Development of Competent Nursing Skills


This essay focuses on a reflection on the development from novice, to competent beginner, to skilled practitioner in the light of my own development in clinical nursing practice. It is based on the signposts identified within my clinical learning portfolio and focuses on the notion of the helping role and caring skills within nursing practice. It utilises a reflective framework to better identify and reflect upon the journey from novice to practitioner.

The model for reflection I have chosen is Gibbs Reflective Cycle (see Appendix). Reflection has been described as as a process of internally examining and exploring an issue of concern, triggered by an experience which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective (Boyd and Fales, 1983). Therefore, the experiences of my three placements are explored under three rotations of Gibbs Cycle. Meretoja et al (2004) state that nurses’ self-recognition of own level of competence is essential in maintaining high standards of care. I have chosen the caring role based on my own recognition of the level of competence achieved in this area.

Cycle One

Novice to Advanced beginner

What Happened.

I had to assist a patient in with personal care; make them comfortable in bed and collaborate in pressure area management; assist with toileting, washing, mouthcare, and application of emollient cream. I also had to document care and any deviations from the norm.


I was very aware of my inexperience and of the trust this patient placed in my and the nursing team. I was also aware of the intimate nature of the care I was providing, and the fact that it was basic care also highlighted the fundamental role such care has in supporting health promotion and patient wellbeing.


I was uncomfortable at first, and clumsy in the provision of the various aspects of care. However, my mentor was informative, supportive and helpful, which assisted me in doing the various tasks. However, I found it difficult to complete these as quickly as I should have. I did learn to communicate with the patient and provide a sensitive approach.


This situation required fundamental aspects of the caring role. It also demonstrates the link between basic nursing care an every other aspect of nursing. The NMC (2004) requires nurses to provide individualised care for their patients. The care for this person was based on their own needs and adapted as those needs changed. I was able to identify those needs and develop competency in providing care at this level. The caring role was very rewarding but physically and emotionally taxing However, I was still in the process of identifying particular needs and responding to them, such as toileting, which required me working with others in a collaborative manner, which I did not find easy. I also realised how much I did not know about nursing.


In this situation, I could have developed more collaborative working skills and modelled myself on those around me more actively ie., copied the ways in which other nurses and healthcare assistants provided care. When I did do this, it was effective. But I found that despite my enthusiastic approach, my knowledge base meant that I did not always understand the rationale for what I was doing.

Action Plan

The action plan from this was to take the confidence and competence I had developed in the practical skills and incorporate them into all aspects of the caring role. It was also to identify areas where my knowledge base was lacking, and seek out this knowledge. Keeping knowledge up to date is a requirement of the NMC code of condut (NMC, 2004). Working collaboratively is another NMC requirement (NMC, 2004). Taking this knowledge forward into practice made this process of reflection a learning activity.

Cycle Two

Advanced Beginner

What Happened

As part of my role assisting with patient care, I had to monitor pain levels and assist with providing analgesia as prescribed, along with monitoring its effectiveness. This was a surgical placement, and I also discussed with elderly patient their coping and wellbeing after hospital discharge. I engaged in health education and support to enable clients to be self-caring.

I was also responsible for monitoring wellbeing through performing and recording clinical observations, recording fluid balance and reporting any abnormalities. I was also involved in providing personal care to patients in a safe manner, especially in the disposal of waste products.


To begin with, I felt glad to be working at a more advanced level of competency, and felt confident in my basic nursing skills including performing clinical observations. However, the increased demand also meant increased pressure and I was aware of this. Again, I felt that I had developed a degree of competency but was very aware of my need to develop further knowledge and skills. The caring role involved supporting people and I had to access other professionals to ensure I gave the right information and that my care had been effective.


It was good to find that I had the clinical competence to effectively monitor clinical status. However, the complex nature of patient needs meant that I still didn’t always know the answers to their questions. Being involved in discharge planning was an enabling activity for myself and the patients. I developed competence in the administration of medications, under supervision, including controlled drugs, but felt I still needed more practice and skill in this area. Colleagues noted my competence and qualified staff were happy to delegate a range of appropriate tasks to me.


It would appear that the caring role means the provision of patient centred, holistic care. This was achievable in this situation but required a lot of knowledge and the ability to provide focused attention and empathic care whilst carrying out complex clinical nursing tasks. This was harder to achieve, and I was made aware of my continued learning needs around medication and surgical care, for example. However, I must have developed some competence as qualified staff were happy to delegate to me and to act on my feedback.


It is hard to see what else I could have done, except perhaps done more reading around surgical care, discharge planning and the nurse-patient relationship.

Action Plan

It was possible to identify future learning needs, and so my action plan included building on my current competence by engaging in more advanced practice, under supervision. Having the confidence to engage in more complex nursing tasks will help me to achieve more competence in advanced practice in the future. Recognising the demands of the caring role means that I will view future practice as based upon this role.

Cycle Three

Competent Level

What Happened.

I monitored patients with chronic pain and helped with analgesia. I also supported patients with freedom of choice for their own care (NMC, 2004) and provided personal and palliative care in sensitive manner. I mastered more advanced practical nursing skills including aseptic technique and safe disposal of sharps. I fully documented all care given, and recorded medication given, and communicated to staff at shift change during the nursing handover.


During this experience, I felt that my knowledge and experience in the caring role was finally coming together. I was confident and happy in engaging with patients and providing empathy and a supportive manner, whilst also carrying out more complex clinical tasks appropriately and effectively. It was very nerve-wracking giving handover, but I became more confident as I had more practice.


I was able to provide care of a high standard, and recognise my sphere of competence and seek help when needed. I was able to engage in effective caring relationships with clients, meet their individual needs, but also value my own input into their wellbeing.


It was obvious that I had moved on to a level of nursing competence which allowed me some autonomy. I was able to act with less direct supervision, but still access the support of the whole care team. The caring role extended to the provision of all care, including end of life care, and I was able to utilise my knowledge and experience and also identify my learning in action, and my future learning needs, which have changed since the first reflection.


The change from novice to competent practitioner in the caring role has demonstrated not only the acquisition of skill but the incorporation of clinical abilities into what is really a way of being with patients.

Action Plan

Signposting future learning needs is important following this reflection. I was able to identify the need to still learn advanced clinical skills and perhaps know more about the range of other professionals who could enhance care in individual situations.


This reflection has signposted my development towards competent nursing practice. The caring role encompasses provision of basic care, advanced techniques, medication and pain relief, health promotion, end of life care and collaborative care. It seems to be the fundamental and most important part of nursing practice.

Collaboration and coordination, as well as the holistic management of the situation, are highly recognized as meaningful characteristics of competent nursing practice (Meretoja et al, 2002).


Boyd E, Fales A. (1983) Reflecting learning: key to learning from experience.

Humanist Psychol

23 (2) 99–117.

Gibbs, G. (1988) Learning by Doing. A Guide to Teaching and Learning Methods Further Education Unit, Oxford Polytechnic, Oxford

Meretoja, R., Leino-Kilpi, H. & Kair, A. (2004) Comparison of nurse competence in different hospital work environments Journal of NursingManagement.12(5) 329–336

Meretoja, R., Eriksson, E. & Leino-Kilpi, H. (2002) Indicators for competent nursing practice

Journal of Nursing Management

10(2) 95-102

Nursing and Midwifery Council (2004) Code of Conduct Available from

Accessed 30-4-07.

Immune System Explained

The immune system is of great importance for protection of the organism against foreign substances, and consists of molecules, cells and tissues that work collectively to provide this protection. One of the key members of the immune system is the MHC (Major Histocompatibility Complex), a molecule expressed on antigen presenting cells, such as macrophages, dendritic cells and B cells, and required for the proper antigen presentation. The MHC is responsible for binding peptides originated from foreign proteins and displaying them on the surface of antigen presenting cells, allowing their recognition by T cells, which will initiate an immune response. MHC molecules are highly polygenic, which means that there are multiple different MHC genes, and consequently different sets of MHC molecules with different specificities in each person. Besides that, MHC genes are also very polymorphic, with many different variants in the population.


The human MHC genomic region, on chromosome 6, encodes HLA (Human Leukocyte Antigen) genes, and the great diversity previously cited is responsible for the differences seen in immune responses within a population.


There are two main classes of HLA (I and II), both responsible to present peptides to T cells and trigger an appropriate immune response. The main difference between these classes is that HLA I molecules present endogenous antigens derived from viruses and phagocytosed or internalized pathogens to CD8+ T cells, triggering a citolytic response on recognized cells, while HLA II molecules present exogenous antigens generated intracellularly in antigen presenting cells to CD4+ T cells, that will trigger the production of antibodies by B cells.1,3,5 Besides that, HLA I and II are differently expressed on cells: HLA class I is expressed in almost all cells of the body, in high frequency on cells of the immune system and in low frequencies in non-nucleated cells, while HLA class II is exclusively expressed on cells involved in immune responses, such as antigen presenting cells.1,2 Both HLA classes I and II are divided into subtypes, being A, B and C the three more important of HLA class I, and DR, DP and DQ the three more important in the case of HLA II.2,3 Besides that, in the region in between HLA I and II regions it is possible to find HLA class III genes, that encodes some complement proteins such as C4A, C4B, C2, and factor B, some cytokines, such as TNF alpha and beta, and some other non-HLA proteins.2,4,6

The adaptive immune system should ensure that the organism do not respond to its own proteins, otherwise it will result in injury to itself. This feature is called self-tolerance, which means that in a normal individual, the immune system has tolerance to self-proteins, being able to do not trigger an immune response against them.1,4,7 This self-tolerance is maintained by two main steps: a) Thymic selection is a process that consists in presentation of self-proteins to T cells precursors in the thymus and elimination of the ones that present reactivity to them. During this step, approximately 95% of the T cells precursors are eliminated by apoptosis because of their reactivity. The surviving ones go out of the thymus as mature T cells, after passing through a process called positive selection.4,8 b) Since not all of the self-reactive T cells are eliminated in this first selection, mature T cells undergo a peripheral secondary selection in lymphoid and nonlymphoid organs, so the remaining self-reactive T cells can be eliminate. Besides that, there is a production of regulatory T cells during thymic selection and in the periphery, that are important to help in the peripheral control self-reactive T cells that were able to escape of elimination.4,7,8

When a breakdown in this self-tolerance occurs and the adaptive immune system reacts to self-proteins, a sustained immune response follows, because it is not possible to promote the clearance of this antigen from the organism. This process, which will lead to inflammatory tissue injury, is also known as Autoimmune Disease, and can have very different manifestations depending on its location.1,4,9,10 According to the review conducted by Gregersen and Behrens (2006)4, around 3% of the population have a known Autoimmune Disease, even though not recognized autoimmune mechanisms can influence other common disorders.

Some authors consider this breakdown or absence of tolerance questionable, as stated by Möller (1998).11 Among other things, even in a normal and healthy organism there are some possible autoreactive T cells circulating peripherally, and this disruption of self-tolerance was never proved in experiments. Still, thinking about self-tolerance as something limited only to the self-antigens that were presented on thymic selection, it remains uncertain if autoimmune responses arises from a self-tolerance disruption or from the potential threat of these normally existing autoreactive T cells.11

Although the exact aetiology of Autoimmune Diseases is not completely certain, there are some known factors related to them, such as environmental triggers (e.g. chemical agents and pathogens), hormonal influences (e.g. estrogen), and region and ethnic differences, but the most important determinant of Autoimmune Diseases is the genetic susceptibility, mainly associated with certain HLA alleles, because of their central action in immune responses.1,4,9,10

Any disturb on HLA expression can lead to development of an Autoimmune Disease because T cell precursors also require HLA to present self-antigens, and if HLA molecules cannot present self-antigens to autoreactive T cells, they will not be eliminated during thymic selection and will circulate in the organism.1,4,8 Besides that, another possible explanation to the influence of HLA on predisposition to Autoimmune Diseases is that self-antigens attached to certain HLA molecules are responsible for driving the positive selection of T cell precursors specific for them, depending on their level of expression: if they are present at small amounts or if they cannot bind properly to HLA molecules, they will conduct the negative selection, and if they are present at the degree needed or if they bind effectively they will conduct the positive selection. Then, insufficient expression of self-proteins during the thymic selection could increase the susceptibility for the development of an Autoimmune Disease. 1,4 There are some theories to explain the separate mechanisms by which HLA class I and II can influence the predisposition to Autoimmune Diseases, cited by Gough and Simmonds (2007).3 Concerning to HLA II mechanisms, in addition to this possibility of low affinity self-antigens leading to impaired elimination of self-reactive T cells, changes in the binding region of HLA II molecules could predispose mature T cells to recognize only a specific group of self-antigens, as a result of ineffective and incomplete thymic selection. Another discussed idea is that polymorphic regions of the receptor of HLA II molecules could lead to selection of ineffective regulatory T cells or self-reactive T cells, predisposing to Autoimmune Diseases.3 On the other hand, concerning to HLA I mechanisms, it is possible that the endogenous antigens presented, such as viruses and phagocytosed bacteria, predispose to an autoimmune response by mimicking self-antigens and activating autoreactive T cells.3,11 Besides this hypothesis, it is believed that some of these peptides can alter HLA I inhibitory activity on NK cells, which would act by lysing the cell and triggering a potential autoimmunity.3,13

