In the United States there are 1.7 million incidents each year where workplace violence has taken place (Mattingly, 1994-2011). Twelve percent of the incident involved a healthcare worker or a mental health worker (Mattingly, 1994-2011). In the Midwest sixty seven percent of nurses have been physically assaulted at least once within six months (Mattingly, 1994-2011). For the longest time they have been using only chemical restraints and seclusion and restraints as an intervention for dealing with agitated patients (Mattingly, 1994-2011). This has been an intervention used by healthcare workers for a long time. They use this method to deal with aggressive agitated patients in both the emergency room and the psychiatric hospitals (Mattingly, 1994-2011). A new method that has been introduced is de-escalation. According to International Journal of Mental Health Nursing the definition of de-escalation is the gradual resolution of a potentially violent and or an aggressive situation through the use of verbal and physical expression of empathy, alliance and non-confrontational limit setting that is based on respect (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Most health care workers do not have the skills needed to care for the mentally ill population. This paper will discuss: what causes this problem; what is the nurse role in caring for the patient; other alternatives and the outcomes and how a nurse would use these interventions in practice .

There are several factors that cause healthcare providers to face difficulties while dealing with aggressive and mentally ill patients. Nowadays they have been working under limited conditions (Bigwood & Crowe, 2008). These units lack teamwork, leadership and they are much very unorganized (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Hospital units are overcrowded. In many regions, in order to get a bed in the psychiatric hospital, patients have to wait in the emergency room until a bed becomes available (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This ends in an overcrowded emergency room, low staffing ratio, the nurse is unable to exercise patience, and the patient is becoming increasingly agitated because they are confined to a bed in a little corner of an emergency room (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Hospitals are not taking the time to properly train these healthcare providers that are caring for this group (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). They are also unorganized when it comes to delegating functions and roles to the staff (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). In a crisis situation when a patient is agitated, if functions and roles are delegated everyone would be able to know what part they will partake in the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Without this training the healthcare provider tends to lack the confidence in caring and dealing with these patients (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003).

There are interventions to take when it comes to de-escalating a patient. The role of the nurse is to recognize the warning signs (Townsend, 2006). People do not just start off escalated. It starts off with small stages. The patient may become anxious. This may be a sign of impeding danger or threat that the patient faces discomfort (Townsend, 2006). They may start pacing, which is a back and forward movement (Townsend, 2006). Patients usually pace as a way to deal with stress or anxiety. They might exhibit excessive body movements which include: tremors, non-purposeful movements and shaking (Townsend, 2006). They also increase the volume and tempo of their voice, and their facial expression (Townsend, 2006). Recognizing these signs can help eliminate an escalating situation (Townsend, 2006) (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003).

Special skills are needed when it comes to de-escalating a patient. The most important intervention is to ensure safety(Townsend, 2006). Make sure the patient and the other patients are safe on the unit (Townsend, 2006). To ensure safety, remove the patient from the environment (Townsend, 2006). If that is not possible, remove the other patients from the environment (Townsend, 2006). Remove any potentially dangerous items from the area immediately (Townsend, 2006). Remove any staff that might be agitating the patient. Identify and remove stressors and remove them from them from the vicinity. The main goal in this situation is to reduce the stimuli (Townsend, 2006).

Healthcare providers will need to learn how to communicate with the patient. Communicating with the patient will involve verbal skills, which is called verbal de-escalation and nonverbal skills. The definition of verbal de-escalation is a complex therapeutic interactive process’ in that it is the act of talking to the patient and decreasing the patient from disturbed and excitability (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). The key to verbal de-escalation is knowing how to talk to an individual to calm them down. When de-escalating a situation make sure open ended questions are asked and open ended statements are made (Townsend, 2006). This will allow the patient the opportunity to express themselves and tell the healthcare provider what is wrong (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Make sure you find a calm space for the patient (Townsend, 2006). This will reduce the stimuli. Always avoid confrontation and judgmental comments to the patient. When talking to the patient give the patient your undivided attention (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Giving someone undivided attention involves facing them directly and giving them direct eye contact (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Speak in a calm tone. Make your presence is known by introducing yourself and your title. Your posture should be relaxed and comfortable (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). A defensive stance like arms around the waist or the hands are not visible can send a threating message to the patient (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Make sure statements will be reiterated to let the patient know that you were actively listening to them (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This will help clarify unclear information. The healthcare provider should be compassionate. At the same time they should be firm. They should not make promises or challenges. Keep statements clear and concise(Townsend, 2006). Lengthy and complex statements are avoided because the patient is mostly focused on one thing at a time (Townsend, 2006). It is also important to identify two types of escalated patients (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). Always keep in mind that some patients will try to gain control of the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). They will try to be manipulative (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). It is the duty of the healthcare provider to allow the patient to take responsibility for their own actions and to regain control of themselves or the situation (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). In any situation, the most common solution to any problem is respect. Showing respect to anyone goes a long way.

