6- Pressure sores and polypharmacy

Question 1

A pressure ulcer is an

Answer 1

is an area of damaged skin and/or the tissues below as a result of being placed under pressure.
Pressure ulcers can cause pain or lead to an extended stay in hospital. They can become infected which could lead to sepsis and in extreme cases it can be life threatening.

Question 2

why do we need to prevent pressure sores

Answer 2

• huge financial costs on the NHS
• huge cause of morbidity

Question 3

RF for pressure sores

Answer 3

immobility

• dementia
• hip fracture/ surgery
• stroke
• OA/RA

others

• CVD
• DVT
• malignancy
• lower limb oedema
• DM
• COPD

Question 4

commonly used assessment screens for pressure sores

Answer 4

Norton, Braden and the Waterlow scales.

Question 5

waterlow score

Answer 5

Question 6

braden scale

Answer 6

Six factors that contribute to either higher intensity and duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development

1. Sensory perception
2. Nutrition
3. Friction and shear
4. Mobility
5. Moisture
6. Activity

Each item is scored between 1 and 4 guided by a descriptor. The lower the score the greatest the risk

Question 7

where are pressure sores common

Answer 7

sacrum

Question 8

Pressure ulcers and the person’s general physical condition are very closely related and the two should be assessed together. Health status includes:

Answer 8

• Comorbidities.
• Nutrition.
• Pain.
• Continence.
• Neurological (sensory impairment, level of consciousness, cognitive status).
• Blood supply.
• Mobility.
• Signs of local or systemic infection.
• Medication.
  
  • Previous pressure damage.
  • Psychological and social factors.

Question 9

ulcer assessment

Answer 9

should be supported by photography (calibrated with a ruler) and tracings. Ulcer assessment should include:

• Cause of ulcer.
• Site/location.
• Dimensions of ulcer.
• Stage or grade (see ‘Classification system’, below).
• Exudate amount and type.
• Local signs of infection.
• Pain.
• Wound appearance.
• Surrounding skin.
• Undermining/tracking (sinus or fistula).
• Odour.

reassessment- weekly

Question 10

classification of pressure ulcers

Answer 10

Question 11

which patients with pressure sores should be referred to a specialist service

Answer 11

grade 3 or 4

Question 12

management of pressure ulcers

Answer 12

Healing is not usually a fast process. However, as long as the patient has adequate pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal in most cases.

• Repositioning of the patient.
• Treatment of concurrent conditions which may delay healing.
• Pressure-relieving support surfaces such as beds, mattresses, overlays or cushions.
• Local wound management using modern or advanced wound dressings and other technologies.
• Patients with identified Grade 1 pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
• pain relief
• infection control

Question 13

management of pressure ulcers

Answer 13

Healing is not usually a fast process. However, as long as the patient has adequate pressure redistribution, good nutrition and appropriate wound management, the ulcer will heal in most cases.

• Repositioning of the patient.
• Treatment of concurrent conditions which may delay healing.
• Pressure-relieving support surfaces such as beds, mattresses, overlays or cushions.
• Local wound management using modern or advanced wound dressings and other technologies.
• Patients with identified Grade 1 pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
• pain relief
• infection control- abx if appropriate
• management of malnutrition

General

• a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
• wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
• consider referral to the tissue viability nurse
• surgical debridement may be beneficial for selected wounds

Question 14

repositioning of patients

Answer 14

• Patients should be repositioned in such a way that pressure is relieved or redistributed.
• All patients with pressure ulcers should actively mobilise, change their position or be repositioned frequently.
• Passive movements should be considered for patients with pressure ulcers who have compromised mobility.
• Avoid positioning individuals directly on pressure ulcers or bony prominences.

Question 15

debridement ofprrssure ulcers takes into account

Answer 15

an assessment of the need to debride a pressure ulcer in adults should be undertaken, which takes into consideration:

• The amount of necrotic tissue.
• The grade, size and extent of the pressure ulcer.
• Patient tolerance.
• Any comorbidities.

