Mary- I think it is for my blood pressure, it was a bit high

Nurse- Have you ever taken a blood pressure medication before?

Mary- No this is my first time

Nurse- Do you know the side effects of this medication?

Mary- No, I don't. I was just told to take it. the pharmacy told me not to take grapefruit with it. I don't take grapefruit anyway.

Nurse- Ok Mary, that is great that you are aware of the grapefruit. would you like me to go through the side effects with you?

Mary- Yes please

Nurse- the most common side effect that is linked with this medication is fluid retention. You could see this with ankle swelling. headaches, dizziness and tiredness are also common. they are quite mild, and it is just your body adjusting to the treatment. If your symptoms continue after 2 weeks, please call the clinic and leave us know.

Mary- ok thank you. I have been feeling well on it over the past week.

Nurse- Yes the blood pressure is good today. Mary do you know the symptoms of low blood pressure?

Mary- I'm not sure, I have always had high blood pressure.

Nurse- Ok so Mary, listening to you, You know the symptoms of High blood pressure, but unsure of how low blood pressure feels, will I go through that with you?

Mary- Yes- please.

Nurse- so if you take more of the prescribed dose- your blood pressure could drop- this could present with the feelings of light -headedness- dizziness- feeling faint, or weak. your skin could feel cold or clammy also. if this does happen Mary you would need to seek medical attention.

Mary- Ok Thank you

Nurse- Ok Mary, what do you think of all this information? is this too much for you, would you like some written information also?

Mary - Yes that would be great please.

Nurse- ok Mary- here is the written information for amlodpine. Is there anything else I can help you with today?

Mary- no thank you

Nurse- ok so Mary- you are scheduled to be seen again in 4 weeks. we can check the blood pressure again then, in the meantime- keep up the daily walks, these are so benefical for you and the blood pressure. Well done.

Mary- thank you

Can you tell me why you were prescribed vimovo?

Did the doctor tell you how you should take this medication?

Can you repeat what they told you?

Can you tell me what other medications you are taking both prescribed and over the counter.

I see you are taking nurofen - when was the last time you took a nurofen tablet? Just to let you know that it is not advisable to take nurofen with vimovo? They are part of the same medication family and should not be taken together.

Reassurance given to patient that as he has only just started to take vimovo, it is not likely to be a cause of concern but emphasise the importance of following the patient leaflet guidelines. Ask patient to read the manufacturers guidelines.

Formulate a plan with the patient when is the best time for him to take this medication.

Discuss possible side effects - and explain that vimovo contains esemoprazole which helps to protect the stomach from the side effects normally associated with NSAIDS.

Advised to report any unusual effects when taking the tablets.

Agree to check in with patient in three days to see if the vimovo is helping with pain relief and if not, to refer back to GP.

Pt: Honestly as its the first time I have had to take medication, I find it hard to remember every day. So I take it whenever I think of it.

PCN: I can understand this can be difficult at the beginning. But if you set an alarm on phone as a reminder to take tablets it might help.

Pt: That's a good idea, I never thought of that I will give it a go.

PCN: That's great I hope it helps. You get the most benefit from this medication when its taken on an empty stomach before bed, so it has time to work. You should not take more than one or two small glasses of grapefruit juice per day because large quantities of grapefruit juice can change the effects of Atorvastatin.

Nurse: What do you know about this medication?

Patient: It's for reducing weight and Diabetes.

Nurse: Would you like to know more about how it works?

Patient: Yes

Nurse: It increases the amount of insulin from the pancreas in response to food being eaten. This in turn helps with weight loss.

Patient: Are there any risks with this medication?

Nurse: The main risks are diarrhoea, nausea and vomiting. Less common side affects are vision disturbances, retinopathy, inform your doctor if you experience eye problems, such as changes in vision, during treatment with this medicine.

Uncommon inflamed pancreas (acute pancreatitis) which could cause severe pain in the stomach and back which does not go away. You should see a doctor immediately if you experience such symptoms.

Rare severe allergic reactions you should seek immediate medical help and inform your doctor straight away if you get symptoms such as breathing problems, swelling of face, lips, tongue and/or throat with difficulty swallowing and a fast heartbeat.

Injection Site Reactions In placebo-controlled trials, injection site reactions (e.g., injection-site discomfort, erythema) were reported in 0.2% of OZEMPIC®-treated patients.

Increases in Amylase and Lipase In placebo-controlled trials, patients exposed to OZEMPIC® had a mean increase from baseline in amylase of 13% and lipase of 22%. These changes were not observed in placebo-treated patients.

Increases in Heart Rate In placebo-controlled trials, OZEMPIC® 0.5 mg and 1 mg resulted in a mean increase in heart rate of 2 to 3 beats per minute. There was a mean decrease in heart rate of 0.3 beats per minute in placebo treated patients. Fatigue, Dysgeusia and Dizziness Other adverse reactions with a frequency of >0.4% were associated with OZEMPIC® include fatigue, dysgeusia and dizziness.

If you forget to use it and it's 5 days or less since you should have used Ozempic, use it as soon as you remember. Then inject your next dose as usual on your scheduled day, it is more than 5 days since you should have used Ozempic, skip the missed dose. Then inject your next dose as usual on your scheduled day. Do not use a double dose to make up for a forgotten dose. Do not stop using Ozempic without talking to your doctor. If you stop using it, your blood sugar levels may increase.

Diabetic diet should be adhered to despite taking this medication. Also to check BSLs especially for the first month while adjusting to the new medication.

Suzanne- I asked the doctor to help with stomach issues and he started me on this. I take regular nurofen and I think this doesn’t help with my tummy.

RGN- ah I see so you have an upset tummy and the doc prescribed this.