Most of the known and described Autoimmune Diseases are related to an alteration of HLA II molecules, and some of the main examples include Rheumatoid Arthritis, Type 1 Diabetes and Hashimoto’s Thyroiditis. Ankylosing Spondylitis is another well-studied and important Autoimmune Disease, although it is associated with HLA I molecules.3,12

Rheumatoid Arthritis is one important example of cell mediated Autoimmune Disease, caused indirectly by T-lymphocytes and associated mainly with environmental factors and genetic susceptibility, among other potential influences. It is a chronic inflammatory disease that affects multiple synovial joints, such as fingers, knees, elbows, shoulders and ankles, with systemic psychological and systemic repercussions, affecting cardiovascular, respiratory, and skeletal systems.14 According to the review conducted by Ghodke et al (2005)10, it occurs worldwide in a prevalence that varies from 0.3 to 1.5% in almost all populations, being women more susceptible than men. In summation, the mechanism of the disease begins when a self-antigen, still uncertain, but probably a peptide derived from the connective tissue (e.g. collagen) is recognized by T cell receptors of CD4+ T cells, which release cytokines (e.g. IFN-). These cytokines promotes phagocyte activation and release of other cytokines, including TNF-ɑ, interleukins and other substances that along with IFN- will activate resident synovial cells to produce proteolytic enzymes (e.g. collagenase). As a result, there is inflammation on the synovial tissue (also known as synovitis), destruction of synovial cells and synovial hyperplasia, followed by cartilage damage and bone erosion and consequent destruction of the joints.1,14

Several genetic loci are associated with susceptibility to Rheumatoid Arthritis, but the most studied and well-known of them is the HLA class II DRB1,4,9,11,12,14 contributing to a third to half of the general genetic predisposition risk.15 The hypothesis first presented by Gregersen (1987)16, suggests that some HLA-DRB1 alleles express a “shared epitope”, that is a five amino acid sequence (QKRAA) responsible for the increased susceptibility to Rheumatoid Arthritis by influencing peptide binding and interaction between HLA and T cell receptor.15,17 These HLA-DBR1 alleles include DRB1*0101, DRB1*0102, DRB1*0401, DRB1*0404, DRB1*0405, DRB1*0408, DRB1*1001 and DRB1*1402.3,16 As summarized by McInnes and Schett (2011), the function of HLA-DRB1 in the pathogenesis of this disease is related to MHC molecule-based antigen presentation, self-antigen selection and T cell repertoire. However, they also present multiple other ideas as possibilities of influence of HLA-DRB1 on Rheumatoid Arthritis, including senescence induction on T cells and a potential proinflammatory function.14 The study carried out by de-Vries (2002) suggested another association between HLA-DRB1 and Rheumatoid Arthritis, but in a distinct way: differences in the regular shared epitope may have a protective effect, rather than a predisposing effect. These HLA-DRB1 alleles include DRB1*07, DRB1*1201, DRB1*1301 and DRB1*1501, among others.18 Besides HLA-DRB1, many other non-HLA genes were described as having a potential link with Rheumatoid Arthritis, such as PTPN22, AFF3, CD28, CD40 and CTLA4, among other ones.

The symptoms of Rheumatoid Arthritis include pain and stiffness of the affected joints, both usually in the morning or after resting, as well as warmth, redness and long-term deformities. The treatment may be performed in a multidisciplinary way, with physiotherapy, occupational therapy, diet, pharmacological treatment and complementary therapies. The pharmacological management may include symptom control with analgesics and NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), glucocorticoids, DMARDs (Disease Modifying Anti-Rheumatoid Drugs) and biological drugs, depending on each case.19

Type 1 Diabetes, also known as Insulin Dependent Diabetes Mellitus (IDDM), is a multi-systemic metabolic disease, originated as a result of impaired insulin production and/or function and associated with genetic predisposition and environmental factors. It is another important example of a cell mediated Autoimmune Disease where a self-antigen, such as insulin or other Islet of Langerhans proteins, activate CD4+ T cells triggering the release of cytokines by activated phagocytes and activation of in situ CD8+ T cells, leading to inflammation and injury of insulin-producing pancreatic β-cells.1,15,20 Because of reduction of insulin production, there is a disturbance in blood glucose control, leading to clinical symptoms caused by hyperglycaemia and ketoacidosis.

Several genetic loci were also described as being related to Type 1 Diabetes, but it is known that this disease has a particular link with HLA-DR3, DR4, DQ2 e DQ8, especially when combined DR4-DQ8 or DR3-DQ2.9,20 According to Devendra and Eisenbarth (2003), these two combination of HLA alleles are found in 9 out of 10 people with Type I Diabetes. As well as in Rheumatoid Arthritis, some protective HLA molecules were described, being DQA1*0102-DQB1*0602 the most common and effective of them, and several other non-HLA genetic loci have been described as potential influences on Type 1 Diabetes, but only one was proved to be associated: IDDM 2 on chromosome 11p5.5.21

As suggested by one of the names of the disease, injection of insulin is essential for regulation of blood glucose levels and for the effective treatment of Type 1 Diabetes. However, hypoglycaemia (low blood glucose levels) can occurs with treatment using insulin, mainly when used in excess, and because of this, another important part of the treatment is the monitoring of blood glucose levels.


  1. Janeway CA Jr, Travers P, Walport M, et al. Immunobiology: The Immune System in Health and Disease. 5th edition. New York:

    Garland Science


    (accessed 27 Mar 2014)
  1. Robinson J, Halliwell JA, McWilliam H, Lopez R, Parham P, Marsh SGE. The IMGT/HLA Database Nucleic Acids Research; 2013;41:D1222-7.

    (accessed 27 Mar 2014)
  2. Gough SCL, Simmonds MJ. The HLA Region and Autoimmune Disease: Associations and Mechanisms of Action. Paris: Curr Genomics 2007;8(7): 453–465.

    (accessed 27 Mar 2014)
  3. Gregersen PK, Behrens TW. Genetics of autoimmune diseases – disorders of immune homeostasis. Nature Reviews Genetics 2006;7:917-928.

    (accessed 27 Mar 2014)
  1. Mantegazza AR, Magalhaes JG, Amigorena S, Marks MS. Presentation of phagocytosed antigens by MHC class I and II.


    2013; 14(2):135-52.

    (accessed 28 Mar 2014)
  1. Deakin JE, Papenfuss AT, Belov K, Cross JGR, Coggill P, Palmer S, Sims S, Speed TP, Beck S, Graves JAM. Evolution and comparative analysis of the MHC Class III inflammatory region. BMC Genomics2006;7:281.

    (accessed 28 Mar 2014)
  2. Sakaguchi S. Naturally arising CD4+ regulatory T cells for immunologic self-tolerance and negative control of immune responses.

    Annual review of immunology

    , 2004; 22: 531-562.

    (accessed 28 Mar 2014)
  3. Kyewski B, Klein L. A central role for central tolerance.

    Annual Review of Immunology

    2006; 24: 571-606.

    (accessed 28 Mar 2014)
  1. Ray S, Sonthalia N, Kundu S, Ray SG et al. Autoimmune Disorders: An Overview of Molecular and Cellular Basis in Today’s Perspective.

    J Clin Cell Immunol

    2012; S10.

    (accessed 29 Mar 2014)
  1. Ghodke Y, Joshi K, Chopra A, Patwardhan B. HLA and disease.

    European Journal of Epidemiology

    2005; 20(6): 475-488. (accessed 29 Mar 2014)
  1. Möller E. Mechanisms for induction of autoimmunity in humans.

    Acta Paediatrica

    1998; 87:16-20.

    (accessed 29 Mar 2014)
  1. Nepom GT. Class II antigens and disease susceptibility.

    Annual Review of Medicine

    1995; 46: 17-25.

    (accessed 31 Mar 2014)
  1. Mandelboim O, Wilsons SB, Valés-Gómez M, Reyburn HT, Strominger JL. Self and viral peptides can initiate lysis by autologous natural killer cells. Proc Natl Acad Sci 1997;94(9): 4604–4609.

    (accessed 31 Mar 2014)
  2. McInnes IB, Schett G. The Pathogenesis of Rheumatoid Arthritis.

    N Engl J Med

    2011; 365:2205-19.

    (accessed 1 Apr 2014)
  3. Kallon D. Autoimmune Diseases and HLA.

    HLA Disease Associations: The Autoimmune diseases site


    (accessed 02 Apr 2014)
  4. Gregersen PK, Silver J, Winchester RJ. The shared epitope hypothesis. An approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis.

    Arthritis Rheum

    1987; 30: 1205-1213. [PubMed: 2446635]
  1. Holoshitz J. The rheumatoid arthritis HLA-DBR1 shared epitope.

    Curr Opin Rheumatol

    2010; 22(3): 293-298.

    (accessed 02 Apr 2014)
  2. de Vries N, Tijssen H, van Riel PLCM, van de Putte LBA. Reshaping the shared epitope hypothesis: HLA-associated risk for rheumatoid arthritis is encoded by amino acid substitutions at positions 67–74 of the HLA–DRB1 molecule.

    Arthritis & Rheumatism

    2002; 46:921–928.

    (accessed 03 Apr 2014)
  1. National Collaborating Centre for Chronic Conditions (UK). Rheumatoid Arthritis: National Clinical Guideline for Management and Treatment in Adults. London: Royal College of Physicians (UK); 2009. (NICE Clinical Guidelines, No. 79)

    (accessed 04 Apr 2014)
  1. Gillespie KM. Type 1 diabetes: pathogenesis and prevention. CMAJ2006;175(2): 165-170.

    (accessed 02 Apr 2014)
  2. Devendra D, Eisenbarth GS. Immunologic endocrine disorders.

    J Allergy Clin Immunol

    2003; 111(2): S624-S636.

    (accessed 03 Apr 2014)

Developing Patient Choice In Nhs Health And Social Care Essay

This essay investigates how patient choice in the NHS has been developed by New Labour and coalition government. I will do this by first defining the term ‘choice’ and then providing some background information on the emergence of choice agenda under the 1979-1990 government of Margaret Thatcher. . I will then go on to discuss how patient choice has been developed under the New Labour and coalition governments that followed by discussing the reforms that both have implemented in relation to the patient choice agenda. Finally, I will examine the uptake of patient choice agenda. This is likely to include patient travel distances in order to access better and faster healthcare, as well as the performance ratings of hospitals, which are published online and so available to the public to use. However, people that live in certain areas in the UK tend to have a somewhat limited choice of medical care providers. Overall, choice empowers the general public, offering them the ability to make autonomous decisions about their health-care providers and likely to improve the health outcomes of the British people.

The patient choice agenda outlined above relates to offering patients a choice among various types of service providers in the NHS analogous to that of the private healthcare market . Central to it is the notion that without competition, there is no real choice, and therefore a choice among competing options is offered which is intended to improve quality and efficiency. This market discipline will motivate less competitive healthcare providers to upgrade their services to attract customers while giving customers a wider range of options (Le Grant, 2007). Thatcher Government (1970-1990) developed patient choice in order to create a dynamic market-orientated system in the NHS. She intended to introduce this form of internal market as a means of increasing efficiency and to develop the NHS into a more business-type model (Driver and Martell, 1998).Thatcher’s administration intended to achieve these changes though the adoption of a privatisation scheme focused on providers and purchasers. The idea of patient choice derived from the fact that GPs exercised choice on behalf of patients.

Extending the choice agenda aims to eliminate or minimise the healthcare inequalities faced by less affluent patients, to whom it offers equal opportunities of services (Dixon and Le Grand, 2006). In 2005, MORI reported that 50 percent of the general public preferred to select healthcare providers outside of their local areas, which was something that the NHS had not provided for in its original manifestation (Popper, Wilson and Burgess, 2005). Thus, a large proportion of the general public clearly favours the idea of being able to select alterative healthcare providers.

However, merely increasing patient choice may “not successfully eliminate inequities” (Oliver and Evans, 2005, p. 68). Certainly, offering choice to the general public is less likely to improve inequity if non-existent varieties exist within the uptake of choice. Wealthy patients have resources to opt for private healthcare providers if they believe that their local providers offer poor quality of services and low rating (Davies, Tavakoli, Malek, 2001). Therefore, the idea of equal access for meeting the equal needs of all people has failed.

New Labour accepted the neoliberal model that had been developed by Thatcher’s administration during the 1980s and further developed by the Major government of the early-mid 1990s. In 1997, with New Labour’s ascent to power, patient choice was increased with some important reforms that promoted the patient choice agenda, including the establishment of Foundation Trusts (FTs) and the rating system (Driver and Martell, 1998). These reforms aimed to produce cheaper, better quality services by incentivising healthcare providers to compete for funding that equated to the number of patients they treated (Peck, 2003). Another reform introduced was ‘Payment by Results’, which pays secondary care providers using a standard fee tariff linked with the amount of patients treated. This reform enabled patient choice upon referral from GPs. Thus, this conception of the choice agenda served to improve waiting list times and the quality of services offered. Lastly, the government put in place a targets system that measured the uptake of choice. The government also shifted the focus from competition while continuing to promote the business model by promoting partnerships between healthcare providers (Peck, 2003).