There are other alternative interventions that are used other than de-escalation: medication, seclusion and restraints. Medication is also considered to some people as a chemical restraint. Some healthcare providers use it as way to control and restrain a patients’ behavior (Bigwood & Crowe, 2008). The patient does not have any control over their body. A chemical restraint contains Haldol a typical antipsychotic and Ativan a benzodiazepine (Mattingly, 1994-2011). This shot has been known to put a patient down for several hours. Patients have to be monitored very closely to ensure safety and to detect the adverse effects that are involved with the typical antipsychotic medication (Bigwood & Crowe, 2008). Anti-psychotics block dopamine receptors in the body (Unbound Medicine, 2000-2011). It mainly works on the positive symptoms that patients are affected by (Townsend, 2006). The side effects of typical antipsychotics can be anything from seizures, blurred vision, respiratory depression, constipation, dry mouth, neuroleptic malignant syndrome, tardative dyskinesia (Unbound Medicine, 2000-2011). They are called extrapyramidal symptoms. While the patient is on this medication the nurse needs to monitor the patients’ vital signs, assess the mental status of the patient, assess for positive and negative symptoms, and assess intake and output to monitor bowel and bladder function (Unbound Medicine, 2000-2011). Monitor the patient’s laboratory reports, mainly the complete blood count with differential and liver function tests (Unbound Medicine, 2000-2011). These should be monitored during drug therapy (Unbound Medicine, 2000-2011). Benzodiazopines depresses the CNS and increases GABA in the body (Unbound Medicine, 2000-2011). This drug puts patients at risk for psychological and physiological dependence (Mattingly, 1994-2011).

Seclusion and Restraint is another alternative way to control a patient. It is also known as timeout (Townsend, 2006). It is supposed to be used as a tool to guarantee safety to both staff and the patient involved. It has proven to cause more harm physically and psychologically to the patient (Bigwood & Crowe, 2008). These are intended to be used as a last resort for patients that are posing harm to themselves or others (Bigwood & Crowe, 2008). The procedure taken to administer this means of safety can be very risky (Bigwood & Crowe, 2008). Staff and patients tend to become injured as a result of this procedure (Bigwood & Crowe, 2008). Although at times nurses cannot avoid seclusion and restraints they need to administer them with care and compassion. That would include making sure that the patients basic needs are met. Have the patient stay in seclusion and restraints for a very limited time, at least until the patient has calmed down and can guarantee safety (Townsend, 2006). Again the nurse should monitor the vital signs, nutritional status, mental status when the patient is restrained (Townsend, 2006).

Applying de-escalation to nursing practice will decrease the amount of injuries in mental health hospitals and emergency room (Cowen, Davies, Estall, Berlin, Fitzgerald, & Hoot, 2003). This will provide the nurse with the confidence in dealing with the mentally ill population. Patients’ needs will be able to be met more efficiently, because the nurse will be educated on how to care for them and how to communicate with the patient.

In practice, a nurse will treat mentally ill patients like any other type of person in society. This will consist of treating the patients with respect and ensure them with safety. The main thing to remember is that a nurse can never go wrong with taking the time to assess their patient. It will paint a picture of what is going on with a patient. With that, a nurse will be able to notice the early warning signs of an agitated patient. By doing so, their needs will be addressed. The patient may request medication or the patient may just be hungry. Nurses should continue to take classes to learn a lot more communication techniques on how to communicate with these particular types of patients. Giving them undivided attention and showing them that they are cared for as a patient, will ensure and verify that nurses has a lot of compassion in what they do. My passion is taking care of the mentally ill.

The purpose of this assignment, is to identify a patient, under the care of the district nursing team, with a Grade 1 pressure ulcer, to their sacral area. To begin with, it will give a brief overview of the patient and their clinical history. Throughout the assignment the patient will be referred to as Mrs A, in order to protect the patients identity and maintain confidentiality, in accordance with the guidelines set out by the Nursing and Midwifery Council (NMC 2008). A brief description of a Grade 1 pressure ulcer will be given, along with a description of the steps taken in assessing the wound, using The Waterlow Scale (1985). This assignment will discuss the literature review that was carried out, along with other methods of research used, to gather vital information on wound care , such as the different classifications of wounds and the different risk assessment tools available. This assignment, will include brief overviews, of some the other commonly used pressure ulcer risk assessment tools, that are put to use by practitioners and how they compare to the Waterlow Scale. This assignment will also seek to highlight the importance of using a combination of clinical judgement, by carefully monitoring the patients physical and psychological conditions, alongside the ‘at risk’ score calculated from the Waterlow Scale, in order to deliver holistic care to the patient.