Suzanne - yes I never heard of this before

RGN- ok this medicine is to help with your tummy, if you take the medicine in the morning 30min before food this will help with protecting your tummy.

Suzanne - how long do I have to take this medicine?

RGN- I will link with GP but we will review you in two weeks to see if your tummy is still upset and review the effectiveness of the new medication. Does that make sense can you repeat that back to me?

Suzanne - ok so I take it in the morning half hour before my food and I come back in two weeks.

RGN - if you feel any side effects like nausea, vomiting diarrhoea you need to stop taking the Pantium and come back to see us, will you remember that?

Suzanne-

Yes I think so, if I’ve any side effects come back immediately and if I don’t come back in two weeks,

RGN- not to overload you but there are some foods you might want to avoid to help with your tummy issues like caffeine and spicy foods, is that too much to remember?

Suzanne - I think I can manage to remember that.

RGN - just so I know we are on the same page will you repeat to me what we just discussed?

Suzanne- yea so I take it first thing in the morning 30 min before food, if I get side effects stop taking it and come back here, or if I’m ok to come back in 2weeks to see if it’s doing it’s job, and try to cut out caffeine and spicy food

RGN that’s it, well done, we can leave it at that I will see you in two weeks

Suzanne - thanks

HSE LINK https://www2.hse.ie/conditions/pantoprazole/

Suzanne, Jisna,Maeve,Chelsea,Miriam

Pt: Hello, the docotor told me I have diabetes and need to take this medication, what is it?

Nurse: Your new medication is called glucophage, it helps to lower your blood glucose to as normal a level as possible.

Pt: Are there any side effects?

Nurse: If you experience symptoms of hypoglycaemia such as weakness, dizziness, increased sweating, fast heart beating, visions disorders or difficulty in concentration, it usually helps to eat or drink something containing sugar.

Return if you are experiencing any gastrointestinal symptoms, do not crush or break the tablet as this may increase your risk of an upset tummy.

Pt: How long will I be on it?

Nurse: It is a staged approach based on your HBA1C, the dose may be reduced. It is also important to keep up with you lifestyle changes of healthly diet, excercies, vaccines, smoking cesation.

PT: I'm ok but feeling very sick with that new medication.

GPN: Tell me how the medication is making you feel?

PT: I had a sick stomach with cramps and some episodes of diarrhoea

GPN: Ok, do you understand why you are taking that medication?

PT: yes my blood sugars were high

GPN: yes Caroline, you were trying to control you blood sugars with your diet for some time and they were not improving

PT: yes that's right

GPN: What strength of tablets were you taking and how often?

PT: I was prescribed 1G three times a day, but I have been so sick with nausea and diarrhoea I had to go to the out of hours doctor and they advised me stop the medicine and speak to my GP

GPN: so you are not currently taking any at the moment?

PT: no I'm not taking any

GPN: how are you managing your blood sugars at the minute?

PT:I am eating healthily and exercising

GPN: What are you eating for your meals?

PT: I have porridge made with water for breakfast, a salad for lunch and maybe a stir-fry for dinner.

GPN: Are you doing any exercise?

PT: yes I am walking 5 days per week

GCP: that all sounds really good, it seems you are following all the right advice.

GPN: what way were you taking your medications?

PT: I take them with each meal

GPN: good, it is important to to ensure you take them at the end of your meal

PT: yes I do

GPN: So going forward we need to put together a plan

PT: OK

GPN: how would you feel if we were to try 500mg three times a day and see how you tolerate that and if that goes well we can look at increasing it if needed

PT: Yes I am happy to do that, it sounds like a good plan

GPN: Great, so when you are taking them for 3 months we will redo your HBA1C and see if there is any improvement, we will also check your B12 as Metformin can reduce your B12

PT: I didn't realise by B12 could be affected, that would be great.

GPN: Great, so if you are experiencing an side effects like tummy cramps, nausea or diarrhoea please make sure you contact me.

PT: ok, I will

GPN: I am booking you in for a 4 week phone consultation just to ensure everything is going for you

PT: That's perfect, thank you very much

Nurse: Hi Joe, how are you

Joe: Hi Nurse look, I have a problem, look at my stomach, look at the lumps I have after injecting my insulin, even though I am alternating the sides as you told me

Nurse: Oh how long has it been like that?

Joe: ah maybe a few months, it doesn’t hurt so I thought it would go away

Nurse: How do you manage giving your injections?

Joe: Oh I’m very good at remembering, I give it everyday myself, I didn’t like it at the start but I don’t mind doing it now, but I don’t like the lumps (Specific: problem lipodystrophy)

Nurse: How do you feel about giving the injection in other areas of your body

Joe: Oh I didn’t know I could do that?

Nurse- Yes it can be given anywhere that has some fatty tissue, legs, abdo and arms are good sites.

Joe- Oh I can do that?

Nurse: Would you like to try injecting it into different sites and see if this helps reduce the lumps, lets go through this leaflet together about your medication, it contains helpful information including where to inject

Joe- That would be great thanks

Nurse: Then lets review in 1/12 to see if you have noticed an improvement.

Pointers from leaflets: sites to inject (show diagram and discuss through it), how to inject , alternate sites, discuss how the lumps can affect absorption of his insulin, storage of insulin, ensuring fresh needle, not using alcohol wipes can you show me how you inject your insulin and talk me through it.

Is there anything you don’t like about using your insulin? Is there anything else you would like to discuss today? Do you talk to anyone about your diabetes? Would you like to talk to someone else who has diabetes?

Joe... Yes Nurse the Dr told me to take it but I do not know why or anything about it

Nurse.... The tablet is called Apixaban and it is from a group of medications called anti coagulants which means it prevents blood clots from forming.