In order to promote real choice, the market is obliged to offer alternative providers of goods and services (Smith, 2005). Private healthcare providers have operated within the internal market since 1948, providing their services at a standard tariff (Peck, 2003). The internal market that was operated under New Labour was less focused on competition, but rather towards promoting the efficiency and quality of services. Davies, Tavakoli, Malek (2001) argue that patients opt for private healthcare providers over public healthcare providers when they are able to because private providers offer good service quality. In general, patient choice tends to enhance competition among providers, who strive to attract customers in the way that any other private firms do.

Private healthcare providers generally cover limited, mainly non-emergency services and as private businesses, are primarily focused on making profits. Therefore, private providers cost more than services offered by the NHS and hence this market attracts wealthier competitive patients (Le Grant, 2007). Middle class patients are likely to select private providers because material resources are not an issue.




In the 2010 White Paper, Equity and Excellence: Liberating the NHS, the coalition government set out to promote patient choice by introducing a commissioning board to the NHS. The Commissioning Board monitors the performance of primary care providers to ensure that high standards of service care are offered and that patients are involved in decision making as much as possible. The Commissioning Board is also responsible for improving equity within healthcare. Finally, the government seeks to promote patient choice though increasing competition among medical providers. Under the Foundation Trusts obtained the role as regulators that supervise tariff costs and encourages efficiency.

Despite these developments, the fact remains that choice is not real possibly for patients living in certain areas of the UK (Spiers, 2008). People that live in rural area are likely to be excluded from selecting their healthcare providers. One of the reasons for this is that less affluent patients are less motivated to travel greater distances due to car ownership being lower among disadvantaged groups (Appleby and Dixon, 2004). Some people in low-paid employment are also unable to take time off from work to seek medical attention, preventing them from further exercising choice. Additionally, people travelling long distances tend to have poor attendance records for primary care appointments. A study conducted by RAND in 2008 also shows that age, gender and social class differences can serve as obstacles to people in exercising choice, while people over the age of 60, housewives and the working class tend to limit their travelling distances for providers (both primary and secondary care (Powell, 2008). Hence, gender, social class and age are found to be important factors that determine the uptake of choice for healthcare providers.

Affluent patients often have resources to purchase houses in areas near to good-quality healthcare providers. However, Popper, Wilson and Burgess (2005) argue young, affluent patients and those living in inner city areas of London are likely to opt for alternative healthcare providers, whereas disadvantaged patients with low levels of education are found to opt for alternative medical providers the least. Certainly the uptake of choice among less well-off patients would be more likely to improve if subsidised transport were offered to people and covering additional transport funding incurred by people who are not located close to alternative providers. Thus, an effort to improve these issues may encourage poor patients to travel longer distances to have their treatments.




Another factor is the lack of available information, which can prevent patients from exercising choice over medical providers (Fotaki, Roland, Boyd et al., 2008). It is believed that some people require additional support in their choice of healthcare providers. Often, less well-off patients, those with low levels of education and the elderly require supplementary assistance in order to be able to make effective choices (Powell, 2008). These types of groups are less likely to have access to the internet and friends working as medical professionals in the NHS to help them navigate the system. However, making use of internet sources have been criticised for being resource-intensive and a real problem for those who are not computer literature.

Published data is a key element for choice and outlines the performance of various healthcare providers. Making use of this type of data can serve to make patients more autonomous and responsible for their own health (Davies, Tavakoli and Malek, 2001). In general, healthcare providers’ services are rated using ranking systems. With their reputations at stake, medical providers are motivated to improve the quality of their services in order to remain in business. Often, disadvantaged groups use performance data more than middle class people to make healthcare choice (Collins, Britten, and Ruusuvuori, 2007). A lack of available data though is a major factor preventing them from exercising their choices.

The patient choice agenda aims to lead to inequality in the medical system. Appleby and Dixon (2004) claim patient choice agenda in healthcare is far more complex rather than just focusing solely on resources. Poor people tend to lack the self-confidence and knowledge to converse with healthcare providers in a medical vocabulary




. Oliver and Evans (2005) state patient’s poor abilities of expression create imperfect freedom of choice in decision-making amongst individuals. Hence, these issues lead to an “unequal ability to navigate the system” (Mandelstam, 2007, p. 109)

Providing people with choice rather than voice to express tend to be more effective for less well-off patients (Barr and Fenton, 2008). The patient choice agenda offers disadvantaged groups the opportunity to be heard and promotes the necessary self-confidence to exercise choices, in parallel. Thus, choice empowers patients who are the least knowledgeable about how to use the system to their advantage. Middle class people, on the other hand, have the educational capacities, resources and skills to manipulate the system in a way that suites their interests (Spiers, 2008). Certainly, affluent patients are more proactive than less-well of patients in relation to the uptake of choice. Hence, privileged patients are more articulate, confident and persistent, which means that the system in its current form suites privileged patients over poor people.

The impact of patient choice on health service delivery provides mixed views. Patient choice may improve the quality of services offered in the internal market in response to waiting list times, which it may also markedly reduce (Le Grant, 2007). GP fund-holders can improve waiting list times upon referral to hospitals and may also reduce prescription costs. An example that illustrates this capacity is found in a study conducted by the London Patient Choice Project during 2006 (Dixon and Le Grand, 2006). This study states that patients are inclined chooses for alternative providers in order to reduce waiting list times. Certainly, competition, along with large numbers of healthcare providers, may further reduce waiting list times.

However, patients dissatisfied with services offered by medical providers can opt to search for alternative medical providers that meet their needs. Under the internal market, money dictates the choices that patients make, meaning that hospitals lose money if patients choose alternative medical providers (Dixon and Le Grand, 2006). Thus, healthcare providers must be responsive to consumer demands in order to remain in business, unless they are likely to face closure.

Patients often empower medical experts to decide on their treatments because of the generally held view that the “doctor knows best” (Burge, Devlin, Appley, et al., 2004, p. 190) Often, patients shift choice into the hands of doctors, particularly in life-threatening situations. In such serious situations, medical staff are likely to decide on treatments on behalf of patients. Therefore, the choice agenda in this case is not taken into account. However, Popper, Wilson and Burgess (2005) suggest that seven out of ten patients prefer to relocate treatment choices to primary care providers. This example tells us that people like the idea of having an input in relation to deciding on medical providers.

In reality, GPs are seen as the “gatekeepers” for making medical choices (Powell, 2008, p. 77). They act as agents for the patients, and are often empowered to select treatments on their behalf, thus undermining the ability of patients to exercise choice. This happens because of people tend to have limited skills and access to information that could otherwise inform them of the various treatment options available. As mentioned above, middle class people are often also better informed of premium treatments options, usually having better access to the internet and sources such as books and journals that inform them of the various treatments available. People with lower levels of education do not generally have access to journals and books which would allow them to make meaningful choices. The London Patient Choice Pilot study (in 2008) on the other hand, contradicts this view. This study claims that the up-take of choice among people with various levels of education has little significance, with only a two percent difference between people with various levels of education with regard to looking for hospitals that provide treatment (Spiers, 2008).

In conclusion, middle class people benefit from the choice agenda to a far greater degree than the working class. Middle class groups have higher levels of income, which allow them to purchase houses near good-quality medical providers. In addition, the middle classes have access to information and money that enables them to travel further in order to have access to the best services. It must also be questioned as to whether patients want choice rather than just high overall quality, as most patients like the idea of a good local medical provider (both primary and secondary providers), rather than travelling longer distances to have their treatment.

Study On Substance Abuse Among Nurses

Alcohol and drug addiction are foremost, habitual, advanced, and often a catastrophic problem. United States society does not acknowledge addiction as a disease, but as a moral failure or lack of will power. (Trossman 27) Several nurses are reserved when faced with a colleague who may have a substance-abuse addiction because of dedication, concerns of being a hypocrite, or concerns of threatening a colleague’s license to practice. Substance abuse addiction must be accepted as an illness so that nurses can help one another recognize and seek treatment for the problem.

The prevalence of substance abuse in the nursing population has not been fully documented, but it is thought to be equal to the general population. An estimated 10 percent of the nursing population has an alcohol and/or drug abuse problem, and of that 6 percent of nurses have problems that are serious enough to interfere with their ability to practice. (Ponech) The American Nurses Association shows that 6 percent to 8 percent of nurses abuses alcohol or drugs to an extent adequate enough to impair their professional judgment. (Daprix) Nurses tend to use prescription-type medication more than marijuana and cocaine. (Trinkoff) Statistics show that nurses are more likely to practice sobriety when compared to other occupations. (9)

A significant underlying reason for nurses to participate in substance abuse is associated to family histories that include emotional impairment, alcoholism, drug use, and/or emotional abuse that result in low self-esteem, overachievement, and overwork. (Monahan) Nurses are often highly caring individuals who often take on the role of caregivers, which could be healthy or unhealthy; this characteristic attracts them to the nursing field. Many nurses find this occupation allows them to continue with the role of a caregiver, the same role they play as the children of alcoholic parents. (Monahan) Nurses have a higher occurrence rate of alcoholism then their family history. (Fisk) One statistic shows that family alcoholism contributed to alcohol abuse in approximately 80 percent of nurses who had an alcoholic family member. (Stammer)

Stress in the workplace presents another reason for why some nurses abuse substances. Increased workloads, decreased staffing, double shifts, mandatory overtime, rotating shifts, and floating to unfamiliar units all contribute to feelings of alienation, fatigue, and, ultimately, stress. (Bennett, Mustard) Many nurses are workaholics and are addicted to their careers so they choose to deal with these issues. (Trossman)

Nurses are also at risk for substance abuse due to the high availability of medications in their workplace, and with their knowledge of pharmacological agents, this provides a climate that makes it seem safe to correct internal feelings or illnesses. (Serghis) Nurses have always been taught that medications solve problems such as pain, infections, and anxiety. Not only are medications highly accessible, but nurses wrongly believe that they are able to control and monitor their personal self treatment without becoming addicted. (Creighton, Ellis) Nurses become familiar with controlled substances and easy access to them increases the changes that they will use them for personal use. Due to the fact that nurses administer these medications and watch how they affect their patents, they tend to falsely believe that they can control and monitor their own personal use. (Trinkoff) Some nurses “believe that they are immune to the negative consequences of drug use because they are so familiar with drugs.” (Trinkoff 581)

The effectiveness of a nurse’s job performance can be aggravated by sleep deprivation, a poor social life, financial problems and being overworked. Several nurses blame psychological or physical pain, emotional problems that are too complex to handle, added with a demanding, high -pressure, and stressful work environment reasons that led them to chemical substance abuse. (Stammer) Even though these nurses who abuse substances have a hard time admitting that they have problems, they are well-liked and respected, highly skilled, and ambitious.(Stammer) Statistics shows that nurses who abuse alcohol “tend to be achievement oriented people who strive to be ‘super nurses’ at work and ‘superwomen’ elsewhere.” (Stammer 79)

Studies have proven that nurses don’t abuse substances more than the rest of the society, (Trinkoff) there are nursing subgroups that are more prone. Exposure to death and dying, lack of education on alcohol and medication hazards, and burnout in general increase the risk of substance abuse. (Trinkoff) Every nursing specialty has different personnel factors, demands and availability of controlled substances.

Critical care nurses, in the emergency rooms, intensive care units, and operating rooms, show more prescription-type substance abuse along with easier access. (Trinkoff) The frequency of patients dying, work pace, work demands, access to controlled substances results in an increase in substance abuse for these subgroups. (Trinkoff) Critical care unit nurses show to be emotionally and technically demanding. Nurses can have feelings of failure, if patients die unexpectedly. These work demands can test a nurse’s training which can have its downfalls, leaving the nurse with high levels of stress.

