pressure sores

Question 1

where are pressure sores likely to occur?

Answer 1

Sacrum!!!!
Bony prominences (eg. greater trochanter, ischium)

Question 2

Why do pressure sores occur?
causes?

Answer 2

Pressure - MC
Increased friction
shearing
moisture - ischemia - if >2hr = necrosis

Question 3

what score do we use to assess the severity of pressure sores?

Answer 3

WATERLOW score

Question 4

What does the Waterlow score assess?

Answer 4

stratified risk of pressure sores

Question 5

Waterlow score:
>10?
>15?
>20?
what is taken into account with these scores?

Answer 5

> 10 = risk
15 = high
20 = very high

BMI, Sex, age, mobility, diet, meds

Question 6

Waterlow score:
what do the scores 1-4 mean?

Answer 6

1. Non blanching erythema, no mucosal tear
2. Mucosal breach
3. Full thickness skin involvement
4. Bone/Joint involvement

Question 7

Dx of pressure sores?
what other tests/investigations are done?

Answer 7

Bloods
MC+S (Incl site swab)

Question 8

Tx of pressure sores?
prevention

Answer 8

repositioning
barrier cream

Question 9

Tx for pressure sores?
1+2 Waterlow score

Answer 9

pain ladder
consider IV flucoxacillin (if cellulitis suspected)

Question 10

Tx for pressure sores?
3+4 Waterlow score

Answer 10

Wound dressing
surgical debridement (+ Tx for 1+2)

Question 11

RF for pressure sores?

Answer 11

Immobility
Old age
+ vascular disease (icl DM)
+ Confusion
+ poor nutrition/dehydration

Question 12

What is the definition of malnutrition?

Answer 12

Nutritional deficit with functional effects

Question 13

What are some causes of malnutrition?

Answer 13

common with increase age
Eating disorders
Malabsorption (eg. Coeliacs)
Poor diet
dysphagia
cancer

Question 14

what screening tool is used for malnutrition?

Answer 14

MUST tool

Question 15

What 3 things does the MUST tool look at?

Answer 15

BMI
<18.5 = 2 pts
18.5-20 = 1pt

Unintentional weight loss
5-10% = 1pt

Not ate properly in 5 days = 2pts

Question 16

MUST screening tool
what do these scores mean and what happens?
0?
1?
>2?

Answer 16

0 = no action, advice (mild-none)

1 = observe (mod)

> 2 dietician input (severe)

Question 17

Sx of malnutrition?

Answer 17

Anemia Sx (fatigue, angular stomatitis, glossitis)
Poor wound healing
Dehydration
Low libido
Constipation
Low urine output

Question 18

Dx of malnutrition?

Answer 18

Bloods
lying/standing BP
ECG (Low K+)

Question 19

Conservative Tx of malnutrition?

Answer 19

High calorie intake
Fortisips

Question 20

Dietician Tx of malnutrition?

Answer 20

Assess swallowing (dysphagia scale)
Monitor electrolytes if re feeding (referring syndrome)
Advice on diet

Question 21

What feeding tools can we use?

Answer 21

NG
NJ
PEG
PEJ

Question 22

When is NG + NJ feeding used?

Answer 22

shorter term 30-60d

Question 23

When is PEG feeding used, on what Px?
What risk does PEG feeding have?

Answer 23

Dementia
MND

Risk of aspiration pneumonia

Question 24

what organisms can grow from aspiration pneumonia?
Tx?

Answer 24

S.Pneumo, S.aureus, pseudomonas

Tx = IV Cephalosporin or IV Metronidazole

Question 25

When is PEJ feeding used?

Answer 25

If upper GI surgery, pancreatitis

Question 26

If no enteric feeding is possible, what can be used to feed?

Answer 26

PICC feed eg. GI obstruction

Question 27

Complications of malnutrition?

Answer 27

Osteoporosis Falls (high frailty) Referring syndrome CV = Bradycardia, ECG changes, postural hypo

Question 28

What is the definition of osteoporosis?

Answer 28

T>-2.5 on DEXA Fragility fractures due to low BMD Selective destruction of horizontal trabeculae -Low BMD Ratio of mineral:bone = normal

Question 29

Who suffers from osteoporosis? M + F fraction? world wide?

Answer 29

1 in 3 F 1 in 5 M Over 50 world wide (20% + >50y in UK) Caucasian F

Question 30

acronym for causes of osteoporosis?

Answer 30

SHATTERED

Question 31

What does SHATTERED stand for?

Answer 31

Steroids HyperT4 Alcohol Thin Testosterone Low Estrogen Low Renal/liver issues Erosive bone disease (RA) Drugs (Methotrexate, Li, Warfarin) DMT1

Question 32

Sx of osteoporosis?

Answer 32

Pathological fractures: -Colles (fall on outstretched hand) -Neck of Femur (NOF) - external rotation + shortened leg -Vertebral crush (widow stoop) -Hip fracture

Question 33

Dx of osteoporosis? 1st and GS

Answer 33

Bloods (harm, U+E, Bone profile, LFT) 1. XRAY - fracture GS. DEXA scan

Question 34

What is a DEXA scan and Z score?

Answer 34

DEXA: Compares BMD to healthy 30y Px Z score: Someone average of same demographic

Question 35

what are the 3 levels of the scores of a DEXA scan and what do they mean?

Answer 35

0 - (-1) = normal (-1) - (-2.5) = Osteopenia > -2.5 = osteoporotic

Question 36

What score do we use to stratify the risk of a fracture?

Answer 36

FRAX score

Question 37

What does the FRAX score stratify?

Answer 37

10y fracture risk in 40-90y based on certain factors eg. PMHx, SHx, sex, age

Question 38

what does each FRAX score mean and Tx? <10%? 10-19%? >20%?

Answer 38

<10% = low risk, DEXA in 5y/follow up 10-19% = Moderate risk, offer DEXA and consider Tx >20% = high risk, do DEXA + Give tx

Question 39

What is conservative Tx for osteoporosis?

Answer 39

High dietary Ca2+ (milk, dairy) Sunlight exposure (Vit D) Ca2+ supps (ADCAL D3)

Question 40

What is first line medical Tx for osteoporosis? examples? doses?

Answer 40

Bisphosphonates eg. PO Alendronate 70mg Once a week IV Zolendronate 5mg yearly

Question 41

How do bisphosphonates work?

Answer 41

Inhibit osteoclasts

Question 42

How should alendronate be taken?

Answer 42

Take on empty stomach First thing in morning Stay sat up 30 mins after take with water

Question 43

what are some SE of alendronate?

Answer 43

GI (GORD, Oesophagitis) MRONJ (Medication related osteonecrosis of jaw)

Question 44

what is second line medical Tx for osteoporosis? How is it given? How does it work?

Answer 44

Denosumab (mAB) 2x yearly SC injections Inhibit RANK-L

Question 45

What are some third line medical Tx for osteoporosis? How do they work?

Answer 45

Raloxifene - Oestrogen modulator (oest-agonist at bone, inhibits at endometrium) Teriparatide - synthetic PTH HRT