Mrs A is a 84 year old lady who has been referred to the district nurses by her General Practitioner, as he has concerns regarding her pressure areas . Following a recent fall she lost her confidence and is now house bound. She now spends more time in her chair as she has become nervous when mobilising around the house and in her garden. She has a history of high blood pressure and occasional angina for which she currently takes Nicorandil 30mg b.d. as prescribed by her General Practitioner , Nicorandil has been recognised as an aetiological aspect of non – healing ulcers and wounds (Watson, 2002), this has to be taken into consideration during the assessment and throughout the management of her wound. Mrs A has no history of previous falls or problems with her balance. She has always been a confident and independent lady, with no current issues surrounding continence or diet. She has always enjoyed a large network of friends who visit her regularly. It is recommended by National Institute for Health and Clinical Excellence (NICE) that patients should receive an Initial assessment (within the first 6 hours of inpatient care) and ongoing risk assessments and so referrals of this nature are seen on the day, if it is received if not within 24 hrs. In order to establish Mrs A’s current risk of developing a pressure area, an assessment must take place. An initial holistic assessment, looking at all contributing factors such as mobility, continence and nutrition will provide a baseline that will identify her level of risk as well as identifying any existing pressure damage.

A pressure ulcer is defined as, a localised injury to the skin and / or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing, or confounding factors, are also associated with pressure ulcers. According to the European Pressure Ulcer Advisory Panel (EPUAP 2009), the significance of these factors, is yet to be elucidated.

Mrs A is more vulnerable to pressure damage, as her skin has become more fragile and thinner with age (NICE 2005). There are risk factors associated to the integrity of the patient’s skin and also to the patients general health. Skin that is already damaged, has a higher incidence of developing a pressure ulcer, than that of healthy skin. Skin that becomes too dry, or is more moist due to possible incontinence, is also at higher risk of developing a pressure ulcer than healthy skin. An elderly person’s skin is at increased risk, because it is more fragile and thinner than the skin of a younger person. Boore et al (1987) identified the following principles in caring for the skin to prevent pressure damage, skin should be kept clean and dry and not left to remain wet. The skin should also not be left to dry out to prevent any accidental damage . Due to Mrs A spending more time sitting in her chair, she has become at a higher risk of developing a pressure sore, as she is less mobile. The reason being It becomes difficult for the blood to circulate causing a lack of oxygen and nutrients to the tissue cells. Furthermore, the lymphatic system also begins to suffer and becomes unable, to properly remove waste products. If the pressure continues to increase and is not relieved by equipment or movement. The cells can begin to die, leaving an area of dead tissue resulting in pressure damage. Nelson et al (2009) states, pressure ulcers can cause patients functional limitations, emotional distress, and pain for persons affected. The development of pressure ulcers, in various healthcare settings, is often seen as a reflection of the quality of care which is being provided (Nakrem 2009). Pressure ulcer prevention is very important in everyday clinical practise, as pressure ulcer treatment is expensive and factors such as legal issues have become more important. EPAUP (2009) have recommended strategies, which include frequent repositioning the use of special support surfaces, or providing nutritional support to be included in the prevention.

In order to gather evidence based research, to support my assignment. I undertook a literature review of the Waterlow Scale and Classifications of Grade 1 pressure sores. The databases used were the Culmulative Index to Nursing and Allied Health Literature (CINAHL) and OpenAthens. I used a variety of search terms including ‘pressure sores’, ‘Grade 1 classification’, ‘Waterlow Scale’, and ‘How pressure sore risk assessment tools compare’. Throughout the literature review the information was gathered from sources using a date range between the years of 2000 – 2011, although some references were found from sources of information that are from a much later date. This method of research ensured a plethora of articles and guidelines were collated and analysed. The trust guidelines in wound care were used, to show how we implement theory into practise in the community, using the wound care formulary. There was a vast amount of information available, as pressure area care is such a broad subject. The search criteria had to be narrowed down, in some cases to ensure the information gathered was relevant and not beyond the scope of the assignment. The evidence used throughout this assignment, is based on guidelines and recommendations given by NICE (2001), EPUAP (2001) and articles sourced from The Journal of Community Nursing (JCN). This was the most accurate information and guidance on pressure ulcer classifications and assessment although, some articles may not have been the most recent.

The assessment tool used throughout my area of work, is the Waterlow Scale. The Waterlow Scale was developed by Judy Waterlow in 1985, while working as a clinical nurse teacher. It was originally designed for use by her student and is used to measure a patient’s risk of developing a pressure sore. It can also be used as a guide, for the ordering of effective pressure relieving equipment. All National Health Service (NHS) trusts have their own pressure ulcer prevention policy, or guidelines and practitioners are expected to use the risk assessment tool, specified in their trust’s policy. NICE (2003), guidance states, that all trusts should have a pressure ulcer policy, which should include a pressure ulcer risk assessment tool. However, it reminds practitioners that the use of risk assessment tools, should be thought of as an aid to the clinical judgement of the practitioner. The use of the Waterlow tool enables, the nurse to assess each patient according to their individual risk of developing pressure sores (Pancorbo-Hidalgo et al 2006). The scale illustrates a risk assessment scoring system and on the reverse side, provides information and guidance on wound assessment, dressings and preventative aids. There is information regarding pressure relieving equipment surrounding, the three levels of risk highlighted on the scale, and also provides guidance, concerning the nursing care given to patients. Although the Waterlow score is used in the community setting, when calculating the risk assessment score, it is vital that the nurse is aware of the difference in environment the tool was originally developed for.