Oncology nurses have increased substance abuse rates, specifically with alcohol, and binge drinking. (Trinkoff) It is thought that these nurses are trying to distance themselves from the emotional pain they are experiencing while working with patients who have cancer, so they use alcohol to cope. (Monahan)

Psychiatric nurses experience increase levels of substance use, this practice is heavily oriented around pharmacologic agents. (Trinkoff) These nurses tend to self-medicate more because they are exposed to a culture that accepts using psychotropic medications to cope with life. Psychiatric nurses tend to be more willing to report their substance abuse than other specialties because they tend to believe this is an acceptable form of treatment. (Trinkoff)

The lowest nurses to report use of addictive substances are pediatric and women’s health nurses. (Trinkoff) This is most likely due to the lack of availability of these substances, or these types of nurses are emotionally expressive. Most people that express their feelings may have less need for substance use. (Trinkoff)

Some nurses may be successful at disguising or hiding a drinking or drug problem, other peers that are familiar with substance abuse are more likely to detect it. (Bennett) Many of the symptoms are general, but when the nurse’s behavior is scrutinized over a period of time, the outcome becomes conclusive. Symptoms such as poor job performance, such as excessive time off, isolation, fatigue, mood swings, and impaired cognition. (Bennett)

Nurses who abuse drugs may support their addiction with prescription medications. They may forge prescriptions, or divert medications directly from patients or the unit’s supply. (Ponech) Nurses may use saline to substitute for a patient’s dose, and save the medication for their personal use. Another way to distract medications would be to sign them out for patients who are discharged, or needed medication for patients that have not requested it. (Ponech)

Recognizing that substance abuse is a medical illness that requires treatment is start in helping addicted nurses get the help and support needed to become productive members of society and nurses again. Nurses that are suspected of abusing substances need to be reported. Even though it is an emotional issue that follows reporting a colleague, it would be less hampered if the patient being treated by a nurse that was impaired was a loved one. This is a higher level of nursing that every nurse should practice.

A Disorder That Affects The Endocrine System Medical Essay

The patient chosen to partake in this project is a 54 year old male of Asian origin, diagnosed 8 years ago, at 46 years old suffering from Type II Diabetes.

Health Issue

Diabetes Mellitus is a disorder that affects the endocrine system, as it is this system that controls and regulates the hormones (chemical messengers) release into their target cells. Therefore, diabetes is caused by irregular levels of insulin in the bloodstream. There are two types of the disease diabetes, type I and type II.

Type I diabetes is diabetes that occurs because the beta cells (those that produce insulin), of the pancreas are destroyed. It is known to be an autoimmune disease, initially recognised in patients under the age of 40, however, the disease can develop with age. The only treatment and method of survival for this type of diabetes is to be solely dependent on insulin.

Type II diabetes is caused by either insulin deficiency or body resistance to the insulin. As time progresses, extrinsic insulin treatment will be required to ensure the regulation of glucose in the bloodstream. Type II diabetes is most common in older people, especially those people that are obese and are of Asian nationality.

In a normal healthy person, when food is eaten it is digested and broken down into molecules of glucose which is absorbed into the bloodstream and into the cells that require it for energy. However to do this, insulin, a chemical messenger produced by the beta cells in the pancreas, is required to act as a key, complementary to the receptors on the plasmalemma of the glucose requiring cells. However, people suffering from diabetes may be producing the insulin required, yet the receptor becomes less responsive to the insulin or resistant to the insulin produced.

Additionally, receptor downregulation occurs which is a process whereby, in a patient that eats unhealthily there is extreme levels of glucose in the bloodstream so the body try’s to maintain and regulate homeostasis, so in a process of positive feedback, receptor downregulation occurs which increases the amount of glucose in the blood which is toxic. Furthermore, the body may start producing less insulin than required which prevents glucose entering the cells. Therefore, there is an accumulation of glucose in the bloodstream which leads to hyperglycaemia.

The main symptoms of the disease are:

Fatigue usually occurring because the patient is unable to use the glucose for energy.

Polyuria which is passing urine as the body tries to excrete the excess glucose from the body.

Nocturia, passing urine at night.

Blurry vision or decreased vision.

Slow healing of any cuts and wounds.

Polydipsia which is increased thirst.

Unusual weight loss as the body is unable to use the glucose for energy so the body breaks down the stored fat and proteins instead.

Itching, thrush or any urinary tract infections as generally the infection rate will increase as there are high levels of glucose in the blood stream.

Walker et al (2002): Clinical Pharmacy and Therapeutics, page 632 describes that the diagnosis of diabetes should not be based solely on one reading on a prick reading as they should be only used to identify people who may be at risk of diabetes such as screening. Diagnosis is usually established via a venous blood sample verified by thorough lab testing.

TALK ABOUT NICE GUIDELINES HERE for blood glucose levels for diagnosis of diabetes


The treatments that are generally used to control blood sugar levels are:

Lifestyle changes – the patient should be advised to introduce an exercise regime and suitable diet (there is no strict diet for diabetic patients, so patients are advised to eat healthily). However, if this cannot control the blood sugar levels then patients require oral antidiabetic drugs.

Oral Antidiabetic Drugs

Campbell, Ian (Jun 2007) Oral Antidiabetic Drugs: their properties and recommended use, Prescriber Volume 18 Issue 6 page 58 outlines the use of each antidiabetic drug.

First-line Drug Therapy


Types of Sulfonylureas include gliclazide, glibenclamide, glipizide and glimepiride, which work by stimulating the release of insulin into the bloodstream. As stated in the BNF (March 2010), Sulfonylureas must not be given to obese patients or overweight as these drugs can encourage weight gain. Also there is a very high risk of hypoglycaemia as some Sulfonylureas drugs (glibenclamide) are long acting and should NOT be prescribed to the elderly. Side effects include; nausea, vomiting, diarrhoea and constipation.


Types of Biguanide include metformin which improves insulin action. BNF (March 2010) describes that Metformin works differently to the Sulfonylureas drugs as it decreases the action of gluconeogenesis, therefore, limiting the amount of glucose being produced by substrates such as amino acids, glycerol etc. Metformin is usually given first priority to people who are overweight, so unlike Sulfonylureas drugs can be given to the elderly. Another benefit of this drug is that it does not lead to hypoglycaemia but has many more side effects including abdominal pain, anorexia and taste disturbance.

Second-line Drug Therapy

Glitazones (given with biguanides or sulfonylureas drugs as double therapy)

Types of glitazones include pioglitazone and rosiglitazone Glitazone drugs work to reduce the insulin resistance and improve the sensitivity to insulin. However, taking these drugs increases the risk of cardiovascular disease and many other side effects including reports of liver toxicity, alopecia, anaemia etc.

Prandial glucose regulators

Regulators include repaglinide and nateglinide. These second-line therapy drugs can be used as monotherapy or used with metformin. Sexton, John (2006): Pharmaceutical Care made Easy, page 66 describes how these drugs work differently to the Sulfonylureas drugs, by stimulating the increase of insulin using different receptor sites. Side effects of this drug include abdominal pain, diarrhoea, vomiting, constipation and nausea.


There are three types of insulin that can be administered to treat diabetes.

Fast-acting insulin is insulin that is said to be neutral because they are soluble, working to reduce the glucose in as little as ten minutes but only work for a few hours so are suitable for patients that require insulin after a meal. Intermediate-acting insulin is insoluble insulin which takes about one to two hours to work effectively. To cover a whole day this insulin has to be injected twice daily. Long-acting insulin is insulin that lasts a whole day and so does not to be administered more than once each day.

Diabetic Complications

Diabetes MUST be controlled to prevent serious microvascular and macrovascular complications which deter the health of the patient further.

Microvascular Diseases

Peripheral Neuropathy – this is when there is impairment or damage to the nerves, especially on the feet, leading to vibrations and muscle pain, eventually the patient will not be able to feel the feet at all.

Nephropathy – this is when the kidneys become swollen and larger than normal, because of excess fluid in the kidney and can be discovered by testing on urine for a certain chemical called albumin. If high amounts of this substance are found in the urine, then the patient is suffering from nephropathy which can lead to kidney failure.

Retinopathy – blindness in diabetic patients is common, therefore, regular screening is undertaken. Control over blood sugar can prevent retinopathy, and if detected early, the eyesight can be recovered by laser eye surgery.

Macrovascular Diseases

Cardiovascular Disease – Walker, John (2002) page 636 discusses that the risk of someone with diabetes having a myocardial infarction is the same as someone without diabetes having a second myocardial infarction. This highlights the importance of controlling diet and advising patients to stop smoking.

Peripheral Vascular Disease – this is when the blood vessels near the heart or around the heart are affected which increases the risk of suffering from a myocardial infaction or suffering from cardiovascular problems such as hypertension.

Microvascular and Macrovascular Diseases

Diabetic Foot Ulcers – this is the combined result of having many of the diseases above such as neuropathy, peripheral vascular disease and not controlling the amount of glucose levels in the bloodstream. Therefore, this leads to glucose deposits on the toes of the feet which become prone to infection. Therefore, patient education is of utmost importance to prevent ulcers appearing.

Social/Psychological Impairment and Management of the disease

The patient found coping with the disease very difficult, soon after diagnosis lost his job, unable to cope with the physical requirements and unable to drive the patient felt vulnerable and insecure, lost confidence and a sense of independence. Therefore, the patient fell in depression and financial worries increased .The family also felt that learning to manage the disease was difficult. However, education available provided the information required to deal with diabetic emergencies most common being hypoglycaemia which could lead to coma. Furthermore, the patient suffered from retinopathy which is a microvascular diabetic complications Therefore, in order to correct the patients eyesight the patient had to undergo a few laser treatments.


Role of Pharmacist

The pharmacist’s first and most important priority is the patient; hence the pharmacist initially must follow a certain care cycle and criteria to ensure maximum contribution to proper care of the patient. Therefore the patient’s care began with a broad assessment, gathering the information to identify symptoms, all problems and complaints and potential problems. This was when many of the symptoms of the patient were recognised as diabetic symptoms such as fatigue, passing urine excessively etc.

The pharmacist’s role at this point is to prioritise the patient and to advise and explain to the patient to see the patient as soon as possible. Once the patient was diagnosed the pharmacist was able to think about the outcomes of care and how to achieve the desirable outcomes. To do this, the pharmacist counselled the patient in accordance to the severity of the diabetes. The pharmacist at this point discussed lifestyle changes, such as moderate alcohol intake, maintaining a healthy diet, and introducing a sufficient exercise regime and the variety of antidiabetic drug therapy treatment options. Once the suitable drug therapy was identified for the patient, the pharmacist was able to provide and support the patient, by creating a rapport with the patient, providing and establishing self-confidence and asking questions. The pharmacist also counselled the patient by discussing each and every drug in an Medicines Use and Review (MUR) service which taught the patient how to administer insulin properly and effectively, the most common side effects, how to take medication and when to take medication (such as medication that must be taken with a meal or medications to be taken only in the morning etc.), and generally talking about how the patient is coping with the disease. The patient was also advised to join a diabetic clinic so that the patient and patient’s family could attend to receive important information about how to identify when a person is in a state of hypoglycaemia (eg. tremors, sweating, palpitations, drowsiness), and also giving details on how to avoid serious diabetic complications.

In general, the pharmacist has a duty of professional conduct to act in a way to benefit the patient which is publicised in the seven MEP Guidelines (YEAR).








Area for Improvement


Management of Pain in Trigeminal Neuralgia

Percutaneous management of pain in Trigeminal Neuralgia under computed tomography guidance

Corersponding Author

  • Dr. Mitesh Kumar

Main Author

  • Dr. Roy Santosham

Co Authors

  • Dr. Bhawna Dev
  • Dr. Deepti Morais
  • Dr. Rupesh Mandava
  • Dr. R. Jeffrey


Trigeminal Neuralgia (TN) is a brief, excruciating and perhaps the most severe pain known to man affecting the hemifacial region. It occurs mainly due to tortuous vessel compressing the trigeminal nerves, though in many cases, the exact etiology and pathogenesis remain undetermined. The first line therapeutic option for patients affected by TN is the medical line of management and patients refractory to the same, are offered various invasive procedures like balloon compression, gamma knife surgery, radiofrequency ablation, etc. In this paper, we present percutaneous management of the pain by injecting neurolytic drugs in the foramen ovale under Computed Tomography (CT) guidance as the new and promising technique of treatment in TN.


Trigeminal Neuralgia, percutaneous management, CT guidance, neurolytic drugs


To evaluate the efficacy and safety of Computed Tomography guided percutaneous management of pain in trigeminal neuralgia using neurolytic drugs.


Trigeminal Neuralgia is also known as tic douloureux, a term given to this painful disease by Nicolaus Andre in 1756 [1] . TN is a pain which typically is intense, brief, usually unilateral, recurrent shock like involving the branches of fifth cranial nerve [2]. It can be mainly classified into two types. First being, the classical TN (Type I), which is due to neurovascular compression, the most common vessel causing the same being superior cerebellar artery followed by anterior inferior cerebellar artery [3]. Second type is atypical TN (Type II), secondary to causes like trauma, tumor, multiple sclerosis or herpetic infections. The distinction between these two types is mainly based on clinical symptoms [4, 5] as Type I pain is episodic in nature whereas Type II pain is more constant. TN is often called by many as “the suicide disease” [6] as the patients who suffer from it would rather take their lives than bear the pain.

The initial line of treatment for TN is medical management by drugs like Carbamazepine, Gabapentin, Oxcarbazepine among others. Patients of type I TN may also be advised microvascular decompression. Those patients who do not respond or have contraindications to the above mentioned drugs or experience no change in the intensity of the pain are called Refractory TN [7]. Such patients are advised invasive procedures like trigeminal nerve block neurolytic block, radiofrequency ablation, gamma knife surgery and balloon compression.

We describe our experience in percutaneous management of pain by injecting neurolytic drugs in the foramen ovale under CT guidance in six patients, suffering from TN.