Joe..... will that prevent a heart attack because my dad had a heart attack

Nurse.... it will also prevent clots in your legs, brain and lungs. As your blood will be thin, you need to be careful not to cut yourself as you will bleed easily. If you need to take any over the counter medication make sure you tell the GP or pharmacist that you are on Apixaban.

Joe.... Do I take the tablet in the morning with my breakfast?

Nurse.... You need to take one in the morning and one in the evening at the same time every day. It is your choice if you take your tablet with food or not as long as you take it with a glass of water.

Now Joe if you forget to take your tablet take it when you remember and take the next dose when it is due. NEVER stop taking this medication without talking to a Doctor

Joe.... Is there any side effects

Nurse... The most common side effect is bleeding and bruising so be careful not to bang yourself. Some people also get nausea, low Iron and you might feel dizzy. If this happens let us know.

As with all medication if you develop itching, rash or swelling let us us know straight. Joe, make sure you keep it in a safe place away from children.

There will be a card in the tablet box. Come back to me on Tuesday at 10am and I will fill it out for you and we can see how you are getting on with the new tablet.

Joe... That's great Nurse. Ill see you next week. You look after me so well.

I'm good but Dr Murphy started me on a new tablet for my cholesterol.

-Okay, did he tell you what your cholesterol level is ? What do you know about cholesterol?

Yes my cholesterol is 6.1 and all my relatives seem to be on a cholesterol tablet, but my mother and sister says it gives them a lot of leg pain and my brother says I cant eat grapefruit, is that right

-The Grapefruit actually increases the level of the drug in your system and so you may make side effects more common

-Also some people may experience leg pains but not every one. How about you come back into me in 2 weeks time and we can see how you are getting on. Here's is a leaflet from the IHF with other cholesterol lowering tips. You can have a read and if you have any questions we can discuss them when you come back in to me

Patient; Hi my name is Katie and I am coming in for a check up as I have been feeling dizzy for the last couple of weeks.

Nurse: Your blood pressure is reading a little bit low. It is normal for you to feel a little dizzy if your BP is low 90/60mmHg. Has anything changed recently?

Patient: I recently had some ankle swelling and the GP prescribed some medication for it.

Nurse: this could be the potential cause for your dizziness. Do you know much about Furosemide?

Patient: Only that the Dr told me to take it in the morning.

Nurse: I have a patient information leaflet which we might go through, would that be ok?

Patient: Yes that would be great.

Nurse: So this medication is designed to remove the excess fluid in your body. Do you drink much water?

Patient: I only drink 2 glasses of water a day because I feel it makes my ankles worse.

Nurse: 2 glasses of water per day? Could we look to increase your intake? How many glasses do you think you could manage a day? Have you noted any other side effects or changes since starting your medication? Some patients report other side effects of this medication like headaches, Dizziness, dry mouth or increase in urination.

Patient: I have noticed that I am quite thirsty however I am conscious of my intake.

Nurse: Did you drive here today?

Patient: No I did not my daughter drove as she is very concerned about my dizzy spells and potential risk of falling.

Nurse: We might get the Dr to review you today. He might want to reduce your medication in light of your BP being low and the dizzy spells you are experiencing. Can I offer you a glass of water and we might recheck the BP in 10-15 mins.

Patient: Ok no problem.

M = Mary

N=CRGN

N: Mary Do you have an up-to-date list of your medications for me to have a look at please

M: I do.  I have started a new tablet since you were here last.  I'm not sure what it's for.

N: If you dont know then show me and we will have a look together.

N: This is called zanidip, it is used for high blood pressure.  It keeps your blood pressure at a safe level.

M: I couldn't remember what the doctor told me. I've never had high blood pressure before.

N: It is a lot to take in when you have been just told there is something wrong with you. Have you read the patient information sheet that came with the packet?

M: No. I find it hard to understand them and get a bit muddled with all the facts.

N: Ok. Will we have a look together and I can help you understand the important parts?

M: Please Nurse that would be great

N: Do you take your Zanidip medication at the same time every day?

M: The pharmacist told me to take it first thing in the morning about 30 min before food. So I try my best to do that. So far I have not forgotten it

N: That's good that you got that information and you follow their advice. Whenever you get a new medication there's no harm in asking the pharmacist if its ok with your other tablets and how best to take it. They are the experts in all aspects of medications

M: I will. What are the side effects of Zanidip? I am afraid that my blood pressure will go down too much and I wont know what to do.

N: If you are worried about side effects then it will be good to understand them. The most common side effects are headache, feeling your heart beat fast or uneven, you might notice your face, neck, and upper chest get red in color or sometimes your ankles may get swollen or puffy. Do you ever experience any of these things?

M: No but at least I know of them now. What will I do if I get any side effects?

N: Give your GP or Pharmacy a ring and they will advise you. I can put their numbers in your phone for you if you like?

M: Yes please that be great, one less thing to worry about.

N: There are some less common things to be mindful of with Zanidip. Dizziness, heartburn, tummy or chest pain or feeling sick, diarrhoea, passing large volumes of urine, feeling weak, sleepy or tired.

M: That's a lot of side effects.

N: There are a lot but these are not very common, don't worry about them, just be mind full of them. This is a lot to take in at once, I will leave this paper work here on the table when we finish and you can have a read of it yourself, it might be a bit easier to digest when we are finished.

M: That would be great, I feel it a bit easier to understand already.

N: Would it be oK to talk a bit more?

M: Yes please, you make it easy and I feel I wont worry about it as much

N: Just another thing to be mindful of with Zanidip is alcohol and very fatty foods can increase the way it works, maybe cut down on fatty meals and they recommend not to consume alcohol while on Zanidip.

M: I don't drink anymore and I try and keep low fat for my blood sugars.

N: That's a good start for you then. They also advise not to consume any grapefruit products while on the medication.

M: I don't like grapefruit anyway so that be easy to keep to.

