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The extended formulary and wound care

VOL: 98, ISSUE: 14, PAGE NO: 52

Molly Courtenay, PhD, MSc, Cert.Ed, RNT, RGN, is a lecturer, Southampton University

The first recommendations that nurses take on prescribing responsibilities were made over 15 years ago (Department of Health and Social Security, 1986). An examination of the care given to clients in their homes by district nurses and health visitors identified complicated procedures that had arisen around prescribing in the community. Nurses were spending significant amounts of time obtaining prescriptions from their GP for items such as wound dressings and ointments, about which they generally knew far more than the GP.

The first recommendations that nurses take on prescribing responsibilities were made over 15 years ago (Department of Health and Social Security, 1986). An examination of the care given to clients in their homes by district nurses and health visitors identified complicated procedures that had arisen around prescribing in the community. Nurses were spending significant amounts of time obtaining prescriptions from their GP for items such as wound dressings and ointments, about which they generally knew far more than the GP.

The report suggested that patient care could be improved, and resources used more effectively, if community nurses were able to prescribe from a limited list of products agreed by the DHSS.

Primary legislation permitting nurses to prescribe a limited range of items was passed in 1992 (Medicinal Products: Prescribing by Nurses Act 1992). This was amended in 1994 and a revised list of products available to nurse prescribers was published in the Nurse Prescribers' Formulary (NPF).

Eight pilot nurse-prescribing schemes were set up in England and received positive evaluations. Funding for full national implementation was promised in April 1998. By the spring of 2001, over 20,000 DNs and HVs were qualified prescribers.

In 1999, it was recommended that prescribing authority should be extended to other professional groups in specialised areas (Department of Health, 1999). In 2001 the government made funding available for other registered nurses to undergo the training to enable them to prescribe from an extended formulary. This formulary includes:

- All general sales list (GSL) items - those that can be sold to the public without the supervision of a pharmacist;

- All pharmacy (P) medicines - products sold under the supervision of a pharmacist;

- A number of specified prescription-only medicines (POMs), enabling nurses to prescribe in four areas - minor ailments, minor injuries, health promotion and palliative care.

The addition of a number of antibiotics to the extended formulary was confirmed by health ministers in February (www.doh.gov.uk/nurseprescribing). However, legislation is required before the addition of scheduled drugs can occur.

Education and training for extended nurse prescribing started in January this year. Programmes are at academic level three, involve 25 taught days, additional self-directed learning and 12 days' learning in practice with a practice supporter (a doctor), delivered over a three-month period. Nurses working in the area of wound care and prescribing from the extended formulary are able to prescribe a wide range of preparations for a number of conditions.

The treatment management of two of these conditions, chronic skin ulcers and atopic dermatitis, are described below.

Chronic skin ulcers
Pressure ulcers may present as persistently hyperaemic, blistered, broken or necrotic skin and may extend to underlying structures, including muscle and bone (Cullum et al, 2000). They are common at bony prominences such as the shoulders, elbows, hips, sacrum and heels. Risk factors associated with their development include impaired mobility, poor nutritional status, diabetes, incontinence, reduced fluid intake, oedema and the age of an individual.

Basic nursing interventions involve the relief of pressure by regularly repositioning the patient and the use of an appropriate mattress when at-risk patients are in bed, or special cushions for when they are seated in a chair. Although different dressings are frequently used to treat pressure ulcers, their effectiveness is unclear (Cullum et al, 2000).

Chronic leg ulcers are defined as the loss of skin on the leg or foot that takes more than six weeks to heal (Nelson et al, 2000). They are commonly associated with venous disease but can be associated with arterial disease. Careful history-taking, examination of the patient and Doppler ultrasound assessment will exclude significant arterial disease.

If the ankle brachial pressure index (APBI) is greater than 0.8, multilayer compression bandaging is the safest and most effective treatment (Fletcher, 1997; Nelson et al, 2000). The risk of recurrence is also reduced if compression hosiery is worn following ulcer healing (Nelson et al, 2000). Compression therapy works by providing pressure and support for the superficial vessels. This counteracts the raised capillary pressure and prevents oedema.

Preparations available to treat chronic skin ulcers include silver sulfadiazine 1% cream (Flamazine) and metronidazole gel 0.075% and 0.8% (Metrogel, Metrotop, Rozex).

Mode of action

Metronidazole is an imidazole. It is effective in protozoan and anaerobic gram-negative bacterial infections and greatly reduces the odour that accompanies these wound infections. Although its mechanism of action is not fully understood, it is thought to prevent DNA replication and so is bacteriocidal.

Side-effects

Local skin irritation.

Nursing points

The wound should be cleaned and the preparation applied once or twice daily. The gel should be applied liberally to flat wounds, and smeared on paraffin gauze and packed loosely into cavity wounds.

Silver sulfadiazine cream

This preparation is a sulphonamide. These have a similar function to antibiotics but are developed from chemicals, as opposed to fungi or moulds. Silver sulphadiazine has an antibacterial effect against both gram-negative and gram-positive organisms and is also effective against yeasts and fungi. It can be applied to leg ulcers and pressure ulcers.

Mode of action

Bacteria require folic acid in order to grow. This is produced by an enzymatic reaction within the bacterial cell. The sulphonamides interfere with this reaction, thus preventing the formation of folic acid. The bacteria are therefore unable to survive (Henry, 2001).

Contra-indications

This preparation should not be given during pregnancy or breast-feeding. It is not recommended for neonates (BNF, 2002).