Method and Materials used

Pre procedural work up

The pre procedural work up included clinical evaluation and thorough reading of the Magnetic Resonance Imaging (MRI) scans of all the patients to rule out any neurovascular conflict. Any patient with neurovascular conflict was considered an exclusion criterion in our study. These patients were reported taking the drugs for TN for over three months with no improvement in the pain. The pain score evaluation was done using Numeric Rating Scale [8] and Wong-Baker Faces Pain Rating Scale [9] as a baseline evaluating point to be compared to the same scoring system after the procedure. Routine investigations such as coagulation profile, liver function test, renal function test, HIV and HbsAg were done before the procedure.

Numeric Rating Scale

Patients rate pain on a number scale from 0-10, 0 being a depiction for no pain and 10 being the worst pain imaginable.

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Wong-Baker Faces Pain Rating Scale

The Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 (No Pain) to a crying face at 10 (Worst Pain Possible). The patient must choose the face that best describes how they are feeling.

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In our study, we use the Wong Bakers scale to assess the patients’ pain before and after the procedure.

The neurolytic drugs and materials used in the procedure were 22 G spinal needle for block, 25 G needle for skin infiltration, 2% xylocaine , Iohexol – Non ionic contrast medium, 100% alcohol, 1ml syringe and normal saline solution.

The patient was put in the supine position with head placed in reverse occipitomental position (chin up and neck extended), turned 30° to the opposite side of the block. The foramen ovale was identified under CT guidance and a virtual track was made starting from a point which was 2-3cms lateral to the angle of mouth on the skin to foramen ovale (Figure 1). Once the trajectory of the needle and the foramen ovale was confirmed on CT scan, the skin at the point of entry was infiltrated by 2ml of 2% xylocaine using a 25G needle. Then, a 22G spinal needle was inserted at the same point and aimed in the direction of planned trajectory towards the foramen ovale (Figure 2). To prevent the needle from entering the oral cavity, a finger from inside the mouth can be used to guide the same [10]. Though, we did not apply this in any of our patients.

Following this, negative aspiration was attempted to check for Cerebro Spinal Fluid (CSF) or blood aspirate. If the aspirate contained CSF or blood then the needle had to be readjusted. Then 0.5ml of mixture made from 1ml of iohexol and 2ml of 2% xylocaine was injected into the target site in order to check the spread of injectant and exact needle tip position. Once the tip of the needle touches the mandibular nerve root, the patient might complain of the exact similar pain which he/she has been suffering, thus confirming the accurate needle tip location. This injectant acts as a diagnostic block if the trigeminal ganglion is the pain generator with xylocaine providing anesthesia prior to alcohol injection.

A mixture containing 3ml of 100% alcohol, 1ml of iohexol and 1 ml of saline was made. Of this 1ml of the mixture was injected into the foramen ovale (Figure 3 and 4). Post procedure check scan was performed to rule out any complication.


Exact position of the needle tip in the foramen ovale was seen in all the six patients thus achieving 100% technical success. All these patients achieved a significant level of relief with an average pain score of two immediately after the procedure. Twenty four hours after the procedure, they rated their reduction of pain at an average pain score of one.

Four out of the six patients ie Patient No. 1, 2, 4 and 6 were completely relieved of their pain with one year follow up without taking any medication.

In Patient No. 3, the procedure was abandoned as during the diagnostic block, the injectant was seen tracking into CSF cistern and fourth ventricle.

Patient No. 5 reported with a similar pain of TN within three months with a pain score of five, little less than the pre-procedure pain score of six. The pain was more severe in the pterygopalatine segment, hence a pterygopalatine block was carried out and the patient had a pain score of one twenty four hours after the procedure. Hence, the initial trigeminal neurolysis was partially successful in this patient.


Pain Score

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6
Pre Procedure 7 8 6 7 6 6
Post Procedure 2 3 1 1 2
At 24 hours 1 1 1 1 1
At 3 months 0 1 0 5 0
At 12 months 0 0 0 2 0

No post procedural complication was seen in any of our patients.


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The trigeminal nerve arises from the lateral pons at its superior to mid portion. It travels forward in posterior fossa and merges with the trigeminal ganglion in the Meckel’s cave. The trigeminal ganglion is located lateral to the cavernous sinus. It gives three divisions – ophthalmic (V1) segment which emerges from superior orbital fissure, maxillary (V2) from foramen rotundum and mandibular (V3) from foramen ovale. The trigeminal nerve provides sensation for the face, mouth and supplies the muscles of mastication. TN mostly involves maxillary division and mandibular division of trigeminal nerve though it may also involve the ophthalmic division as well.

The reported annual incidence rate of TN is about 4.5 per 100,000 persons [11] but the actual figures may be even much higher because of diagnostic challenges associated with the disease. TN is more common in females than males with a ratio of 3:2 and is usually seen after 50 years of age [11].

Trigeminal nerve block is an upcoming treatment in TN patients who are refractory to medical line of management. It relieves the pain and also reduces the side effects of drugs which are used for the treatment. Earlier studies were mainly done using x-ray or fluoroscopic guidance which had its own limitations in terms of image quality and two dimensional views. In contrast to this, CT scan provides excellent and direct visualization of foramen ovale leading to correct placement of needle [12] and thus scoring over fluoroscopy. This reduces the chances of injecting neurolytic agents at improper locations and thereby reduces the side effects.

In our cases, initial check CT scan was done by injecting 1ml of iohexol to determine whether the needle is in exact location. This doubly ensured us about the location as well as the spread of injectant. This was different from previous studies done using fluoroscopy where a diagnostic block using xylocaine had to be given in order to confirm the location of the needle tip.

We used a mixture of 3ml of 100% alcohol, 1ml of iohexol and 1ml of saline for trigeminal neurolysis however, Han et al stated that trigeminal nerve block with high concentration of lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain and shorter duration of pain prior to the procedure [13].

Alcohol spreads easily and should be used cautiously. The other agents which can be used but were not used in our study are phenol and glycerol.

The side effects that may follow the procedure are numbness and hypoesthesia in the entire trigeminal nerve distribution. There can be abolition of corneal reflexes which can produce exposure keratitis and dryness of eyes. Improper injection of alcohol into CSF space can lead to arachnoiditis/ meningitis.

CASE 1, 2, 4 and 6

These patients were suffering from trigeminal neuralgia with pain score ranging from six to eight before the procedure. All these patients have been taking carbamazepine for more than three months with no relief from pain. MRI showed no neurovascular conflict. These patients had a significant relief of pain with pain score at three months and twelve months being zero. None of these patients had to take oral medicines after the procedures.

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Fig 1: Site marked for needle Fig 2: Tip of the needle in foramen

insertion ovale

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Fig 3: Dispersion of injectant in Fig 4: 3D reconstruction showing

the foramen ovale needle tip in foramen ovale.

Case 3

This eighty year old male came with complains of left sided trigeminal neuralgia. He had been taking carbamazepine for four months with no change in pain intensity. The procedure had to be abandoned as after injecting the diagnostic block, the injectant was seen tracking into the CSF cistern in the cerebello pontine angle and fourth ventricle (Figure 5).

Fig 5: CT scan showing needle tip in the left foramen ovale

Case 5

This forty seven year old female came with complains of right sided trigeminal neuralgia. She had been taking carbamazepine for three months without any relief in pain. MRI scans showed no neurovascular conflict. The procedure was successful with pain score of one immediately after and at twenty four hours after the procedure (Figure 6). However, this patient came back within three months of the procedure complaining of pain, which was more in the pterygopalatine segment. A pterygopalatine block was done with resultant pain score of one at twenty four hours after the procedure and two at nine months of the procedure. Hence, this patient showed partial response to trigeminal neurolysis carried out initially.


Fig 6: CT scan showing the tip of the needle in right foramen ovale.


Percutaneous injection of alcohol, iohexol and saline mixture at the verge of foramen ovale under CT guidance is an effective and promising method to relieve pain in patients of TN refractory to medical line of management. This technique is inexpensive, cost effective and a relatively painless procedure. Being a minimally invasive technique, the chances of any infection and other post operative complications are less. Since our study involved only six patients, this technique needs to be further evaluated on a large sample size to substantiate the result of this procedure. Having said the above, we would like to emphasize that our initial experience of this procedure was quite impressing.


TN – Trigeminal Neuralgia

CT – Computed Tomography

CSF – Cerebro Spinal Fluid

MRI – Magnetic Resonance Imaging


  1. Andre´ N. Traite´ sur les maladies de l’ure`thre. Paris: Delaguette, 1756
  2. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994. P. 59-71
  3. Jannetta PJ. Microvascular decompression of the trigeminal nerve for tic doloreux. In: Youmans ed. Neurological surgery 4th edn. WB Saunders Co. Philadelphia. 1996: 3404-15
  4. Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008; 15 (10): 1013-28
  5. Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence – based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008; 71 (15): 1183-90
  6. Michael D. Chan, Edward G. Shaw, Stephen B. Tatter. Radiosurgical Management of Trigeminal Neuralgia. In: editor Pollock Bruce, Intracranial Stereotactic Radiosurgery, an Issue of Neurosurgery Clinics. Elseiver Health Sciences. 2013. pp. 613-621
  7. Cruccu G, Truini A. Refractory Trigeminal Neuralgia. Non-surgical treatment options. CNS Drugs. 2013 Feb;27(2):91-6. doi: 10.1007/s40263-012-0023-0.
  8. Hartrick CT, Kovan JP, Shapiro S (December 2003). “The numeric rating scale for clinical pain measurement: a ratio measure?” Pain Pract 3 (4): 310–6. doi:10.1111/j.1530-7085.2003.03034.x. PMID 17166126.
  9. Wong-Baker FACES Pain Rating Scale Foundation: Retrieved 6 December 2009.
  10. Michael J. Cousins In: trigeminal nerve block. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine. Lippincott Williams & Wilkins, 29-Mar-2012, 410
  11. Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen, Jeffrey J. Schaider, Ghazala Q. Sharieff. In: Bell’s palsy and trigeminal neuralgia. Harwood-Nuss’ Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins. June 23, 2009, 786
  12. Víctor Whizar-Lugo MD, Francisco Anzorena-Vallarino MD, Roberto Cisneros-Corral MD, Ricardo Valdez-Jeres MD, Rogelio Hernández-Velazco DDS. Use of Computed Tomography Guide for Trigeminal Alcohol Neurolysis. Anestesia en Mexico: Volume 20 No. 1 (January-April 2008)
  13. Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008 Feb;62 (2):248-54. Epub 2007 Nov 23.

Financial Pressures and Patient Safety Essay

The financial pressures on hospitals are continually increasing due to ever-changing reimbursement structures and a heightened focus on quality and value. However, despite these pressures, the association between patient safety performance and financial outcomes remains unclear. Brad Beauvais, Jason P. Richter, and Forest S. Kim’s research, reported in the journal article entitled “Doing well by doing good: Evaluating the influence of patient safety performance on hospital financial outcomes”, seeks to shed insight into this association. More specifically, the purpose of their study was to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance. (Beauvais, Richter, & Kim, 2019)

The article begins by laying out the current situation in patient safety within the healthcare industry. Medical errors specifically are a devastating factor affecting patient safety – with 250,000 deaths per year attributable to medical errors (Cross, 2019) (Makary & Daniel, 2016). Some estimate that the cost of medical errors is around $20.8 billion per year (Cross, 2019), with $154 billion annually attributable to patient safety failures in general. (Berwick & Hackbarth, 2012). There is therefore an obvious correlation between patient safety failures and cost in the healthcare industry generally, but there has not been a link established between patient safety performance impacts on individual hospitals. That connection has evolved, however, in the last 10 years. In 2008, the Centers for Medicare & Medicaid Services (CMS) started decreasing hospital payments for the top 10 preventable hospital – acquired conditions (CMS, 2008). The law also created the Center for Medicare & Medicaid Innovation, which develops and tests payment and service delivery models to improve health and reduce cost. A few of these models are the Accountable Care Organizations and Bundled Payment for Care Improvement Initiatives, which reward or penalize health care organizations for production of quality results and reduction of adverse safety events. CMS also implemented the Hospital Readmissions Reduction Program, which causes a direct financial penalty for hospitals with excessive readmission rates (Lu, Huang, & Johnson, 2016). Furthermore, Medicare’s value-based purchasing program rewards hospitals that perform well on quality metrics and penalizes those that produce unplanned or unnecessary readmissions or preventable hospital-acquired conditions (Gilman et al., 2015).