N: By your list, you don't seem to be on any other medication that works against it.

M: What if I forget to take my tablet?

N: The manufacturers advise that you just skip the dose altogether as taking more than the dose can be dangerous to your Blood Pressure. If you do take too much n error contact your GP or the hospital for advice. Do you keep your tablets somewhere handy?

M: I keep them in a box beside my bathroom sink. I go there first in the morning and it reminds me to have it taken well before food.

N: Mary do you feel a bit more knowledgeable about it now? Is there anything else you would like to ask?

M: I don't think so. If I think of anything else when I am reading the leaflet I will ring you, I have your number on my phone.

N: It be great for you to read it now we have discussed it and of course ring, if you need, and we can figure it out together. If you have any side effects contact your GP, pharmacy or hospital depending on how you feel, I have put the numbers on the fridge. You said you are on a low-fat diet and don't drink so keep that up and be careful of grapefruit. I will ring you to see how you are getting on with it in about 6 weeks, so I will chat you then.

M: I will, thanks for your help, nurse.

N: You said earlier you look after your blood sugars? Are you a diabetic?.................

Mary: Yes I would like to learn more about why I have to take aspirin every day.

Nurse: Can you remember what the Dr told you the aspirin is for?

Mary: I think he said it has something to do with the time I had a mini-stroke about a year ago, a TIA I think he said.

Nurse: Yes that's right Mary, TIA is short for transient ischaemic attack and means there was a temporary interruption to the blood supply to your brain. Aspirin was prescribed for what we call secondary prevention to reduce the risk of having a further TIA. Have you had any problems taking your aspirin?

Mary: No, I take it every morning, sometimes I think it gives me pain in my tummy.

Nurse: Do you take anything for this pain or for heartburn?

Mary: No, I didn't think to take anything for this.

Nurse: Do you take any pain medication for a headache or other pains?

Mary: I occasionally take paracetamol or neurophen for a headache.

Nurse: Paracetamol is fine to take at the recommended dose for a headache or any other mild pain you might experience Mary, but neurophen together with aspirin may irritate your tummy and also may increase your risk of having a tummy bleed. Long-term aspirin use increases your risk of a gastric bleed and it is a good idea to take your aspirin with food. As you are now 75 years of age it may be prudent to discuss with your Dr if a proton pump inhibitor would be beneficial. This medication, PPI for short, reduces the production of acid in your stomach which may stop the pain you can get in your tummy when you take your aspirin and will also reduce the risk of having a gastric bleed. As we get older our risk of having a gastric bleed while taking long-term aspirin increases. The side effects of long-term aspirin treatment are an increased risk of bleeding, mild indigestion, and stomach ulcers. If the Dr prescribes a PPI medication Mary you might experience some side effects, for example, constipation, diarrhoea, windy tummy, headaches, and abdominal pain, if you experience any of these and they are distressing or don't settle after a week or so please let us know. Have you any questions to ask me about these medications or any other medications?

Mary: That seems to be clear information, thank you.

Nurse: Well your doctor would have assessed your diabetes and your HBA1C and they would have determined that, at the moment, diet control isn't enough to manage your blood sugar levels.

Patient: Oh, so what does that mean nurse? Can I eat more sugar then if I'm on the tablet?

Nurse: No, you still need to adhere to your diabetic diet and possibly be more strict with it if you aren't already. The tablet will help to restore your body's response to insulin and keep your blood sugars under control.

Patient: My friend was on this tablet nurse and it didn't agree with her at all. Will it make me sick?

Nurse: Some of the side effects do include nausea so it's best to take the tablet with food. Other side effects are loss of appetite and metallic taste in your mouth. Be sure to contact your GP if you experience these.

Patient: I will do nurse thanks for explaining it all to me. I feel better about having to take the tablets now.

Joe: Hi nurse, yes they mentioned something about an injection but what exactly is it for?

Nurse: Your recent blood tests showed that your Vitamin B12 level was low and we can replace that with a few injections. Have you been experiencing fatigue or lack of energy lately?

Joe: Yes I have been wrecked lately.

Nurse: That should improve after treatment. We will administer 3 doses per week for two weeks, and then you will get a top-up dose once every three months. Are you happy to proceed?

Joe: Where do I get the injection?

Nurse: The injection is administered into your muscle either in your upper arm or glute.

Joe: Yes I am happy to ahead.

Nurse: Before I start can I enquire if you are allergic to anything?

Joe: No, I am not.

**Post administration of injection**

Nurse: If you experience any side affects such as a rash, nausea or dizziness or anything that you may be concerned about please contact your GP and notify me afterwards. Your next dose is due in two days, can you please keep the other injection vials in the fridge and bring one with you on the day. Once all six doses have been administered you can book in for repeat bloods with your GP but I will remind you of that in two weeks.

Joe: Thank you nurse. See you on Wednesday.

Anne:Yes nurse I am on warfairn for the last 6 years. I was always popping down to my GP for regular INR blood tests to be completed as requested by the GP however I had a fall 3 weeks ago, and my mobility is still affected. The doctor felt a homevisit would help until I am back on my feet.

CRGN: No problem Anne, I am here to help. I would like to start by identifying that the PHN service do not complete blood tests however I can refer you to the Community Intervention Team (CIT). In order to complete this referral I need to ask you a few questions

Anne: That would be great. Thank you!

CRGN: Why are you on Warfairn? And what is your knowledge of this drug?

Anne: I am on warfairn for 6 years post a hospital admission where the Dr diagnosed me with having Atrial Fibrillation. I believe my knowledge to be quite basic- I know Warfairn is an anticoagultant to prevent clots in my blood

CRGN: Absolutely Anne this is a good explanation of your knowledge. Would you like me to give you a print out of the characteristics of the drug called Warfairn?