The tool uses a combination of core and external risk factors that contribute to the development of pressure ulcers. These are used to determine the risk level for an individual patient. The fundamental factors include disease, medication, malnourishment, age, dehydration / fluid status, lack of mobility, incontinence, skin condition and weight. The external factors, which refer to external influences which can cause skin distortion, include pressure, shearing forces, friction, and moisture. There is also a special risk section of the tool, which can be used if the patient is on certain medication or recently had surgery. This contributes to a holistic assessment of a patient and enables the practitioner to provide the most effective care and appropriate pressure relieving equipment. The score is calculated, by counting the scores given in each category, which apply to your patient’s current condition. Once these have been added up, you will have your ‘at risk’ score. This will then indicate the steps that need to be taken, in order to provide the appropriate level of care to the patient. Identification of a patients risk of developing a pressure sore is often considered the most important stage in pressure sore prevention (Davis 1994).

During the assessment a skin inspection takes place of the most vulnerable areas of risk, typically these are heels, sacrum and parts of the body, where sheer or friction could take place. Elbows, shoulders, back of head and toes are also considered to be more vulnerable areas (NICE 2001). When using the Waterlow tool to assess Mrs A’s pressure risk, I found she had a score of 9. According to the Waterlow scoring system she is not considered as being at risk as her score is less than 10. As I had identified in my assessment, she had a score of 2, for her skin condition due to Grade 1 pressure ulcer to her sacrum. I felt it necessary, to highlight her as being at risk. A grade 1 pressure ulcer on her sacral area, maybe due to her recent loss of confidence and reduced mobility which has left Mrs A spending more time in her chair.

Pressure ulcers are assessed and graded, according to the degree of damage to the

tissue. The National Pressure Ulcer Advisory Panel (NPUAP), classifies pressure ulcers based on the depth of the wound. There are four classifications (Category/Stage I through IV) of pressure damage. In addition to these, two other categories have been defined, unstageable pressure ulcers and deep tissue injury (EPUAP, 2009) Grade 1 pressure damage is defined, as a non-blanchable erythema of intact skin. Indicators can be, discolouration of the skin, warmth, oedema, induration or hardness, particularly in people with darker pigmentation (EPUAP, 2003). It is believed by some practitioners, that blanching erythema indicates Grade 1 pressure damage (Hitch 1995) although others suggest that, Grade 1 pressure damage is present, when there is non-blanching erythema (Maklebust and Margolis, 1995; Yarkony et al, 1990). The majority of practitioners, agree that temperature and colour play an important role, in identifying grade 1 pressure ulcers (EPUAP, 1999) and erythema, is a factor in almost all classifications (Lyder, 1991). The pressure damage usually occurs, over boney prominences (Barton and Barton 1981). The skin in a Grade 1 pressure ulcer, is not broken, but it requires protection and monitoring.

At this stage, it will not be known how deep the pressure damage is, regular

monitoring and assessment is essential. The pressure ulcer may fade, but if the

damage is deeper than the superficial layers of the skin, this wound could eventually

develop into a much deeper pressure ulcer over, the following days or weeks.

A Grade 1 pressure ulcer, is classed as a wound and so I have commenced a

wound care plan and also a pressure area care plan. I will also ensure, Mrs A has

regular pressure area checks in order to prevent the area breaking down. The

pressure area checks will take place weekly until the pressure relieving equipment

arrives, this will then be reduced to 3 monthly checks. Dressings can be applied to

a Grade 1 pressure ulcer. They should be simple and offer some level of protection.

Also, to prevent any further skin damage a film dressing is often used, or a

hydrocolloid to protect the wound area (EPAUP, 2009) . These dressings will assist in

reducing further friction, or shearing, if these factors are involved. It is considered

the best way to treat a wound, is to prevent it from ever occurring. Removing the

existing external pressure, reducing any moisture, which can occur if the patient is

incontinent and employing pressure relief devices, may contribute to wound healing.

Along with adequate nutrition, hydration and addressing any underlying medical

conditions.

The advice given to practitioners, on the reverse of the Waterlow tool is to provide a

100mm foam cushion, if a patients risk score is above 10. As Mrs

A has an ‘at risk’ score of 9, with a Grade 1 pressure sore evident, I feel it

appropriate to provide the pressure relieving mattress and cushion to prevent any

further pressure damage developing. All individuals, assessed as being vulnerable to

pressure ulcers should, as a minimum provision, be placed on a high specification

foam mattress with pressure relieving properties (NICE, 2001). As I am providing a

cushion and a mattress, it is not felt necessary to apply a dressing at this point.

However, the area will need regular monitoring, as at this stage it is unknown how

deep the pressure damage is. If proactive care is given in the prevention and

treatment of pressure ulcers, with the use of risk assessments and providing

pressure relieving resources, the pressure area may resolve. Pressure ulcers can be

costly for the NHS, debilitating and painful for the patient. With basic and effective

nursing care offered to the patients, this can often be the key to success.