Having established the environment around the issue of patient safety in healthcare, the authors continued to build on the theory behind their research. Conceptually, the connection between quality and hospital profitability has not been well defined. The lack of relevant literature in the post-Patient Protection and Affordable Care Act era provides a confounding challenge in understanding the quality-profitability relationship. (Beauvais et al., 2019) However, despite a lack of data on this specific issue, product and service quality metrics have long been known to be influential determinants of a firm’s performance and sustained financial viability. There are reports that hospitals with broad and intense baseline quality improvement programs showed improved average financial performance – though this area requires more study (Beauvais et al., 2019). Within the services sector, it has been indicated that superior service quality supports profitability, directly reducing costs while concurrently leading to improved perceptions of quality, customer satisfaction, customer retention, positive “word of mouth” advertising, and attraction of new customers (Rust, Zahorik, & Keiningham, 1995). This model provides the clarifying theoretical basis for Beauvais, Richter, and Kim’s research; specifically, the connection between service quality improvement, cost reductions and profitability. It makes sense that organizations who take proactive steps to manage the appropriateness of care and improve patient safety can reduce the costs of inappropriate care, medical errors, and complications. Various government programs provide direct organizational and provider financial incentives that promote improved levels of performance in the provision of health care service quality (Beauvais et al., 2019). After all the aforementioned theoretical support were established, Beauvais, Richter, and Kim then gave their hypothesis: that “Hospitals with higher patient safety performance will have greater odds of attaining higher organizational financial performance.”

Upon setting up the theory behind and stating their hypothesis, the authors proceeded to outline the methods and measures of their research. The dependent variables assessed in the study were net patient revenue, operating income, and operating margin. Data on these variables were obtained from a single cross-section from the American Hospital Association (AHA) database from 2014. The AHA database also provided the control variables needed for the study (including total bed count, debt to asset utilization, case mix index, rural versus urban, government owned, sole community provider status, system affiliation, teaching status, profit versus not-for-profit). For measurements of patient safety, the Leapfrog Hospital Safety Score was used. The Leapfrog Hospital Safety Score is a letter grade rating of a hospital’s performance on safety, specifically its ability to protect patients from accidents, injury, harm, and error (Jha, Orav, Ridgway, Zheng, & Epstein, 2008). The timeline of data used in this study ostensibly spans calendar year 2014.

For each dependent variable (net patient revenue, operating income, and operating margin), the authors chose to categorize each hospital into one of four equal quartiles. Quartile 1 was the 0th to 25th percentile for hospitals, Quartile 2 was the 26th to 50th percentile, Quartile 3 was the 51st to 75th percentile, and Quartile 4 was the 76th to 100th percentile. A hospital in the bottom quartile had profitability in the bottom 25%, whereas a hospital in the top quartile had profitability in the top 25%. The Leapfrog score ranged in value from 1.39 to 3.74 (presented in a continuous manner similar to a GPA) for all the hospitals in the study. The author’s merged the Hospital Safety Score and AHA data sets by Medicare provider numbers using statistical software, resulting in a final sample of 2,278 hospitals that provided both financial and Leapfrog data. They then conducted a retrospective cross-sectional study, analyzing each of the three outcome measures of hospital profitability in sperate multinomial logistic regressions.

The results of the study were not surprising. Across all three measures of profitability, a higher Hospital Safety score was associated with a higher relative risk of a hospital being in a higher quartile of profitability. These results indicate that a hospital may simultaneously have high levels of patient safety outcomes and financial performance. The implications of such results are that, despite the often-held belief that there will always be a trade-off between quality improvement and financial outcomes, the cost, quality, and access tradeoffs may not be as rigid as previously thought. (Beauvais et al., 2019) This seems to be an interesting way to meet the seemingly impossible demands of IHI’s goals to improve quality and access of care while decreasing the cost (Schmidt, 2019). Given the results of Beauvais, Richter, and Kim’s research, as well as recent changes in health care reimbursement and value-based incentives associated with several of the CMS measures, it is likely that broad support patient safety improvements will continue to increase. (Beauvais et al., 2019)


  • American Hospital Association. (2016).

    American Hospital Association hospital financial database

    . Retrieved from
  • Beauvais, B., Richter, J. P., & Kim, F. S. (2019). Doing well by doing good: Evaluating the influence of patient safety performance on hospital financial outcomes.

    Health Care Management Review



    (1), 2–9.
  • Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care.


    , 307(14), 1513Y1516.
  • Centers for Medicare & Medicaid Services. (2008).

    Office of Public Affairs

    . Retrieved from
  • Cross, J. (2019, July 16). Guest Lecture.
  • Gilman, M., Hockenberry, J. M., Adams, E. K., Milstein, A. S., Wilson, I. B., & Becker, E. R. (2015). The financial effect of value-based purchasing and the hospital readmissions reduction program on safety-net hospitals in 2014: A cohort study.

    Annals of Internal Medicine

    , 163, 427-436.
  • Jha, A. K., Orav, E. J., Ridgway, A. B., Zheng, J., & Epstein, A. M. (2008). Does the Leapfrog program help identify high-quality hospitals?

    The Joint Commission Journal on Quality and Patient


    34(6), 318-325.
  • Lu, N., Huang, K. C., & Johnson, J. A. (2016). Reducing excess readmissions: promising effect of hospital readmissions reduction program in US hospitals.

    International Journal for

    Quality in Health Care

    , 28(1), 53-58. doi:10.1093/intqhc/mzv090
  • Makary, M. A., & Daniel, M. (2016). Medical errorVThe third leading cause of death in the US.


    , 353, i2139.
  • Rust, R. T., Zahorik, A. J., & Keiningham, T. L. (1995). Return on quality (ROQ): Making service quality financially accountable.

    The Journal of Marketing

    , 58-70.
  • Schmidt, R. N. (2019, June 11). Class Lecture.

Impact of HIV on Society

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic is one of the most serious contemporary sexual health related issue affecting the human race today. By the end of 2009, it was approximated that 34 million people were living with the HIV virus and deaths related to AIDS were about 1.8 million people. HIV/AIDS has been the worst pandemic since its discovery; having claimed over twenty five million lives by 2005 with the Sub- Saharan Africa being the most affected (Douek, Roederer & Koup, 2009). This paper focuses on the impact – psychosocial, cultural and economic of HIV/AIDS and its related sexual health problems on the individual as well as the community. HIV/AIDS has a huge impact on the infected individual’s family unit and the community they live in. The impact is dependent on the mode in which the virus is transmitted among communities (and who it infects), the diagnosis of infection, and the community setting in which the individual and family live.


Human immunodeficiency virus (HIV) is a retrovirus that causes acquired immunodeficiency syndrome (AIDS). Two strains of the virus, HIV-1 and HIV-2, have been described. AIDS is a human disease in which there is gradual failure of the body’s defence (immune) system thereby leading to severe and fatal opportunistic infections and cancers (Douek, Roederer & Koup, 2009). Infection with HIV occurs through coming in contact with infected body fluids such as blood, breast milk, and sexual fluids such as pre-ejaculate, semen and vaginal fluids. The key modes of transmission are unsafe sex with infected person-both heterosexual and homosexual, contaminated items such as needles and razors, breastfeeding, and infected mothers infecting the newborn during birth. Blood and blood products screening for HIV has greatly eradicated infections transmission through infected blood and blood products transfusions. HIV eventually progresses to AIDS; the individuals mostly succumb to opportunistic infections or malignancies resulting from progressive weakening of the immune system. Different individuals infected with HIV develop AIDS at different rates depending on the host, viral, and environmental factors; many develop to AIDS within ten years but in some it may be earlier or later. There is no cure for HIV/AIDS; treatment involves life-long use of a combination of anti-retroviral drugs and a cocktail of other drugs to treat any opportunistic infections (Douek, Roederer & Koup, 2009).

Infection with HIV usually has a huge physical, mental, social and economic impact on infected individuals, their families as well as the community in which they live. Stigmatization by other community members aggravates this impact; it hampers the prevention and management of HIV and impedes social support and disclosure of HIV status. The family units mostly affected by the HIV scourge are those of low socioeconomic status, such as drug users, asylum seekers and emigrants. The long-term impacts of living with HIV due to invention of better HIV care and management such as HAART (Highly Active Anti-Retroviral Therapy) have also evolved and changed many social aspects such as parenthood, disclosure HIV status and long term effects of the use of HAART on the individual. Another impact of the HIV is depicted in the inequality and discrimination individuals living with HIV experience when it comes to matters such as securing or sustaining employment and vital services like life assurance. Children have been known to bear the greatest impacts of HIV especially those orphaned and those infected with HIV. The number of orphans has been on steady rise due to AIDS-related deaths of the guardians and the fact HAART is ensuring infants born with HIV can live with the virus till they reach adolescence or beyond. All these factors collectively affect the community around them both socially and economically.

The Physical, Psychological and Social Impact of HIV on Individual and Families

Infection with HIV/AIDS leads to numerous bodily, mental and social issues that affect the individual and impacts on their families and communities at large. In the contemporary society, the definition of a family shifts from the traditional structure of biologically related members to include socially chosen relationships, for instance, close friends, partners, and close external family relationships such as homosexual men (Green, 2011). Before the discovery of anti-retroviral drugs, infection with HIV meant death within a short period of time. However, after the invention of HAART over a decade ago, there has been a gradual decline on the number of individuals succumbing to AIDS-related diseases in Australia, Europe and the United States. Currently, families have to deal with HIV infection as a chronic disease to be coped with for the life span of the infected individuals (Zuniga, Whiteside and Ghaziani, 2008). The requirement to take complex regime of many drugs is the foremost burden for the HIV-infected individual; many patients suffer anxiety, frustration, depression and hopelessness especially when the drugs do not accomplish or maintain the perceived benefits expected from the treatment regime. This could be due to virus mutation and individual resistance to the drugs (Zuniga, Whiteside and Ghaziani, 2008). It is documented that even when the treatment is effective, patients have other form uncertainties and distress.

The impact of the HIV treatment is further aggravated by other factors such as worry about employment, sexuality, the prospects of relationships, and the social reactions of other community members. HAART has numerous side-effects, such as cardiovascular diseases and several of which have psychosocial consequences like lipodystrophy (Zuniga, Whiteside and Ghaziani, 2008). Members of the family may also be burdened by giving care to the infected as the disease advances, and they may be distressed by the stigma often associated with HIV infection.

Another impact of HIV is the stigma and discrimination against persons living with HIV/AIDS. Apart from having to endure treatment with severe side-effects, they constantly have to cope with rejection and social discrimination. People with HIV/AIDS have to put with being labelled as “victims” a term that implies defeat, helplessness and dependence upon help from others (Matic, Lazarus & Donoghoe, 2006). The forms of stigma and discrimination vary geographically. Many nations have regulations that control the travel, entry and residence of persons living with HIV/AIDS. By the end of 2010, individuals living with the virus were restricted on long stays of over three months in sixty countries and eighteen of these even applied limitations on short term residence (Stutterheim et al, 2009) In healthcare sector, the common examples of stigma and discrimination experienced are being denied access to facilities and drugs, mandatory HIV testing without individual consent, and breach of confidentiality over the person’s status. In the workplace, stigma from employers and fellow workers include social isolation and mockery, or experience biased practices, such as dismissal or denial of employment (Stutterheim et al, 2009). Others instances include denial of entry into a country, forced eviction from residence by their families and rejection by colleagues and friends.

Stigma and discrimination associated with HIV/AIDS greatly hinders efforts to successfully battle the HIV and AIDS pandemic. This fear of discrimination frequently averts individuals from seeking treatment and management of AIDS or from publicly disclosing their HIV status. On numerous occasions, the stigma associated with HIV/AIDS can extend to the family and siblings of the infected individual, creating an emotional burden on those left behind. HIV/AIDS-related stigma modifies over time as infection levels, understanding of the disease and treatment availability vary. For instance, in the Netherlands, the community response to persons with HIV/AIDS is quite positive; understanding of HAART was linked to perception of lower risk, with a positive attitude towards gay people, less fear, and a greater readiness to have personal contact with people with HIV/AIDS. However, in Eastern Europe, discrimination may be more severe, particularly of specific groups, such as gays (Stutterheim et al, 2009).

Economic Impact of HIV

HIV/AIDS has had the greatest negative effect on the economies of many countries all over the world. The pandemic has been devastating for many nations where it has caused deep poverty both to the individual, families and community. The magnitude of economic and demographic impact of HIV/AIDS infection in third world countries is pronounced due to the fact that it affects persons in the most economically able and productive age. Besides, it is also weighing down on the economic and health gains made in the last few decades. People with HIV/AIDS create a profound burden for public finances, especially in the sector of health. In a number of Caribbean countries, HIV/AIDS patients take up as many as a quarter of existing hospital beds (Green, 2011). The sub-Saharan Africa is the most affected with southern Africa leading with the effects of the virus. The World Bank approximation shows that gross domestic product (GDP) of South Africa reduced by twenty percent in 2010 due to the effects of the deadly virus (Salinas & Haacker, 2006). Many other countries are using huge portion of their economic resources in providing treatment and care for people with HIV/AIDS. A research carried out by the University of the West Indies shows that the GDP of countries such as Trinidad and Tobago will drop by over five percent and that of Jamaica by 6.4 percent as a result of HIV/AIDS. The economic impact is poverty, a reduction in investments and savings, and rise of unemployment in vital industries such as agriculture and manufacturing (Salinas & Haacker, 2006).