Anne: Yes please. My daughter told me that Cranberry juice can interact with Warfairn? Is this true?

CRGN: It has been documented by the British Heart Foundation that cranberry juice can increase the effect of Warfairn, so it is best to avoid drinking this.

Anne: Thank you. I will have a look at the website called British Heart Foundation on my ipad.

CRGN: Great Anne, knowledge is power. It is important to have a great understanding of the medication you are taking. I will refer you to CIT so that a home visit can be schedued for INR testing.

Anne: I am so relieved. I was worried about how I would get the blood test completed. I really appreciate your help.

Patient: I've been doing ok; I'm a bit nervous, though, since I haven't started the new Saxenda drug yet.

Nurse: Totally understandable. Starting medication can be intimidating. I am here to help you understand everything about Saxenda. Have you been able to read through the information leaflet?

Patient: Yes, I did, but I still have some questions. How does Saxenda work exactly?

Nurse: That's a great question. Saxenda is an injectable prescription that works by mimicking a hormone called GLP-1. It helps regulate your appetite and food intake. In other words, it signals to your brain that you are full, which can assist with weight loss.

Patient: That makes sense. How should I take the medication, and are there any instructions I should follow?

Nurse: Yes. Saxenda comes in a prefilled filled pen; you can inject it under the skin, typically in your lower abdominal area. It is important to use different injection sites to avoid potential reactions. The dose of saxenda usually starts low and gradually increases. I will demonstrate the injection process to you if you are comfortable.

Patient: yes, a demonstration would be very helpful. What about side effects? I read in the leaflet that nausea could be a side effect?

Nurse: Yes, Nausea is quite a common side effect, especially when starting Saxenda, but this improves over time as your body adjusts to the medication. Drinking water and starting on a lower dose can help manage this. However, please let me know if you experience severe or persistent side effects.

Patient: Thank you for that information. Are there any changes that I should make while on Saxenda?

Nurse: It is important to maintain a healthy diet and exercise routine. The medication is meant to complement a lifestyle change, not to replace it.

Patient: The sounds good. How often do you think I should check in with my progress?

Nurse: I recommend regular check-ins, especially in the first few weeks. We can monitor weight, etc, and discuss any new side effects. Don't hesitate to contact me with any questions or concerns between our appointments.

Patient: Thanks for the information and support; I feel more relaxed about starting Saxenda now.

Nurse: Hi Mary how are you doing today?

Mary: I am only ok I have just been with the GP for symptoms of a UTI and I am a bit uncomfortable with it, I have pain on urination and I am constantly going to the toilet. He dipped my urine and it was positive for an infection so started me on nitrofuraton he said you would explain it to m .

Nurse: Oh I’m sorry to hear you are uncomfortable Mary, hopefully these antibiotics will help with the infection and symptoms. We have sent your urine sample off for analysis so that can tell us what type of infection you have and if you are on the right antibiotic.

Mary: Oh I do hope I am on the right antibiotic as I really want this infection gone. Can you tell me more about the antiobic.

Nurse : Of course Mary but I just wanted to ask a little bit first about maybe why you have developed a UTI so we can potentially stop this from happening again and cause you less discomfort?

Mary: Yes no problem I would really like to try avoid getting another UTI.

Nurse : Great Mary, I would like to start with your hydration? How much water do you drink on average each day?

Mary : Oh I am very bad with the water maybe two glasses but I do drink a lot of Tea.

Nurse: Yes who dosn’t love tea Mary. It is important to try and drink at least 2l of water a day to prevent a UTI. Drinking 2l of water can dilute your urine and lower the concentration of bacteria in the bladder which can prevent you from getting a recureent UTi.

Mary: Oh really gosh I never released how important drinking water was. So what will the tablets do how to they work ?

Nurse: Yes hydration is key really so it may be a good idea to increase the water intake. Nitrofurantoin is an antibacterial agent that is used to prevent and treat infections of the bladder, kidney and other parts of the urinary tract.

Mary: OK that sounds good and can I eat with them?

Nurse: The antibiotic should be taken at meal times with food or milk. This will help to avoid stomach upset and also to help the absorption.

Mary: How many tablets should I take?

Nurse: The prescription is for one tablet 100mg twice daily for three days.

Mary: Oh good three days is ok. What will happen if I still have symptoms after 3 days?

Nurse: If you still have symptoms after 3 days Mary you will need to come back to us with a repeat urine sample if the infection has not cleared. Sometimes it can be extended to 5 days but you will need to see the GP to discuss this.

Mary: ok that’s fine and is there any side effects?

Nurse: Yes there is some side effects Mary I will also give you the patient information leaflet to bring home. The most common side effects are feeling sick (nausea) and headaches, you may also experience loose stools, dizziness, drowsiness. If you do experience any side effects please ring us and let us know.

Mary: Oh I will of course.

Nurse: Just to note Mary the tablets can turn your urine a different colour a dark yellow ir brown this is normal and is not a reason to stop taking the medicine so don’t be alarmed!

Mary: Oh I am glad you told me that.

Nurse: Yes otherwise you may think something is not as it should be. Have you any other questions Mary?

Mary: No I am really happy thank you and I will do my best to drink 2l of water a day.

Pat: I got on fine, they've started me on a new medication when I was in with them a month ago. I'm not sure about it, is it in the notes there?

RGN: I'll just have a look. Yes, I see you were started on a low dose of forxiga for your heart failure symptoms.

Pat: What does it do? I've no clue, I can barely say it.

RGN: Yes, it's a difficult one alright! It is a medication that can be used in a few different conditions. In your case its for your heart failure. Forxiga helps to protect your heart from any deterioration and should improve your symptoms. Have you noticed any difference at all?

Pat: Well actually my daughter was just saying how she's noticed I'm less short of breath.