Bliss (2000) suggests that the majority of Grade I ulcers heal, or resolve without

breaking down if pressure relief is put into place immediately. However, experiences

in a clinical settings supports observations, that non-blanching erythema can often

result in irreversible damage (James, 1998; Dailey, 1992).

McGough (1999) during a literature search, highlighted 40 pressure ulcer risk

assessment tools, but not all have be considered suitable, or reliable for all clinical

environments. As there are many different patient groups this often results in a wide

spectrum of different patient needs. The three most commonly used tools in the United Kingdom (U.K.) are, The Norton scale, The Braden Scale and The Waterlow Scale.

The first pressure ulcer risk assessment tool was the Norton scale. It was devised by Doreen Norton in 1962. The tool was used for estimating a patient’s risk for developing pressure ulcers by giving the patient a rating from 1 to 4 on five different factors. A patients with a score of 14 or more, was identified as being at high risk. Initially, this tool was aimed at elderly patients and there is little evidence from research gathered over the years, to support its use outside of an elderly care setting. Due to increased research over the years, concerning the identification and risk of developing pressure ulcers, a modified version of the Norton scale was created in 1987.

The Braden Scale was created in the mid 1980’s, in America and based on a conceptual schema of aetiological factors. Tissue tolerance and pressure where identified, as being significant factors in pressure ulcer development. However, the validity of the Braden Scale is not considered to be high in all clinical areas (Capobianco and McDonald, 1996). However, EPAUP (2003) state The Braden

Risk Assessment Scale is considered by many, to be the most valid and reliable

scoring system for a wide age range of patients.

The Waterlow Scale, first devised in 1987, identifies more risk factors than the Braden and the Norton Scale. However, even though it is used widely across the U.K., it has still be criticised for its ability to over predict risk and ultimately result in the misuse of resources (Edwards 1995; McGough, 1999).

Although there are various tools, which have been developed to identify a patients individual risk, of developing pressure sores. The majority of scales have been developed, based on ad hoc opinions, of the importance of possible risk factors, according to the Effective Healthcare Bulletins (EHCB, 1995). The predictive validity of these tools, has also been challenged (Franks et al, 2003; Nixon and Mc Gough, 2001) suggesting they may over predict the risk, incurring expensive cost implications, as preventative equipment is put in place, when it may not always be necessary. Or they may under predict risk, so that someone assessed as not being at high risk develops a pressure ulcer. Although the Waterlow scoring system, now includes more objective measurements such as Body Mass Index (BMI) and weight loss after a recent update. It is still unknown, due to no published information, whether the inter-rater reliability of the tool, has been improved by these changes. It has been acknowledged, that this is a fundamental flaw of these tools and due to this clinical judgement, must always support the decisions made by the results, of the risk assessment. This is clearly recognised by NICE, as they advise their use as an aide-mémoire (2001). The aim of Pressure ulcer risk assessment tools, is to measure and quantify pressure ulcer risk. To determine the quality of these measurements the evaluation of validity and reliability would usually take place. The validity and reliability limitations, of pressure ulcer risk tools are widely acknowledged. To overcome these problems, the solution that is recommended is to combine the scores of pressure ulcer risk tools, with clinical judgment (EPAUP 2009). This recommendation, which is often seen in the literature, unfortunately is inconsistent as Papanikolaou et al (2007) states: “If pressure ulcer risk assessment tools have such limitations, what contribution can they make to our confidence in clinical judgment, other than prompting us about the items, which should be considered when making such judgments?”. Investigations of the validity and reliability, of pressure ulcer risk tools are important, in evaluating the quality, but they are not sufficient to judge their clinical value. In the research of pressure ulcer tools, there have been few attempts made to compare, the different pressure ulcer risk assessment strategies. Referring to literature until 2003, Pancorbo – Hidalgo et al (2006) identified three studies, investigating the Norton scale compared to clinical judgment and the impact on pressure ulcer incidence. From these studies, it was concluded that there was no evidence, that the risk of pressure ulcer incidence was reduced by the use of the risk assessment tools. The Cochrane review (2008), set out to determine, whether the use of pressure ulcer risk assessment , in all health care settings , reduced the incidence of pressure ulcers. As no studies met the criteria, the authors have been unable to answer the review question. At present there is only weak evidence to support the validity, of pressure ulcer risk assessment scale tools and obtained scores contain varying amounts of measurement error.