The economic impact of HIV is greatly felt by the individual and their families. HIV/AIDS in many cases results in loss of income of the breadwinners and increase in expenditures as a result of caring for the infected. Families affected by HIV deplete their savings and assets in order to cope with increased expenditure and income shocks. Firm profits, savings and investments may reduce due to increase AIDS-related expenditure and lower labour productivity (Whiteside, 2008). According to ILO estimates, close to thirty seven million persons worldwide who are engaged in productive economic activities are HIV-positive. The mortality of these adults leaves the children as orphans and in cases where they were the sole bread winners; the children are left destitute (Green, 2011).

Impact of HIV on Parenthood and Children

The development of HAARTs has had an impact on pregnancy planning among people living with HIV. In the pre-HAART era, HIV-positive women were faced with their HIV status and the expected bleak outcome of death. The number AIDS-related deaths, however, has drastically gone down in women living with AIDS due to HAART; they now live longer healthier lives. Among the women in the reproductive age who are living with HIV, the decision about pregnancy is becoming an important one; this due to reduction of the risk of vertical transmission of the virus to the newborn (Noroski, 2009). Gains in prevention of mother to child transmission have led to emergence of new dimensions in the way communities view parenthood. Parenthood in HIV infected people is still eliciting many physical and social effects especially due to stigma and discrimination associated with the virus. Noroski (2009) outlines that concerns that might determine parenting decisions among people living with AIDS are the aspiration for parenthood, religious beliefs, children one had before, the position of spouse and health care providers, and apparent spouse capacity to parent successfully.

HIV/AIDS has greatly changed parenthood. Research findings shows that close to seventy percent of all HIV infected parents regarded their family planning to be over, since they did not plan bear any more children, sixteen percent were undecided, while fourteen percent had an explicit longing to have more children (Wacharasan and Homchampa, 2008). Children who are infected with HIV either during birth or later through breast milk now have a chance to survive up to adolescence owing to better treatment regimes. This means that more adolescents increasingly have to cope with the virus. Children living with HIV/AIDS have a high risk of death from opportunistic infections. The virus affects the children psychologically and leads to neurological impairment; as a result they have pronounced cognitive insufficiency or diminished cognitive abilities, have behavioural difficulties, and have a general low quality life. Children living with HIV may also experience challenges in leading a normal life due to the medication they must use regularly as well as problems that result from disclosure of their HIV status (Noroski, 2009). The other main impacts of HIV on motherhood are ethical concerns about the possible danger of spreading the virus to the newborn, the socioeconomic impact, concerns and stigma associated with bringing up a child by a parent who has a potentially fatal disease.

The HIV/AIDS pandemic has greatly contributed to increase in the number of orphans universally. In Africa alone, there are over twelve million children orphaned by AIDS pandemic. The children are left destitute; at times the elder adolescents have to take up the parenting roles while majority are taken care of by their extended family members or foster parents. This long term care causes economic difficulties as financial resources are strained. The children become fully deprived of the care, guidance and protection of their parents and social problems begin to crop up. The children find themselves prematurely out of school. Statistics show that many of these children have to drop their education due to lack of resources, stigma and discrimination or simply to take up the role of premature parenting resulting from death of their parents. These effects are more pronounced especially after death of both parents. HIV/AIDS in the long term leads to numerous social impacts on the community such increase in crime rates, poverty, drug abuse, illiteracy, reduced productivity and eventual collapse of social system.

Impact of HIV on Caregivers and Healthcare Sector

The major burden of caring for the people living with AIDS rests with the family and the health care providers. In the era before anti retroviral therapy, this used to be an immensely stressing task because most of times the health of the infected patients deteriorated rapidly, they were bedridden and has to be taken care of. The advent of HAART has greatly improved the need for round the clock help since the patient can now lead a healthier life without need for much help. Important care givers are mainly the family, close friends and health workers.

The major impact of HIV on the caregivers is stigma; usually referred to as secondary stigma or stigma by association. Parents of people living with HIV may be held responsible for the ‘immoral’ behaviour that led to infection of their children with HIV. Wacharasan and Homchampa (2008) reported stigmatization as a primary concern for the caregivers. Rather than face stigmatization, caregivers may try to conceal their care giving activities by withdrawing from social relationships. In clinical practice, family caregivers may exacerbate demands of care giving by driving long distances to avoid community awareness of their care recipient’s HIV status. Some informal caregivers even avoid employing the professional home services of home health care, infusion therapy hospice, and hospice providers to avoid HIV/AIDS disclosure in their communities. Nurses working with informal caregivers fearful of status disclosure must be sensitive to the family’s caregiver’s fear of discrimination and stigma (Wight et al, 2006). Nurses, knowledgeable of ‘HIV friendly’ referral agencies with well established histories of providing confidential services can play a role in meeting the need for professional home-centred services and bringing solace to an informal caregiver fearful of HIV stigmatization.

Caregivers of HIV-infected children also face stigma. Thampanichawat (2008) found primary caregivers of children with HIV infection dealt with the stigma of AIDS while managing their anxiety and fear of loss. Bore much burden of care and faced many difficulties because of limited resources. Similar studies report increased financial difficulties, problems in child care and support and compromised help-seeking due to stigma. These findings emphasize the need to develop interventions to enable caregivers to seek out and identify financial resources and child care to support and empower caregivers to deal with stigma. Health care providers also may fears stigmatization in their work with HIV-positive patients. Caregivers, both formal and informal, commonly experience stigma from their association with HIV/aids and people living with it. This stigma may influence their willingness to work with those with HIV/AIDS or make their work more difficult.


Annually, across Australia and the world, many individuals get infected with HIV; thousands living with HIV develop AIDS. The impact of contracting and living with this virus hugely challenging and depends on the society the infected person lives in. The impact may determine the effectiveness of the management program, adherence to the treatment regimen and prevention of new infections. The major challenges are to encourage HIV testing for the risk groups, encourage status disclosure, availing a timely and effective management and care to all people living with HIV/AIDS, to endeavour in developing contemporary prevention methods that consider the variable patterns of the pandemic, and to eradicate the economic, physical and psychosocial impacts of HIV infection. Policies should incorporate the needs of individuals, families and the community in order to effectively address the impact of HIV on various sectors.

Aortic Valve Stenosis: Symptoms- Causes and Treatments

Aortic Valve Stenosis is a condition caused by the narrowing of the hearts aortic valve. This congenital heart defect is very common among people in the U.S., as over 200,000 cases are noted per year

(Mayo Clinic, pg. 28)

. This condition presents itself with many signs and symptoms, and can eventually cause many issues if left untreated. The good thing about this condition, though, is that with a proper diagnosis and understanding, it can be treated and repaired with the help of a cardiovascular doctor

(Mayo Clinic, pg. 42)


When experiencing symptoms related to that of aortic valve stenosis, it is important for sufferers to understand the cause and reason behind the symptoms and signs they are experiencing. Although aortic valve stenosis seems like a rather anatomical problem, there actually is quite a pit of pathophysiology behind the disease. As described by the Mayo Clinic, pathophysiology is the disordered physiological processes associated with disease or injury

(Mayo Clinic, pg. 2).

To truly understand just what the heart is going through when presented with aortic valve stenosis, it is important to understand how a normal heart without AVS should actually function. In a normal heart, all four valves should properly open and close when there is an increase or decrease in pressure, during diastole and systole to ensure that the blood is flowing through the heart properly

(CCN-Cary, pg. 7)

. Between early and mid diastole, blood flows through the tricuspid and mitral valves into the right and left ventricles to make sure there is enough blood being regulated

(CCN-Cary, pg. 7)

. After that, during late diastole, the right and left atria fully contract which leads us into early systole. During the early stage of systole, ventricular pressure increases which forces the mitral and tricuspid valve to properly close. When the pressure of the ventricles increase, all four valves close for a small amount of time in response to ventricular contraction, also known as isovolumetric contraction. After all of this, the pulmonic and aortic valves should open. “During mid systole, when ventricular pressures exceed pulmonic and aortic pressures, the pulmonic and aortic valves are forced to open, and blood is ejected into the pulmonary vasculature and aorta”

(CCN- Cary, pg. 6).

When blood is ejected into the pulmonary vasculature and the aorta, the pulmonic and aortic valves should close right after that. This brings us to late systole where the ventricular muscle slowly begins to untwist and relax. This ensures that the pressure against the pulmonic and aortic valves close properly and effectively but the normal heart into isovolumetric relaxation

(Cary, pg. 8).

With aortic valve stenosis, there are a few elements of pathophysiology behind this disease that causes the actual narrowing of the heart’s aortic valve, in which case is the problem for this congenital heart defect and makes this heart differ from the processes of a normal heart. The pathophysiology of this heart defect starts in the four valves of the human heart which include the mitral valve, tricuspid valve, the pulmonary valve and the aortic valve

(HealthLine, pg. 48)

. Attached to these four valves are little flaps, or cusps, that open and close each time your heart beats. It is possible for the valves to unsuccessfully open and close properly, which  can damage your heart by disrupting blood flow. With the disruption of blood flow in the heart, the heart can potentially become impaired during the process of pumping blood

(HealthLine, pg. 53)

. In aortic valve stenosis, the aortic valve that lies between the left ventricle and the aorta is narrowed; because of this, the left ventricle struggles a lot harder at pumping a precise amount of blood to the aorta, which then goes on to deliver filtered blood to the rest of the body. When this happens, it physiologically can thicken and enlarge the left ventricle, and make that side work about 4 times harder than a healthy heart would work. When it begins to work so much harder than normal, it can not only weaken the left ventricle and the heart as a whole, but it can eventually lead to severe heart problems, and in serious cases, heart failure

(HealthLine, pg. 67)


As a result of the complications caused by aortic valve stenosis, patients with AVS become very dependent on the atrial kick (the contraction of the atria during ventricular diastole) to ensure they maintain correct stroke volume and cardiac output. When a patient with AVS has a loss of atrial kick resulting, fluid or blood volume overload might create pulmonary congestion, hypotension and even angia

(CCN- Cary, pg. 8)

. Along with pulmonary congestion, it is possible for a patient with AVS to have atrial arrhythmias (irregular flutter or heartbeat) which might result from calcific infiltrates from the aortic valve (

CCN- Cary, pg. 9

). So, it is really important to understand the symptoms and get yourself checked to ensure proper diagnosis and individualized care/ effective treatments.

Although AVS is in fact a congenital heart defect, most people are not born with aortic stenosis, but are born with a damaged aortic valve. Later in life is when aortic valve stenosis can actually present itself, and it can come on strong with several signs and symptoms, or not many at all. Some people with AVS have reported experiencing no symptoms from this condition, but those that do present with symptoms, complain of a wide variety of things.

Symptoms of aortic valve stenosis include breathlessness (caused by the overworking of the heart), chest pains (caused by rapid valve motions), edema (caused by decreased oxygen), fainting, heart palpitations or feelings of heavy heartbeats, heart murmur, and even a decrease in activity and energy levels (caused by your body’s inability to pump blood in the heart fast enough)

(JACC, pg. 2).

With any of these symptoms, a clear diagnosis will be appropriate before starting the necessary treatment. When symptoms of AVS present later in life, it is important to have this condition treated as it can progressively get worse with time. But, before treatment can begin, a proper diagnosis must be given by your doctor. There are a couple of ways to diagnose this condition; some of which are more common than others.

One method of diagnosis is an echocardiogram, this test uses sound waves to watch the rhythm of your heart in motion. An echocardiogram when used to diagnose AVS is specifically looking for the size and shape of your heart, thickness of the heart, movement of your heart’s walls, the heart’s pumping strength, if the

heart valves

are working correctly, if blood is leaking backwards through your heart valves (


), if the heart valves are too narrow (


), and if there is a tumor or infectious growth around your heart valves relating to AVS

(JACC, pg. 4).

Other possible methods of diagnosis include an electrocardiogram, a chest x-ray, exercise tests or even sometimes stress tests, CT scans or MRIs, and in some severe cases, cardiac catheterization

(Mayo Clinic, pg. 12)

. Diagnosing AVS is not super, especially using any of these methods. Although, an echocardiogram is the most common and oftentimes, the most effective.

