HIV as a result of vertical transmission, which is the spread of infection from the mother to child in the uterus. A GUM clinic in Ealing operates a ‘gay and bisexual men’s clinic’ on Wednesday evening from six to eight o’clock. Furthermore, the ‘Working Men’s Project’ clinic in Paddington is only for ‘men who work in the sex industry’ (GMFA, 2009). This is also a feature of charity based events. ‘Africa Days’ is an example of a targeted peer mentoring scheme at Lighthouse West London (Terrence Higgins Trust, 2008). These specialist clinics, in my opinion, may help to make the target population more willing to become better informed.

GUM clinics do not function autonomously and are well coordinated with various charitable organisations across London. Dr. A’s clinic works in cooperation with the Terrence Higgins Trust, the UK’s national HIV/AIDS charity. The Terrence Higgins Trust is a valuable asset for people with HIV as it offers mentoring, legal advice, support groups, help with accessing treatment including post exposure prophylaxis (PEP), and educational publications to name a few (Terrence Higgins Trust, 2009b). In essence it is a patient’s advocate group and a hub for information. They directly provide services such as HIV testing but also indirectly advice people about other charities available to support them.

Body and Soul is a London based charity supporting children and families living with or closely affected by HIV. It offers weekly support sessions and counselling and various other activities (Body and Soul, 2009). It has the benefit of being age appropriate for the patients at Dr. A’s clinic and a lot of them have reported enjoying this charity’s facilities. For homosexual HIV patients, GMFA, the gay men’s health provides counselling support and informative leaflets (GMFA, 2009). Mainliners, a London based company seeks to ‘improve the quality of life for people affected by drug use and the spread of blood borne viruses’ by providing educational publications and courses. Their ‘SMART Service’ aims to reduce transmission by offering a clean needle exchange programme (Mainliners, 2008).

Furthermore, some London councils have combined their resources to create social services for HIV/AIDS patients. The South London HIV Partnership (SLHP) is a consortium of ‘a range of organisations in South London working together’ to make it easier for HIV patients to obtain information, advice and support (SLHP, 2009). They offer free ‘reliable’ and ‘confidential’ services. They even make ‘home visits’ in exceptional circumstances. Councils are able to offer social services such as ‘meals on wheels’ and can provide benefits such as ‘income support’ for HIV patients and carers as well (Greenwich Council, 2009).

There are a number of socioeconomic and psychological barriers that prevent people from using the services available to them. Patients may encounter rampant stigmatisation, communication barriers, a conflict of cultures, beliefs and values, of HIV and a lack of information amongst other individual barriers.

Dr. A and Mr. Y both mentioned that HIV is a highly stigmatised condition. According to UNAIDS (2008, pp. 78), ‘HIV-related stigma’ is the ‘process of devaluation of people living with or associated with HIV’. Scrambler (2008, pp. 211-212) noted that ‘a persistently negative societal reaction has continued to play a vital role in the experiences of individuals with the [human immunodeficiency] virus’. Stigma exists because it connotes behaviours such as homosexuality, prostitution and drug abuse (Avert, 2009). I think this displays extreme prejudice and ignorance is exacerbating the problem of socially isolating HIV patients. HIV-related stigma is detrimental for both the individual patient and public health and Mills (2006, pp. 498-503) has shown that ‘HIV-related stigma’ has a significant affect in preventing patients from accessing care. They may be worried about being discriminated against or being shunned by friends and family. Mr. Y commented that he is ‘angry at the stupidity that some people display [towards HIV]’ and that he fears ostracisation. This stigma has been noted in practise. Dr. A explained that her clinic has several single locked rooms where patients will wait to be seen without fear of recognition as they feel humiliated in common waiting rooms. Some make long journeys to prevent being identified by anyone they might know.

Criminalising HIV has certainly not helped to reduce stigma. There have been numerous cases throughout the world where people have been prosecuted for transmission with great disparity in the application of law (Cameron et. al, 2008). This includes a HIV positive homeless person who was jailed for thirty five years for spitting in a police officer’s face as he used a ‘deadly weapon’ which was his ‘saliva’ (Kovach, 2008).