To improve our clinical practise, it is suggested that although tools such as the

Waterlow Scale are used to distinguish a patients pressure ulcer risk, other

investigations and tests, may need to be carried out to ensure a effective

assessment is taking place. Practitioners may consider, various blood tests and more

in depth history taking, including previous pressure damage and medications. Patients

lifestyle and diet should also be taken into consideration and where appropriate, a

nutritional assessment should be done if recent weight loss, or reduced appetite is

evident. Nutritional assessment and screening tools are being used more readily and appear to be becoming more relevant in managing patients who are at risk of or have a pressure ulcer. The assessment tools should be reliable and valid, and as discussed previously with other risk assessment tools they should not replace clinical judgement. However, the use of nutritional assessment tools can help to bring the nutritional status of the patient to the attention of the practitioner, they should then consider nutrition when assessing the patients vulnerability to pressure ulcer development. The nutritional status of the patient should be updated and re-assessed at regular intervals following a assessment plan which is individual to the patient and includes an evaluation date. The condition of the individual will then allow the practitioner to decide how frequent the assessments will occur. The EPUAP (2003) recommends that as a minimum, assessment of nutritional status should include regular weighing of patients, skin assessment, documentation of food and fluid intake.

As Mrs A currently has a balanced diet, it is not felt necessary to undertake, a

nutritional assessment at this point. Her weight can be updated on each review visit,

to assess any weight loss during each visit. If there is any deterioration in her

condition, an assessment can be done when required. Continence should also be

taken into consideration and where necessary a continence assessment should take

place. Incontinence and pressure ulcers are common and often occur together.

Patients who are incontinent are generally more likely to have difficulties with their

mobility and elderly, both of which have a strong association with the development

of pressure ulcers (Lyder, 2003).

The education of staff, surrounding pressure ulcer management and prevention, is

also very important. NICE (2001) suggest, that all health care professionals, should

receive relevant training and education, in pressure ulcer risk assessment and

prevention. The information, skills and knowledge, gained from these training

sessions, should then be cascaded down, to other members of the team. The

training and education sessions, which are provided by the trust, are expected to

cover a number of topics. These should include, risk factors for pressure ulcer

development, skin assessment, and the selection of pressure equipment. Staff are

also updated on policies, guidelines and the latest patient educational information

(NICE 2001).

Education of the patient, carers and family, is essential in order to achieve optimum

pressure area care. Mrs A is encouraged to mobilise regularly, in order to relieve

the pressure as a Grade 1 pressure sore has been identified, she is at a significant

risk of developing a more severe ulcer. Interventions to prevent deterioration, are

crucial at this point. It is thought, that this could prevent the pressure sore from

developing into a Grade 2 or worse. NICE (2001) have suggested, that individuals

vulnerable to or at elevated risk of developing pressure ulcers, who are able and

willing, should be informed and educated about the risk assessment and resulting

prevention strategies. NICE have devised a booklet for patients and relatives, called

Pressure Ulcers – Prevention and Treatment (NICE Clinical Guidance 29), which gives

information and guidance on the treatment of pressure ulcers. It encourages patients

to check their skin and change their position regularly. As a part of good practise,

this booklet is given to Mrs A at the time of assessment, in order for her to

develop some understanding of her pressure sore. This booklet is also given to the

care givers or relatives so they can also gain understanding, regarding the care and

prevention, of her pressure ulcer. An essential part of nursing documentation, is care

planning. It demonstrates the care, that the individual patient requires and can be

used to include patients and carers or relatives in the patients care. Involvement of

the patient and their relative, or carer is advisable, as this could be invaluable, to

the nurse planning the patient’s care. The National Health Service Modernisation

Agency (NHSMA 2005) states clearly that person – centred care is vital and that care planning involves negotiation, discussion and shared decision – making, between the nurse and the patient.

There were a number of improvements that I feel could have been made to the holistic care of Mrs A. I feel that one of the fundamental factors that needed to be considered , were the social needs of the patient. As I feel they are a large contributing factor, towards why the patient may have developed her pressure sore. The patient was previously known to be a very sociable lady, who gradually lost her confidence, resulting in her not leaving the house. There are various schemes and services available, which are provided by the local council or volunteer services, to enable the elderly or people unable to get around. For example, an option which could of been suggested to Mrs A are services such as Ring and Ride, or Werneth Communicare. Using these services or being involved in these types of schemes, may have empowered Mrs A to leave the house on a more regular basis. This would enable her to build up the confidence, she lost following her fall. This would have also lead to positive impact on the patient’s psychological care, as Mrs A would have been able to overcome her fears of leaving the house, enabling her to see friends and gain communications lost. As previously mentioned in this assignment, although Mrs A had a score of 9, which is not considered an ‘at risk’ score. I still felt it necessary to act on this score, even though the wound was a not considered to be critical. If it is felt the patient is at a higher risk than that shown on the assessment tool, the practitioner should use their clinical judgement, to make crucial care decisions. It should also be considered, by the practitioner that risk assessment tools such as The Waterlow scale, may not have been developed, for their area of practise. Throughout the duration of Mrs A’s wound healing process, a holistic assessment of her pressure areas and general health assessment were carried and all relevant factors, were taken into consideration. The assessment tool used to assess her pressure areas, is the most common tool used currently in practise and the tool recommended by the Trust.