RGN: That's brilliant she's noticed that and how do you feel?

Pat: Yeah, she's right to be fair, I can walk to the bathroom and back without stopping now. I've also noticed my legs are less swollen.

RGN: Great - its having the desired effect so. Now, there are a few things to watch out for with Forxiga, you can get a rare infection in the genital area so if you think you notice any signs of infection down there make sure to talk to your GP or go straight to hospital if out of hours, you would need antibiotics straight away if this happens.

Pat: Thanks Nurse, I didn't realise that. Is there anything else I need to be watching out for?

RGN: Taking this medication just make sure you drink your 1.5L of water/fluid a day and don't get dehydrated as you can become very unwell if this happens on this medication and the way this medication works can cause you to pass more urine than previously. If you are concerned please contact us or shannondoc out of hours or if you are very unwell you need to seek help in a&e. One other thing to mention is that sometimes this medication can cause urinary tract infections so that is something we would need to know about - if you notice fever, flank pain, pain when passing urine make sure to give us a call. I have the patient information leaflet here to give you and if you have any questions when you get home please feel free to give us a call and I can get back to you. I know there's a lot of information involved when starting a new medication.

Pat: Will do nurse, thanks for that. I'm taking one tablet once a day is that ok?

RGN: That's perfect, you can take it at any time of the day you like but it is ideal to take it at the same time every day. You can take it with water and with or without food.

RGN: So just in relation to the Forxiga, how do you feel about it now?

Pat: I feel a bit better about it all. I might have to contact you again if I forget something.

RGN: Absolutely, that's what were here for but you're doing everything right so don't worry. You've told me how you're less short of breath and have noticed your leg swelling has improved which is fantastic. You now know you can take it once a day at the same time every day. We've gone through some of the more serious adverse effects to look out for and you have the patient leaflet and can contact me to discuss anything else further you might need.

Pat: That's great, thanks nurse.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10453961/

Mary: Ah you know, not great. I broke my leg so I haven't been able to do the exercise I'd hoped and my eating has gone to pot.

Nurse: Oh that's a shame Mary, has your leg recovered now?

Mary: Yes it's much better but I was called in today to discuss my recent blood results so I'm a bit nervous.

Nurse: It's ok to be nervous coming in to a setting like this but very often we just want to give you the opportunity to ask any questions that you may have and in particular to explain your results to you and make a plan for the next review.

Mary: Ok, the girl on the phone said you want to check my weight and that, she said my cholesterol is high, what does that mean?

Nurse: So your cholesterol levels are a little over the normal range and unfortunately, as your activity level was reduced over the last few months due to your injury it just means that the cholesterol has built up a little while you were laid up. It's nothing to be worried about though, I brought you in today so I could discuss options with you. How would you feel about starting on a cholesterol lowering tablet called a statin?

Mary: Oh gee I don't know, Jimmy next door started on one of those and he got awful pains in his muscles.

Nurse: I totally understand your apprehension, often if we hear negative reviews about something it can be daunting, but I can assure you that not everyone has ill effects and if you do, we can reevaluate. How does that sound?

Mary: Ya alright, I really want to get my cholesterol back on track. Tell me more about this tablet.

Nurse: So it's a medication called Rosuva, and the doctor would like to start you on a relatively low dose to see how you tolerate it. We will bring you back in 6-8 weeks to recheck your bloods and see how you're getting on. If you take the tablet at the same time every day, it will help you to remember it. Does that sound like something you could try?

Mary: Ya, I'm hoping to get back walking more regularly and now that I'm not sitting at home all day, I'm hoping to improve my diet.

Nurse: That's great, Mary. Lifestyle changes can really help to improve cholesterol levels along with the medication so what we'll do is get you started and bring you back in 2 months time. Will I get you booked in with myself?

Mary: Ya nurse, that would be great, thank you. I feel much more at ease now that you've explained things to me.

P: Oh yeah, I’m taking them

GPN: So, according to my records you’re taking Pantoprazole, Co-diovan, Calcichew D3 forte, and atorvastatin. Is that correct?

P: Yeah that sounds right.

GPN: Any issues with the medication?

P: No, all good. I take them most days, but I don’t take the Cholesterol one on the weekends. I like to go to the Pub on Sat and Sun and didn’t want to overload my liver, my neighbor said they had to stop theirs because of their liver.

GPN: I hear you’re worried about the effect of the medication and alcohol on your liver and have heard about people having to stop statins under certain circumstances. However, I can reassure you that it is usually safe to take your Statin while drinking alcohol. Would it be ok to talk to you about your alcohol consume later in the consult?

P: Yes, but I won’t change going to the pub!

GPN: That’s ok, I understand that this is important to you. Alcohol is not a contraindication to taking your statin. There are some foods and a few medications we need to be careful with, but your pharmacist would usually check interactions as well as the person prescribing your medication. It's important not to take the Statin with Grapefruit juice and you should avoid taking it at the same time as high fat foods. When do you take yours usually? P: in the evenings, just before bed. And it just take it with Water. GPN: That's perfect. The medications I was talking about you may need to watch out for is a certain group of antibiotics called Ciclosporins, the most common one we would use being called Clarithromycin or Klacid. We will also monitor your liver function regularly while you are on the Statin. And checking your last blood test, your liver function was within normal limits. So how do you feel about taking your statin now?

P: That’s good to know. I was worried about damaging my body with both but also about not taking the statin. So I’m glad to know I can do both.

GPN: I’m glad I was able to clarify and reassure you. I’ll give you the information leaflet from the HPRC website so you can have a list of medications at home yourself that can cause interactions. Just in case you get a prescription from an out-of-hour service where you forget to mention your other medications.

P: Thank you.