After receiving a proper diagnosis of aortic valve stenosis, luckily, there are several ways to effectively treat the condition as well. Many cases are not severe enough to require treatment, but if they do, open heart surgery is the proper treatment for this condition. During this pretty invasive procedure, surgeons will replace the narrowed aortic valve that is failing to open properly (aortic valve stenosis)

(Mayo Clinic, pg. 15)

. During the procedure, the surgeon will make an incision on the breastbone or sternum, and go in to completely remove the affected valve. After it is removed, the surgeon will replace it with a healthy valve which can be either a mechanical (handmade valve out of titanium or body safe plastics) or a biological valve (transplanted from someone with a healthy aortic valve)

(Mayo Clinic, pg. 17)

. The prognosis proves to be mild, treatable, and moderate

(CCN- Cary, pg 14)


According to the Mayo Clinic for Healthy Hearts, among 2,441 patients who received the surgery for AVS experienced complications within 30 days

(WebMD, pg. 44)

. Some complications include gastrointestinal issues, neurological complications, and many severe falls were also reported. Some more severe cases included a paravalvular leak (a gap between the prosthetic valve and the native annular tissue, PVL results in regurgitation of blood from downstream to upstream chamber), and a greater left ventricular mass (buildup of benign cells that can’t properly disperse due to prolonged narrowing of the valve) at 30 days post op

(WebMD, pg. 48)


In conclusion, although aortic valve stenosis is a congenital heart defect, it is important to note it does not start out that way. In the early years, it starts out as an aortic valve abnormality, which later in life has the potential to develop into valve stenosis. It ultimately starts with the narrowing of the aortic valve, which causes the left ventricle to struggle to pump an adequate amount of blood to the aorta and the rest of the body, which ultimately can cause a lot of serious problems with your heart, including in some severe cases, heart failure. When these symptoms happen, and you start to show physical signs, it is important to be checked out by a physician to ensure a proper diagnosis. With the proper diagnosis or aortic valve stenosis, a treatment can be properly put in place and you can move forward with the recovery from this heart defect. Although this condition can be very scary and potentially cause several risks with you heart and overall health, the condition is fortunately treatable.

Works Cited

  • “Incidence, Predictors, and Prognostic Impact of Late Bleeding Complications After Transcatheter Aortic Valve Replacement”

    Journal of the American College of Cardiology.

    24 Dec 2014. Web. 22 July 2019.
  • “Aortic Valve Disease.”

    The Mayo Clinic for Healthy Hearts.”

    14 May 2018. Web. 22 July 2019.
  • “Aortic Valve Stenosis.”

    HealthLine Major Health.

    24 Jan 2018. Web 22 July 2019.
  • “What Is Aortic Valve Stenosis?”

    WebMD Health A-Z.

    4 June 2014. Web. 22 July 2019.
  • “Aortic Stenosis: Pathophysiology, Diagnosis, and Medical Management of Nonsurgical Patients.”

    Critical Care Nurse for High Acuity Health (Theresea Cary).

    12 Feb 2016. Web. 22 July 2019.

Causes of Childhood Asthma


This case study aims to review the causes of childhood asthma in the United Kingdom (UK) as well as worldwide and look at current guidelines used within the UK Ambulance Service, National Health Service (NHS) and global health care providers. Evaluating care pathways, treatment plans and management of the disease will increase awareness and ensure treatments are used effectively to avoid hospital admissions and unnecessary mortality amongst children.

Asthma is a chronic, or long-term condition that intermittently inflames the bronchi and narrowing the airways in the lungs. The inflammation makes the airways swell causing periods of wheezing, chest tightness, shortness of breath, and coughing (NHLBI, 2020). The Global Initiative for Asthma (GINA) describes asthma as “a heterogeneous disease, usually characterised by chronic airway inflammation.

According to Asthma UK, approximately 1.1 million children (1 in 11) in England are currently receiving treatment for asthma with an average of 3 children in every classroom having the disease and one child every 20 minutes being transferred to hospital for treatment (2020). Childhood asthma has a significant impact on school days lost each year, with 25,128 children in England under the age of 16 going to hospital in 2018 (NHS England, 2019).

The high number of children living with the disease puts a huge strain on the NHS including the Ambulance Service in this case study. These statistics highlight the ever-growing need for Health Care Professionals, families and children in the care of educators to fully understand the seriousness of childhood asthma and ensure appropriate treatment and care plans are put into place and utilised.

Case Presentation

In September 2019 a call was made via 999 to the North West Ambulance Service (NWAS) for a 6 year old male patient who had severe difficulty in breathing. It was categorised by the dispatcher as a Cat 2 red response. The patient was in school on the day of the incident and had been running outside when he was suddenly unable to catch his breath. The asthma attack was caused by suspected exercise-induced asthma (EIA) which is a reversible airway obstruction that is triggered by moderate to vigorous exercise (Rundell, Wilber and Lemanske, 2002). Exercise-induced asthma is thought to be related to the loss of heat and water from the airways during exercise which causes the airways to narrow, especially in exercise such as running which can provoke wheezing (Asperen and Mellis, 1997).

On arrival, the ambulance crew was directed to the school office where the patient was sat leaning forward in the tripod position, which is a position of comfort for a child in respiratory distress (, 2020). He was a white British male, slim build and a normal height for his age group. The teachers on scene stated that they had given the patient three puffs of his Ventolin (Salbutamol) Inhaler, which was used with a spacer device. The inhaler is a plastic device that delivers the medication as an aerosol, and a spacer is a plastic tube that has a mouthpiece on one end and space to attach the inhaler onto the other end (Medical News Today, 2020).

A primary survey was undertaken using a stepwise approach which is a tool used by ambulance clinicians to assess a patient. The patient is assessed step by step checking Danger, Response, Catastrophic Haemorrhage, Airway, Breathing, Circulation, Disability, Expose (DR

ABCDE) (JRCALC, 2019 p.138). The child appeared to be alert with a pale complexion and was unable to speak in full sentences, only being able to tell the ambulance crew his name. He was tachypnoeic (fast respiration rate) of 40 beats per minute (BPM) and an audible wheeze could be heard from the patient on expiration, which is suggestive of lower airway narrowing and respiratory distress (Fergusson and Lawton, 2009, p17). On further examination, there was intercostal recession present, which in children of his age can be a sign of severe respiratory problems (Charters, 2017, p21). The ambulance crew quickly recognised that the patient was in significant respiratory distress and his oxygen level and pulse were quickly assessed. His oxygen level was 90 % on room air and his pulse was 135 BPM. High flow oxygen therapy at 15 litres was commenced, following JRCALC protocols (2019, P177). Asthma is categorised in to mild/moderate, severe and life-threatening in NICE guidelines (2019) (see appendix A) and this patient’s attack was showing as severe asthma. Paramedics usually carry out a Peak Expiratory Flow Rate test (PERF) to ascertain the degree of obstruction in the patient’s lungs, however as this was an acute severe attack the crew did not want to exacerbate the attack so refrained from carrying out this task.

A Nebuliser is a device that converts a solution of a drug into a fine spray which is then inhaled through a mask (British Lung Foundation, 2020). The patient was administered 5 milligrams of Salbutamol through the device which is a Selective beta2 adrenoreceptor stimulant drug. The Paramedic auscultated the patient’s chest and a widespread wheeze could be heard bilaterally. Post Salbutamol treatment the patient’s condition improved with oxygen saturations of 95% and a pulse of 125 BPM, and he was transferred to the ambulance. His mother arrived on scene and stated that the patient had been diagnosed with asthma when he was 5, there was no family history of asthma. She also advised that he was prescribed a corticosteroid preventer inhaler (ICS), but had not been taking this daily as instructed by his GP.

In the Ambulance, the patient still had an audible wheeze and looked in distress, so the decision was made to administer 250 micrograms of Ipratropium Bromide which is an antimuscarinic bronchodilator drug via nebuliser on route to the hospital. The EMT communicated with the Emergency Control Centre (EOC) via the radio so that the receiving hospital could prepare for the incoming patient.


The patient discussed in this case was primarily assessed using the mnemonic DR

ABCDE which a clinical guideline used by ambulance clinicians is found in JRCALC (2019). This method of emergency assessment is utilised by most Health Care Professionals and is recommended by the Resuscitation Council (UK) in their clinical guidelines (, 2020). Paediatric assessment is done using a systematic approach and different methods are used both in the pre-hospital setting and within the health care system. Paediatric Education for Prehospital Professionals (PEPP) states that the best way to carry out a primary assessment in children is using the Paediatric Assessment Triangle (PAT) method which can be seen in Appendix B (PEPP, 2018 p5). According to PEPP, the triangle comprises of three main areas: Appearance of the patient, Work of breathing and Circulation to the skin. The paradigm was created by Drs Dieckmann, Brownstein, and Gausche-Hill to enable Health Care Professionals to rapidly assess the patient using visual and auditory senses.

There are many variations of paediatric scoring systems that have been developed worldwide, and Monaghan’s PEWS is one of the most simple and flexible systems (Gold, Mihalov and Cohen, 2014). The Paediatric Early Warning Score (PEWS) and paediatric track and trigger tools (PTTT) are now common tools used by health care professionals across the world since their introduction (Trubey et al., 2018). The Ambulance Service in the UK has moved away from PEWS and has now adopted the Paediatric Observations Priority Score (POPS) to use alongside Emergency Departments (ED’s) and can be found in the Manchester Triage System (MTS). MTS is a triage system used by both Ambulance Services and ED’s in the UK and around Europe (Health Research Authority, 2020). Early Warning Scores were designed to detect deterioration of the patient, whilst POPS has demonstrated an ability to aid detection of paediatric patients requiring hospitalisation and support discharge decision’s for children with minor illness.

The American College of Allergy, Asthma and Immunology (ACAAI) states that EIA is more likely if exercising in cold weather as opposed to humid climates. EIA should be treated with beta2-agonists and Inhaled corticosteroids (ICS), both are prescribed long-term asthma medications, however, it may take two to four weeks before corticosteroids reach their maximum effect (ACAAI, 2020). This patient was prescribed both medications by the GP but had not been taking his budesonide (preventer inhaler) regularly. This meant that the treatment was no longer effective for this patient and may have contributed to this episode. The National Review of Asthma Deaths published in 2014 by the Royal College of Physicians found that approximately 2,000 children are only using long-acting reliever inhalers on their own rather than with a steroid preventer which is putting them in danger of more severe attacks. The review also acknowledged that only 23% of people who had died from asthma had been given Personal asthma action plans (PAAPs). These personal plans help to improve all aspects of asthma care so that patients are better equipped to manage their symptoms and therefore less likely to be admitted to hospital for their asthma. Research has shown that people without a written asthma action plan are four times more likely to be admitted to hospital for their asthma, with three out of five children not having one. An effective asthma care plan should involve an asthma review, being on the right medication, awareness of how to use inhalers correctly and a written asthma action plan that can be given to schools (Asthma, UK).

The treatments of asthma in the pre-hospital setting within the ambulance service follow a stepwise approach according to JRCALC (2019). In severe asthma, the patient should be given high levels of Oxygen, followed by an oxygen driven nebuliser containing salbutamol. If no improvement Ipratropium Bromide by nebuliser and Intravenous steroids should be administered. In this case study steroids were omitted from the treatment, however, guidelines such as the GINA report show that systemic corticosteroids given early during treatment of acute asthma exacerbations were overall shown to be an effective way of managing asthma. Oral and intravenous steroids are of similar efficiency, with oral steroids being the preferred route in children (sign 158, 2019). A recent study carried out in China also looked at the difference between oral dexamethasone compared to oral prednisolone in the treatment of acute asthma exacerbations in children. The study found that both treatments had similar results however, children who had Dexamethasone had fewer side effects including vomiting compared with Prednisolone (Wei et al., 2019). In an article published in the Medical News Today (2018) another line of treatment for severe asthma is Magnesium Sulphate. This medication is a vasodilator and bronchodilator and can be given nebulised or by IV infusion. It is a safe treatment for children suffering from a severe acute asthma attack according to the most recent (2019) BTS/SIGN guidelines. The use of Magnesium Sulfate in the UK Ambulance Service is currently not indicated; however, the drug is routinely used in the Queensland Australia Ambulance Service protocols for treatment of severe life-threatening asthma (, 2020).


Children around the world suffer from asthma exacerbation and attacks regularly, which can have an impact on their daily activities. If patients understand their condition and attempt to remove the triggers that cause attacks such as allergens, lost school days and hospital admissions will be reduced. Children with asthma should be prescribed regular ICS therapy by their practitioner as a preventative measure. Adherence to daily ICS therapy is a key determinant of asthma control to prevent future attacks from occurring (Hossny et al., 2016). Having a PAAP in place will also help patients stay in control of their asthma and acts as a guide for health care professionals and those in the care of the child in an emergency (Asthma UK, 2020). Schools should have the correct training and designated persons to deal with emergency medical situations including sudden asthma exacerbations. If the situation is dealt with appropriately it will reduce the severity of the attack.

Ambulance clinicians should ensure that paediatrics are assessed as quickly as possible and in a systematic approach. Using the PAT triangle method of the initial assessment will be an evaluation tool that will be easily implemented into future practice, as it takes only a few seconds and requires no equipment. Ensuring that clinicians use the POPS effectively and with every paediatric patient will enable rapid diagnosis of the most poorly patient and will allow ED’s to assess if the patient has deteriorated or improved.

Based on the evidence I have found treatments such as Magnesium Sulfate and oral Prednisolone may be of benefit to the patient’s in the long term, however, in the pre-hospital setting bronchodilators are the quickest most effective way of treating acute asthma attacks. Hydrocortisone should be given for treatment in moderate to severe asthma attacks and could have been administered in this case. Studies are continuing worldwide for the best treatment pathways of acute asthma and more research into if corticosteroids should be routinely administered by paramedics will be needed before they can be introduced as an out-of-hospital treatment.

Appendix A NICE Guidlines

Appendix B – The Pediatric Assessment Triangle and its components