To conclude, there is evidence to prove that pressure ulcer risk assessment tools are useful, when used as a guide for the procurement of equipment. However, they cannot be relied upon solely to provide holistic care to a patient. It has been highlighted, that to ensure a holistic assessment of patients, it is necessary to complete a variety of assessments, to create a complete picture. Although The Waterlow scale covers a number of factors that need to be considered, throughout the assessment, it has become evident that the ‘at risk’ score, can often be over or under scored depending on the practitioner. Clinical judgement has proved to be, a very important aspect of pressure ulcer prevention and treatment. The education of the patient, carer and relatives has also been highlighted, as an important aspect of care. Empowering the patient with information regarding their illness, may decrease the healing time and help prevent has further issues.

Embolic stroke, a type of ischemic stroke, occurs when a vessel in the brain is blocked.  Brain tissue is deprived of oxygen and can die in just a few minutes.  Thrombotic issues like blood clots contribute to this kind of stroke which constitutes 87% of all strokes.  An embolic stroke occurs when a thrombus travels from another part of the body (embolism) and becomes lodged in a vessel in the brain (Johns Hopkins Medicine, 2019).  Those at increased risk for thrombosis that may lead to stroke include smokers, those with atherosclerosis, diabetes, are obese or have metabolic syndrome.  Heart failure or an irregular heart beat called atrial fibrillation (afib) may also contribute to the development of clots in the heart that may be released into circulation, ultimately reaching the brain (American Heart Association , 2019)

Overview of Current Therapy

If a stroke is occurring, there is only one medication FDA approved for the treatment, tissue plasminogen activator (tPA).  This drug works by dissolving the clot to stop the ischemic damage to the brain (National Stroke Association , 2019)  It is best if the medication is given within 4 hours and there could be sustained damage to the tissue leaving the patient with deficits.  For this reason, primary treatment is focused at prevention.

Historically, therapy for stroke prevention centered on the administration of aspirin or warfarin to prevent the formation of clots.  The Trial of Org 10172 in Acute Stroke treatment (TOAST) developed in the 1990s further clarified appropriate treatment by classifying types of ischemic strokes.  Following this, the implementation of clopidogrel into treatment regimens provided more options.  Unfortunately, these medications proved to have negative effects in studies due to the tendency to cause hemorrhage, though when used in those with low bleeding risk, the results were satisfactory (Gurol & Kim, 2018).

In recent years, studies have proven that the use of non-vitamin K antagonist oral anticoagulants (NOACs) outperform warfarin in nonvalvular afib trials.  The first NOAC approved for use in 2010 was dabigatran (Pradaxa) and is classified as a direct thrombin inhibitor.  Three more NOACs are now available: rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa) and are classified as factor Xa inhibitors (Cruz & Summers, 2016) More data is being collected and recommendations for use are making these medications a first line treatment for many providers (Gurol & Kim, 2018).  NOACs such as dabigatran have been proven more effective than warfarin in the RE-LY (Randomized Evaluation of Long-term Anticoagulation) trials for prevention in nonvalvular afib (Edmunds & Mayhew, 2014).  This study will examine how dabigatran performs compared to aspirin in the prevention of stroke.  Current guidelines for treatment of this kind of ischemic stroke call for aspirin, dipyridamole ER and aspirin, or clopidogrel and aspirin (Diener, et al., 2019)

Analysis of the Study

In the study entitled,

Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source

, researchers compare the effectiveness of dabigatran versus aspirin for the prevention of stroke.  Previous research indicates rivaroxaban was no more effective than aspirin, but studies have not included dabigatran (Diener, et al., 2019).

At 564 different sites in 42 countries, 5,390 participants were randomly selected for this trial.  The selected participants were divided in half: 2,695 receiving aspirin 100mg once daily and 2,695 receiving dabigatran 150mg once daily or 110mg twice daily.  Dabigatran dosage was decided based on age greater than 75 years and/or creatinine clearance of 30-50 mL/min received the twice a day dosing.  All participants were greater than 60 years of age and mean age was 64.2 years old.  Participants had all experienced an embolic stroke of undetermined source in the previous months, or had risk factors present   Baseline characteristics of participants, including comorbidities, gender and race are detailed in table 1 appendix A.  Efficacy was based on prevention or occurrence of stroke after treatment.  The study design was a randomized double-blind trial conducted between December 2014 and January 2018 concluding with median follow up at 19 months.  Appropriate approval by ethic committees at all locations was secured (Diener, et al., 2019).

All outcomes were discussed in a time-to-event analysis and included the following: ischemic stroke, non-fatal myocardial infarction (MI), death from cardiovascular causes.  A modified Rankin scale was used to display data for disabling recurrent stroke.  Results on the Rankin scale ranged from 0-6 with 0 being no deficit and 6 being death.  Type I errors were eliminated through adjustments to statistical significance (Diener, et al., 2019).

In the dabigatran group, 177 participants had recurrent stroke of any kind compared to 207 in the aspirin group.  172 and 203 strokes respectively were deemed ischemic in nature.  Dabigatran was discontinued at 19 months in 671 participants and aspirin in 568, both due to adverse events as the main reason.  The composite outcome for combined nonfatal stroke, MI, or cardiovascular death was 207 participants in the dabigatran group and 232 in the aspirin group.  Nonmajor bleeding occurred in 70 participants and 41 participants, respectively (Diener, et al., 2019).