Teresa: Thanks for seeing me today. The doctor has told me that I have Asthma and that I have to start using an inhaler now when I feel my chest getting tight or wheezy. I'm not sure how to use it. I've never used an inhaler before and I'm a little bit nervous about side effects as I don't like taking medications.

Nurse: That's no problem at all. If it's ok with you I can explain how the inhaler works, some of the side effects you might experience, and how to use your inhaler.

Teresa: Thank you very much that would be great.

Nurse: The doctor has prescribed this medication for you to give you relief from your symptoms. It will relieve the tight feeling in your chest and help to reduce the wheezing you are experiencing. It will help to relax the muscles around the airways which will help the airways to open up so that you can breathe more easily. If I'm going too fast for you will you stop me. I don't want to overwhelm you.

Teresa: No thats ok I understand what you are saying will I be able to go back to my morning walk again I had to stop because my breathing was so bad and it scared me.

Nurse: I'm sorry to hear that. What we want is for you to resume your normal day-to-day activities and for you to feel safe doing that. You should be able to get back to your walk again with no problems. Well done for keeping up with your regular exercise. It's important that you always carry your inhaler with you in case you need it and you can use it up to 4 times a day if needs be. There will be days when you won't need it at all.

Teresa: My sister said she once had a nebuliser when she had a bad chest infection and her heart was racing after it will I feel like that?

Nurse: I'm not surprised to hear that. Yes some people can experience their heart beating a little faster after using their inhaler and your hands may feel a little shaky but this doesn't always happen to everyone and it wont last very long. It's also not unusual to have a headache and if you experience this and you are finding it difficult to cope with please come back to see the doctor again as he may be able to prescribe something different for you. There are loads of options. I'm going to give you some information to read at home in your own time and please contact me if you have any questions.

Teresa: Thank you that's very reassuring. Is the inhaler difficult to use?

Nurse: I think you will manage it very well. It's not difficult. Give your inhaler a little shake to make sure the medication inside is well-mixed. I want you to breathe out like this and put the mouthpiece of the inhaler in your mouth and close your lips around it. Now start taking a breath in and press down on the top of your inhaler at the same time. Try to hold your breath for as long as you are able and take the inhaler out of your mouth. Well done that's great. You're managing this very well. Sometimes you can get it wrong so if you see mist coming from the top of the inhaler or the sides of your mouth just start again you won't be overdosing.

Teresa: Thank you thats great. Would it be ok if I practice a little to make sure I'm getting the hang of it?

Nurse: That's a really good idea Practice makes perfect. Do you want to come back to me in 2 weeks so we can check your inhaler technique and you may have some questions that you would like to ask?

Teresa: That would be fantastic thank you so much.

Patient: Hello, Nurse. I am well have you got the results of my dexa scan?

Nurse: Your DXA scan confirmed osteoporosis, indicating weaker bones. To help try to protect your bones the doctor would like to prescribe an injection called Prolia. It's a small injection given every 6 months usually just under the skin on your belly. This injection is vital for maintaining or even improving your bone health and reducing fracture risks.

Patient: Okay

Nurse: We will need to check your bloods no more than 3 months before your injection to make sure your calcium levels are normal, as sometimes your calcium levels can drop when taking prolia.

Patient: Okay

Nurse: Before your first injection, it's important to visit your dentist for any necessary dental work. And please, stick to the 6-month schedule for your injections, as any delays can results in a drop in bone density.

Patient: I'll call the dentist today

Nurse: Is it okay if we discuss your diet and exercise ?

Patient: Yes

Nurse: How is your diet?

Patient: Not great

Nurse: Okay well I can give you some information on diet and we can discuss dietary adjustments if needed. Most people living in Ireland don’t get enough Vit D (the sunshine vitamin) so we may need to prescribe you a vit D supplement after we check your levels. How is your physical activity?

Patient:  I try to stay active a few times a week, but I could do better.

Nurse: Okay, exercise has loads of benefits, it reduces the rate of bone loss and lowers risk of fractures and can also reduce risk of falls. I could refer you to an exercise programme if that interest you?

Patient: Yes that all sounds good.

Nurse: Great, well here is a patient information leaflet for you to review, and feel free to give me a call to discuss any queries you have.

Patient: Thank you, Nurse. I will do that.

Christy: thanks Claire

GPN: ok so today Christy, you are to have a 24 hour blood pressure monitor on, is that correct?

Christy: yes, unfortunately I am,I was with the doctor a few days ago and my blood pressure was sky high and I made the mistake of telling her I stopped all medications.

GPN: ok Christy, tell me why you stopped all the medications, were they give you any side effects?

Christy: No no nurse, I feel I don’t need them anymore.I am taking all natural stuff now, turmeric and apple cider vinegar with cayenne pepper…

GPN: that’s great you are looking after yourself by using more natural remedies but let’s take a look at the medications you were on previously, is that ok if we chat about them?

Christy: yeah nurse that’s fine but you won’t change my mind

GPN: thank you Christy.Ok so I see you are on Bisoprolol 5mg ,is that correct?And I see you have also been prescribed Lipitor 20mg?

Christy: yes that’s the two tablets I was on but not anymore.I feel great but my face is a little hot today and I have a headache that just won’t go away.

GPN: ok can I check your blood pressure before I attach the monitor?You BP may be a little elevated

Christy: yeah Nurse, I just had an argument with someone there and I know my blood pressure is up, I can feel it.

GPN: Christy it looks like your blood pressure is indeed raised today, we will check it again in a few minutes.Can I chat about the way Bisoprolol works and a little information about the side effects etc?

Christy: go on nurse sure while I’m waiting

GPN: ok so this medication is used for people with high blood pressure,this is when the pressure of the blood flow in the vessels becomes too high.If left untreated, there are a number of health issues associated with this, such as, stroke and bleeding behind the eyes.Along with the natural remedies, have you thought about other changes you could make in your daily routine ?I see here you smoke?