Debridement may be autolytic (see below), mechanical (allowing a dressing to become moist and then wet before manually removing the dressing), or surgical:

Question 16

debridement ofprrssure ulcers takes into account

Answer 16

an assessment of the need to debride a pressure ulcer in adults should be undertaken, which takes into consideration:

• The amount of necrotic tissue.
• The grade, size and extent of the pressure ulcer.
• Patient tolerance.
• Any comorbidities.

Debridement may be autolytic (see below), mechanical (allowing a dressing to become moist and then wet before manually removing the dressing), or surgical:

Question 17

prevention of pressure sores

Answer 17

• correct positioning, transferring and repositioning techniques
• pressure redistributing equi[ment
• elimibate sources of excess moisture due to incontinence, perspiration or wound drainage
• optimise nutrition
• eduction
• emollients if skin is dry or barrier products if skin is mois

Question 18

define polypharmacy

Answer 18

Polypharmacy is often defined as the routine use of five or more medications. This includes over-the-counter, prescription and/or traditional and complementary medicines used by a patient.

Question 19

Who should be targeted for medication review

Answer 19

• Taking lots of medications!
• Complex medication regimens
  
  • E.g. how to take inhaler
• Recently discharged (or admitted)
• Frequent admissions to hospital
• Comorbidities
• Medications prescribed from multiple sources
• High risk medications – narrow therapeutic window, known and serious side effect profile

Question 20

pharmacokinetics and dynamic changes in older people

*

Answer 20

• Body composition – increased fat, decreased body water and lean mass
• Renal mass and function reduced
• Hepatic function and blood flow
• GI absorption, GI bleed risk
• Baroreceptor sensitivity reduced
• Reduced first pass metabolism
• Protein binding?
• Receptor expression level changes
• Psychotropic drugs and extra pyramidal effects

Question 21

Whenever you prescribe a drug ensure:

Answer 21

• That the correct agent is prescribed for the correct patient with the correct diagnosis.
• Check for drug allergies.
• Check for potential interactions with other drugs (prescribed and over the counter).
• Use generic drug names and write the drug in CAPITALS.
• Don’t use abbreviations.
• Ensure that the dose, frequency and times, and route of administration are clearly identified. Include a start date (and a review/end date if appropriate).
• Be cautious using decimal points; these may be difficult to read resulting in 10x the dose.
• Write ‘Units’ rather than ‘u’ as the latter can be misread as ‘0’; again 10x the dose.
• Print name as well as signing if on a paper chart
• Always make sure you review medications on a daily basis and stop medications which are not needed.

Question 22

which tool used to support medication review

STOPP-START

Answer 22

STOPP-START

Question 23

STOPP-START tool

Answer 23

Old people are known to have increased risk of adverse effects with medication due to age related alteration in pharmacokinetics and pharmacodynamics

• When to stop and start drugs
  
  • Screening tool first introduced and validated in 2008
  • Brought together expertise including geriatricians and clinical pharmacists
  • For use in older patients ≥65 (use some judgment)
  • Many trusts/ regions have their own adapted documents which may have local nuances
  • In conjunction with your clinical judgement

Question 24

STOPP-START aims to

Answer 24

Aim to highlight and prevent inappropriate prescribing → reduction in DDIs and or ADRs

Question 25

example of STOPP-START

Answer 25

• Anticholinergic effects (burden)
  
  • Antipsychotics
  • Alzheimer’s medication
• Other side effects
  
  • Drowsiness
  • Lowering BP
  • Lowering blood glucose
• Balancing risk and benefits

Question 26

problem with polypharmacy

Answer 26

• increases the risk of adverse drug effects, including
  
  • falls
  • cognitive impairment
  • harmful drug interactions
• forgetting to take medication

Question 27

methods to help stop patients from forgetting medicstion

Answer 27

• dossette box
• apps
• visual reminders
• timers/alarms
• education on the importance of medication