Ultimately, dabigatran did not prevent recurrent stroke more effectively than aspirin regimen.  While major bleeding was not greater with dabigatran, there was more nonmajor bleeding events in the dabigatran group (Diener, et al., 2019).  These results in addition to increased cost of dabigatran should be considered when designing treatment regimen.

This study’s strengths were a large study size and good generalizability.  The number of recurrent strokes was not outside the margin of prediction.  Weaknesses include the ad hoc nature of the test and the inability to determine if dabigatran was more effective for those with undiagnosed afib (Diener, et al., 2019).

New Findings and Current Therapy

Although dabigatran does not outperform aspirin in trial studies, it is as effective.  When prescribing medication, the provider must consider many factors, including what risk factors the patient may have, especially risk for bleeding.  Determining the cause of previous stroke or the risk factors present that may induce stroke, is the first, and most critical determination for treatment.  Once this has been decided, medication can be selected to address the underlying cause.  NOACs such as dabigatran are relevant in treatment and prevention of ischemic stroke and provide options that were not previously available.

A Case Study

Advanced Pharmacology Spring 2019 presents the following case study in week three:

CC/HPI

TG is 57-year-old male who presents to your office with complaints of frequent nosebleeds (3 in the past week) and easy bruising. He also complains that he has a cold. TG has a history of chronic atrial fibrillation for which he takes warfarin. About 2 weeks ago he started taking cimetidine (Tagamet) OTC for symptoms of heartburn.

Medications:

Warfarin 7mg QD

Digoxin 0.25mg QD

Cimetidine OTC BID

Pseudoephedrine SR 120mg BID

Allergies:

NKDA

Physical Examination:

GEN:  Well developed, well-nourished man

VS:  BP 175/96, HR 70, irregularly irregular, RR 18, Wt. 94kg

HEENT:  WNL

COR:  slight atrial enlargement

CHEST: WNL

ABD:  (+) bowel sounds

EXT:  bruising on arms and knees

NEURO:  A&O x 3

ECG:  a. fib

Laboratory

Na 143

K 4.5

Cl 99

CO2 25

BUN 18

SCr 0.9

INR 4.7

Hct 43

Hgb 14

Digoxin 1.6ng/ml (Lynch, 2019)

This patient is taking warfarin (Coumadin) to prevent clot formation related to his afib.  Embolism of these clots could cause ischemic stroke, as discussed previously.  He has a supratherapeutic INR of 4.7.  In cases of nonvalvular afib, cases of afib not causes by valve failure, NOACs offer another option of treatment.  Coumadin is extensively protein bound causing competition with other medications that are protein bound creating chances for drug to drug interactions or increased serum levels (Condo, 2018).  In addition to this, Coumadin requires frequent monitoring to ensure therapeutic INR.  In contrast, using an oral direct thrombin inhibitor such as dabigatran (Pradaxa) requires no monitoring and has much fewer drug interactions.  Dabigatran does not have any significant interaction with any of the medications that this patient is taking.  Of course, it should be recommended that the patient not take pseudoephedrine with digoxin due to potential for arrhythmia (Epocrates; Athena Health , 2019).

It is important to teach the patient that dabigatran should be stored in an airtight, original container and discarded 30 days after opening.  Most patients are started on 150mg twice daily.  It is essential for patient to adhere to the treatment regimen to avoid the potential for occurrence of the black box warning associated with dabigatran, development of stroke or thrombotic event.  Before transitioning this patient to dabigatran, the patient’s INR should be decreased to <2.  This can be accomplished by administration of vitamin K.  Should it be required, the reversal agent for dabigatran is idarucizumab (Praxbind) (Condo, 2018).  Adverse reactions in addition to stroke or thrombosis if suddenly discontinued include, GI bleeding, bleeding, thrombocytopenia, hypersensitivity, or anaphylaxis (Epocrates; Athena Health , 2019).  Follow up should occur with this patient in two weeks to ensure that no adverse reactions have occurred.

This case differs from the study as dabigatran is being used to replace warfarin, which studies like RE-LY have supported.  As dabigatran does not perform better than aspirin, and aspirin lacks the interactions and required monitoring of warfarin, it would not be prudent to switch a patient from aspirin for thrombosis prevention to dabigatran without clear reason.  If it was determined that dabigatran was a more appropriate therapeutic regimen, the same adverse reactions discussed above would be included in patient education and monitoring.  Therefore, this exercise further concludes that that the selection of a mediation for the prevention of clot formation and subsequent potential ischemic stroke is a very individualized process that begins with determining the risk factors involved, comorbidities, potential adverse effects, cost of medication, and required monitoring.  Being knowledgeable of all medications and their therapeutic properties allows providers to select the medication that best meets the client’s needs.

Appendix A

(Diener, et al., 2019)

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