Christy: I didn’t know all of those could be caused by high blood pressure!Thats serious!I thought I would just get a few headaches…yes nurse I smoke 20 roll ups possibly more per day and to tell the truth nurse, I usually have a few cans of cider most nights.

GPN: ok Christy, it is ok if we chat a little about this?

Christy: ofcourse Nurse, I think I need to make a few changes.

GPN: ok let me start by saying well done,it’s not easy to admit these issues. High blood pressure has been shown to be closely linked to smoking and alcohol intake. Would you consider cutting down and even quitting smoking?I can refer you to the HSE Quit services which will support you through this.How would you feel about this?With the alcohol intake, we do recommend you have at least 2-3 nights free of alcohol. Maybe switch to the 00 beers non alcoholic.This will all help towards bringing down the blood pressure.Are you active most days?

I see you don’t have any allergies and you are not asthmatic or have an irregular heart beat. This tablet can interact with alcohol Christy, it can cause light headedness and dizziness when mixed. We will monitor your bloods as it can have effects on the liver also.How do you feel about the medication now you know a little more about it?

Christy: yes nurse I will try and reduce the smoking as it’s costing me a fortune as well as giving me blood pressure!Can you give me the number for the Quit service?The cans every night will have to stop too, it’s a bad habit I got in to during Covid so I must start by not drinking every night of the week. I walk to the shops and back for my groceries but nothing much.

I didn’t realise it can interact with alcohol, I was feeling pretty rough when I was taking it so it’s good to know it wasn’t just me. And look, I know I must make changes, it’s just all a bit overwhelming to change everything so maybe one thing at a time.

GPN: that’s a great idea Christy, let’s start with one change for the moment.What would you like to change first?

Christy: I think the smoking Nurse, I feel I want to change this.And I think I should go back on those yellow tablets for the blood pressure.

GPN: that’s great Christy, well done. Now when you go back on these tablets they do have some possible side effects; such as; abdominal pain, diarrhoea, nausea.But let us know if this happens and the doctor can chat to you and titrate the dose.Let’s put on the blood pressure monitor and go from there.Do you have any other questions Christy?

Christy: no nurse, thanks.

PT: I've noticed that my sugars have gone up and the doctor says my long term sugar is rising so I need to take tablets.

GPN: Ok you noticed that your sugars are rising, how has your diet and exercise been ?

PT: Well I feel I'm doing well, eat regularly and healthy, exercise 5 times/week with only occasional treats, I don't understand why the sugars are getting worse.

GPN: I hear that you feeling frustrated , you have been diabetic for over a year now and while diet and exercise are the first line of treatment for diabetes which you manged very well, diabetes is progressive so so if these changes are no longer enough we can prescribe medication to support your efforts. How do you feel about taking medication?

PT:I feel nervous as I hear it can make you feel sick.

GPN: I hear you anxious about the new medication. It s called glucophage and works by helps your body become more effective at making insulin which is needed to use glucose or sugar in your body, it also stops the production of you glucose in your liver. It can initially cause some gastric side effects like nausea, diarrhoea, abdominal discomfort but it usually settles within a couple of weeks. Are you willing to try it ?

Pt : Yes ok I'll give it a try, so what do I do now?

GPN: We'll make a plan. The doctor has prescribed a low dose, 500 mg twice daily, take with food to help prevent reduce symptoms. You continue to record your blood sugar before breakfast and hopefully you'll notice the readings coming down the goal is to get between 4 - 7. I'll give you an information sheet telling you about medication and a return appointment in 3 months to check your long term sugar to see improvement and see how your feeling. Any concerns in the meantime let me know.

Patient(P): I have a history of AFIB. I was recently been switched from Warfarin to a new tablet called Apixaban to prevent blood clots. I used to have my INRs checked regularly and it gave me peace of mind. I'm told now that I don't need INR's anymore. Have I picked that you correctly? How will I know my levels are normal?

N: Okay Mary. Let me give you some peace of mind now again. You have picked that information correctly, Unlike warfarin, Apixaban doesn't require frequent monitoring.

I see you had your blood done before switching your INR was at the appropriate level before switching and your renal function was normal. We will need to check your renal blood again in 3 months to monitor that. I will give you a PIL that explains all you need to know about side effects etc. It also explains how Apixaban works (This medicine helps to prevent blood clots from forming by blocking Factor Xa, which is an important component of blood clotting.)

P: Thank you Roisin. I feel at ease now and it's great not having to have my blood checked regularly. I will make an appointment for 3 months.

N: I'm glad to help If you have any other questions feel free to pop in or we can arrange a telephone consultation. Use your PIL also for information. Inside the medication box, there is a patient Alert Card. It's important to fill that out and carry it with you.

Patient(P): Hi Roisin thanks for seeing me. I was a little concerned because my doctor switched my warfarin to a medication called apixaban. I've been taking apixaban now for a month I'm concerned because I used to have my INR checked regularly. The GP has told me that I don't need to do this anymore, is this true? How will I know my blood is at the correct level? I'm afraid that I might get a clot like before.

N: OK Mary I can see how you are concerned. What the GP told you is correct. Unlike warfarin, regular monitoring of INR is not required while on apixaban. Your blood was checked before commencing apixaban, and the switch was made when your INR was at the correct level. I will give you a patient information leaflet which gives you more information for example in it explains that  (This medicine helps to prevent blood clots from forming by blocking Factor Xa, which is an important component of blood clotting.)

P: OK Roisin thank you so much I feel at ease now I was afraid I had picked up the doctor wrong and I didn't want to bother him to ask him about the INR.

N: You are very welcome Mary feel free to come back if you have any more questions.