According to Dr. A, communication is a crucial barrier for patients who do not speak English as a first language. Almost ninety percent of her patients are from sub-Saharan Africa and those who have recently migrated to the UK in particular find it difficult to access HIV services in London due to the language difference. She uses an interpreter during her consultations but hinted that it is possible that relevant pieces of information may be missed. I believe this is a crucial obstacle as direct translation, or the lack of it, from one language to another could result in omission or substitution of crucial words which could affect her service delivery. Dr. A’s clinic has attempted to resolve this issue by employing a doctor who speaks French who is better suited to treating people from the Ivory Coast. Counselling services in her clinic have been supplemented through the provision of an African counsellor.

Interestingly, Mr. Y believes that doctors lack adequate listening skills. He believes that in ‘conventional medicine’ as he describes it, doctors are not willing to understand the patient as a whole, and he remarked that ‘patients are just facts and numbers’. It should be noted that Mr. Y is an alternative medicine practitioner for the past fifteen years and I believe this has most likely biased his views as both types of medicine adopt different techniques to manage and resolve disease. However, in general, Mr. Y’s opinion raises an interesting point. Some people may have a fear or dislike of doctors and this could prevent them from seeking treatment.

Dr. A mentioned that a significant majority of her patients are asylum seekers from sub-Saharan Africa. Currently, almost a quarter of HIV patients in London acquired the infection in Africa (HPA, 2009, table 3). The UK government aims to remove failed asylum seekers from the country as it believes that their country has antiretroviral drugs even if the patients are personally not able to access them. The fear of deportation and cost could deter patients from coming forward and seeking help. Cost recently became a barrier following an appeal in the case of R v Secretary of State for Health [2009] EWCA Civ 225 whereby failed asylum seekers are no longer entitled to free treatment from the NHS. Based on Dr. A’s experience, some of her patients from Africa consider HIV as a secondary problem and are more interested in immigration and housing, a problem compounded if they children.

I think that are a few barriers on an individual level which were raised in my discussion with both Dr. A and Mr. Y. Religious beliefs may prevent people from seeking treatment or advice and in an interesting debate, it was argued that Catholicism has ‘beliefs contrary’ to effective management and prevention of HIV such as the use of condoms (Rodriguez et al., 2008). Some of Dr. A’s patients refused treatment as they thought it was ‘God’s will’. I believe other barriers could be issues such as a lack of knowledge of available services and general misconceptions about the condition. This is further complicated for people who may be new to the country.

It is now important to consider the methods health and social services can use to overcome barriers. Current guidelines for the clinical management of HIV emphasises the need to ’empower’ patients and understand the ‘social exclusion and stigma’ associated with HIV (MedFASH, 2003, pp. 9-10). I believe that stigma stems from a lack of knowledge. There needs to be greater public awareness of HIV

Service delivery needs to account for the extremely sensitive nature of HIV. Doctors can reaffirm the patient’s right to confidentiality.

Some patients

This is an ideal approach as partnership between care providers and the patient will ultimately benefit the patient in overcoming social exclusion.

Dr. A’s clinic advocates a patient’s forum where people have a voice. Patients can obtain more information about the extended services available to them as well as having a playing in the ways in which the existing service could be improved. However, Mr. Y, as a patient believes he does not have a voice in the current system and has instead created a personal creative outlet to express his feelings in the form of artistic therapies.

The services discussed are just a brief glimpse of the entire range on offer in London and as per Dr. A are ‘among the best in the UK’. Availability of healthcare services means very little if people are unwilling to use them. Even though HIV has received mass media coverage and support, World AIDS day for example, it is true to say that a crucial barrier in service delivery is stigmatisation. I believe through greater public awareness, education and tolerance, there will be a reduction in HIV-related stigma. To quote AIDS advocate Dame Elizabeth Taylor, ‘it is bad enough people are dying of AIDS, but no one should die of ignorance’.