Flashcards in Geriatrics - Assessments in elderly medicine & Rehabilitation Deck (22):
What are pressure ulcers?
These may present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures such as bone and muscle. A pressure ulcer may be caused by pressure, shear or friction or a combination of these.
Identify some risk factors for pressure ulcers
Pressure ulcers are caused by pressure and/ or friction over bony prominences in the presence of a number of risk factors, the most important of which is IMMOBILITY.
Other conditions that increase risk are:
- Alzheimer's disease
- Cardiovascular disease
- Hip fracture and hip surgery
How should a risk assessment be carried out for pressure ulcers?
The use of pressure risk assessment tools is an important part of the assessment process to identify at risk patients.
Commonly used assessment tools include the Norton, Braden and Waterlow scores. The Braden risk assessment scale is made up of six subscales: (i) sensory (ii) perception, (iii) moisture, (iv) activity, (v) diet, (vi) mobility, friction/ shear. Each item is scored between 1 and 4. The lower the score the greater the risk.
However, there is no reliable evidence to suggest that the use of structured, systematic pressure ulcer risk assessment tools reduces the incidence of ulcers.
How would you assess a pressure ulcer?
Pressure ulcers can develop in any area of the body and are common over bony prominences in adults. Patients with pressure ulcers should receive initial and ongoing assessment which should include:
1) Pressure ulcers and the persons general physical condition are closely related and the two should be assessed together. Health status includes:
- neurological exam
- blood supply
2) Previous pressure damage
3) Psychological and social support
4) Ulcer assessment calibrated using a ruler (tissue viability are useful contacts):
- site and location
- stage or grade (following classification system)
- exudate amount and type
- local signs of infection
- wound appearance
How are pressure ulcers classified?
European pressure ulcer advisory panel grading system
Grade 1 = non blanching erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators
Grade 2 = partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister. Surrounding skin may be red or purple
Grade 3 = full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, the underlying fascia
Grade 4 = extensive destruction, tissues necrosis, damage to muscle, bone and supporting structures with or without full thickness skin loss. Extremely difficult to heal and predisposes to infection
Ungradable = full thickness tissue loss in which the base of the ulcer is covered by slough in the wound bed, resulting in true depth and therefore category being unknown
Outline an approach to pressure ulcer management
Pressure ulcers are often painful, difficult to heal and impact on the patients quality of life. Patients with extensive superficial pressure ulcers, grade 3 or 4 or those with deteriorating ulcers should be referred for specialist care. Healing is not necessarily a fast process, but as long as the patient has adequate pressure redistribution, pain relief, nutrition and infection control the ulcer will heal in most cases.
1) Pressure redistribution - reposition the patient and treat other concurrent conditions that may delay healing; pressure relieving support (e.g. mattresses); local wound management; patients identified with Grade 1 pressure ulcers are at significant risk of developing further pressure ulcers
2) Pain relief - paracetamol may be sufficient; NSAIDs may increase peripheral oedema and are unsuitable for patients with pressure ulcers; patients may require referral to pain clinic
3) Infection control - all pressure ulcers are colonised with bacteria, most local infection can be managed using antimicrobial wound products; systemic antibiotics should not be used for local infection; if purulent material is present, more frequent cleaning and possibly debridement are required
4) Nutrition - no clear evidence for nutritional interventions for pressure ulcers, nutritional supplements should not be specifically offered to prevent pressure ulcers; high calorie, high protein nutritional supplementation can be used in patients with nutritional risk and pressure ulcer risk
What pressure relieving therapies can be used as part of the management of pressure ulcers?
Pressure relieving equipment helps redistribute the load or relieves the pressure at regular intervals. Pressure reducing equipment helps redistribute the pressure by increasing the surface area.
It is currently recommended that:
- high spec reactive foam mattress be used for individuals at risk of pressure damage
- an active support surface (overlay or mattress) be used for individuals at higher risk of pressure ulcer development when frequent manual repositioning is not possible
What type of dressings are better for treating grade 2, 3 and 4 pressure ulcers?
Dressings that promote a warm, moist wound healing environment should ideally be used to treat grades 2, 3 and 4 pressure ulcers. Barrier creams should not be used to treat superficial wounds.
When are alginates used?
These are useful when ulcers have moderate-to-heavy exudates
Infected wounds can be treated well with what type of dressing?
Cadexomer iodine works well for sloughed or infected wounds.
When should films and foams be used?
Films work best on epithelialising wounds with low exudate, whereas foams are best used on granulating wounds.
What are hydrocolloids and when are they used?
These may be used for most types of wounds with low-moderate exudate but are NOT suitable for infected wounds.
What is hydrogel?
This provides moisture to dry sloughy or necrotic wounds and assists autolytic debridement. They can be used on wounds with low exudate. Not suitable for infected wounds.
What agent is often added to dressings to make them antibacterial?
Silver is an antibacterial agent and is generally found as a composite dressing with other products - e.g. alginates, foams, hydrocolloids. Use on infected wounds.
What screening tool can be used to assess cognition in elderly patients?
The Abbreviated Mental Test (AMT) is used as a screening tool to identify cognitive impairment in patients. It is important to remember that the AMT is only a screening tool and gives no information about the cause. Patients with hearing impairment, depression, dysphasia or whose first language is not english must be identified beforehand as they will have difficulty with any such screening test.
What are the ten questions used in the AMT?
1) Time of day (to nearest hour)
4) Identify two people
7) Address to be remembered
8) Name of monarch
9) Dates of the second world war
10) Count backwards from 20-1
Score 1 point for each answer
How is the AMT interpreted?
a) AMT score 8-10 indicates normal cognition
b) AMT score <8 indicates significant impairment of cognition
A low AMT may be the result of an acute confusional state (delirium) owing to infection, dehydration, hypoxia etc. and one would expect the score to improve on repeat testing once the underlying illness has been treated. In the context of progressive impairment of memory over the last 6 months, a low AMT might be due to a dementing illness and would not be expected to improve on repeat testing.
What should follow a low AMT score?
It is usual to proceed to more detailed cognitive testing in those patients with suspected dementia. The Mini Mental State Exam (MMSE) is a 30 question cognitive assessment which is used selectively in clinical practice (normally 27+/30).
What is the Barthel self care index?
The Barthel self care index is an outcome measure of functional independence in activities of daily living.
The index measures and assesses an individuals ability to carry out activities of daily living. It is based on a 3 point scale. If a patient scores below 40 he/she has a poor prognosis at home. The activities assessed are:
- walking/ wheelchair use
- stair mobility
The tool has limitations and is more commonly used to highlight the potential need for nursing home or rehabilitation support.
What is the Waterlow score?
This is a pressure ulcer assessment tool that looks at 11 areas and stratifies patients into low, medium and high risk for pressure damage. Using this information, nursing staff can complete appropriate care plans (e.g. regular turning, control of continence, improved hydration and nutrition) and organise preventative measures such as pressure relieving aids. Ongoing assessment of the risk should be carried out at regular intervals.
Why is it important to assess nutrition in the elderly?
Up to 40% of patients are malnourished on admission and two thirds of these deteriorate during their stay. Impaired nutrition in elderly patients increases susceptibility to infection and predisposes to pressure ulcers. The assessment of nutrition identifies those already malnourished or who are at risk of becoming malnourished.