Side-effects

Allergic reaction, including stinging and rash.

Nursing points

Silver sulfadiazine should be applied daily or every 48 hours and used with an absorbent, retaining dressing. It should not be used in wounds with high levels of exudate (BNF, 2002).

Atopic dermatitis
Dermatitis or eczema is an inflammatory disorder of the skin. Individuals who suffer from atopic dermatitis generally have a family history of hypersensitivity reactions. It is seen more frequently in children but can persist throughout life (LeMone and Burke, 1996). In adults, areas of the skin become red, thickened and hardened and may become infected as a result of scratching.

Evidence supporting the avoidance of house dust mites, wet wraps or other forms of bandaging and changes in diet is limited (Charman, 2000). The treatment of atopic dermatitis includes the regular use of emollients, topical corticosteroids for acute episodes and oral antibiotics for exacerbation of infection (MCA, 2001).

Emollients

Emollients soothe, smooth and hydrate the skin and are used in the treatment of dry skin. Their effects are short-lived and they need to be applied frequently even after improvement occurs. Emollient preparations are available in a variety of presentations. Those with a high water content produce a greater cooling effect on the skin and so are extremely effective for patients suffering from pruritus. People with very severe dry skin may benefit from an emollient with higher oil content. This produces a greater sealing effect on the skin and thus prevents water evaporation to a greater extent.

Mode of action

- Creams

Creams are oil-in-water emulsions. Following the initial application of the preparation, water is lost from the mixture by both evaporation and absorption into the skin. This has the effect of cooling the skin and alleviating pruritus. The water loss from the mixture, combined with the mechanical stress of applying the preparation, causes the emulsion to crack. During this phase, oil is released on to the surface of the skin, sealing it and preventing any further water evaporating from the skin's surface (Nathan, 1997). Creams are popular for the treatment of minor dry skin conditions.

- Ointments

Ointments are greasy preparations that do not normally contain water and are insoluble in water. They are more occlusive than creams and are particularly effective in chronic, dry lesions. Commonly used ointment bases consist of soft paraffin or a combination of soft, liquid and hard paraffin.

A wide range of emollient preparations are currently available. However, there is little published evidence of their relative effectiveness, and choice is often a matter of personal preference or restricted by practice formularies. All emollient products can be bought over the counter.

Contra-indications

Generally, emollients are very safe to use, their only contra-indication being sensitivity to the constituents in the preparation. This is most notable with hydrous wool fat (lanolin) and should be suspected if an eczematous reaction occurs after the use of an emollient.

Nursing points

Patients with severe conditions may need to have a daily bath containing an emollient, and then to apply further emollient creams or ointments. Those with less severe conditions may only require the infrequent application of cream to an area of dry skin.

Patients with severe dry skin will benefit from having a bath before using an emollient. The bath water will hydrate the skin and therefore provide an extremely good base for the application of these preparations. The bath water must only be lukewarm - if it is any hotter the blood vessels will dilate and itching may be exacerbated.

Emulsifying ointments can also be used as a bath additive. Approximately 30g should be mixed with hot water and poured into the bath. Following bathing, the skin should be gently patted dry. If an emollient preparation is to be applied to the skin this should be done before the skin dries out and immediately following the bath. Emollients can be applied as often as they are required throughout the day.

- Corticosteroids

Mode of action

Corticosteroids act by enzyme inhibition, suppressing the formation of prostaglandin and leukotriene inflammatory mediators. They also decrease histamine release from basophils. Their effect is therefore to suppress the inflammation and allergic/immune responses (Hopkins, 1999).

Topical corticosteroid are administered to relieve inflammation and itching in skin diseases. Preparations vary in potency:

- Mildly potent: hydrocortisone;

- Moderate potent: alclometasone, clobetasone, fluocinonide, fluocortolone, flurandrenolone, halcinonide;

- Potent: beclomethasone, betamethasone, desoxymethasone, diflucortolone, fluocinonide, fluticasone, mometasone, triamcinolone;

- Very potent: clobetasol, halcinonide (Henry, 2001).

Side-effects

Mild and moderately potent topical corticosteroids are rarely associated with side-effects. However, care must be taken if they are applied over a large surface, if an occlusive dressing is applied to the area, or if the skin is damaged, as systemic absorption will be increased. Permanent changes to the skin will occur if potent corticosteroids are used in high concentrations over a prolonged period.

Thinning of the skin and prominent blood vessels are the most common side-effects. Therefore, if they are to be applied to the skin on the face only mild corticosteroids should be prescribed. Rebound erythroderma can occur if a treatment is stopped abruptly (Henry, 2001).

Nursing points

The topical corticosteroid applied should be the least potent preparation that is effective. In mild to moderate atopic eczema it should be used for periods of one to two weeks in conjunction with an emollient. A more potent corticosteroid may be required in more severe cases, followed by a weaker preparation. An emollient should also be applied (BNF, 2002).

Corticosteroids in combination with antimicrobials can be used to treat small, localised areas of infected eczema. Infection may also be treated with oral antibiotics, which must be prescribed by a doctor.

Conclusion
As more nurses gain prescribing qualifications and skills it is likely that further extensions will take place. This should increase the independence of nurses caring for patients with wounds and enhance their ability to provide high-quality care in a timely manner, rather than having to wait for doctors to ratify decisions that nurses are better qualified to make themselves.

- This article is based on a book by Courtenay, M. and Butler, M. Essential Nurse Prescribing, to be published in April 2002 by Greenwich Medical Media, London

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