Case Study. This essay will examine the nursing process involved in managing chronic venous leg ulcers (CVLU).

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This essay will examine the nursing process involved in managing chronic venous leg ulcers (CVLU). The decision to focus on CVLU was made during a community placement where their treatment accounted for more than half of nurse’s workload.  According to Posnett et al. (2009), CVLU affect 1-2% of the UK population with over half having an active ulcer for more than one year, costing the National Health Service (NHS) between £266- £314 million. Personal cost to individuals living with CVLU was highlighted by Briggs & Flemming (2007). They report the majority of CVLU sufferers find it incapacitating with physical impacts such as pain & reduced mobility along with psychological impacts of low self-esteem, depression & social isolation. NHS Choices (2012a) define leg ulcers as sores below the knee that are non-healing by six weeks. They advise that different ulcers such as diabetic, traumatic & arterial ulcers can occur however Brown (2011) states around 80% of ulcers are venous. CVLU occur when blood in the lower extremities cannot adequately return to the heart causing hypertension & congestion in the legs. This occurs when calf muscle pump function is reduced, failing to pump blood back towards the heart or if valves in the leg veins that normally prevent blood flowing backwards are damaged. Pressure forces blood and fluid through the capillaries, resulting in irritation to the skin, causing ulceration (Brown, 2011). To illustrate the nursing process, consent was obtained to follow the care of a lady with CVLU, renamed Agnes ensuring confidentiality in line with the Nursing & Midwifery Council (NMC) Code of Conduct (2008).

Agnes, a cognitively bright 68 year old widow has been receiving treatment for CVLU for over 10 years. She became housebound in the last 5 years. Hess (2011) advises healing declines with age due to a number of factors such as poorer hydration, reduced circulation, respiratory or immune function or poor nutritional intake. Living alone, Agnes suffers social restriction and isolation due to reduced mobility. Palfreyman (2008) concurs this is common amongst CVLU patients.  Agnes presented with recurrence of an ulcer on the medial gaiter region of her left leg. She was previously diagnosed with chronic venous insufficiency through assessment of medical history, leg, ulcer, symptoms & ankle brachial pulse index (ABPI) measurement.

Ousey and Cook (2011) specify the importance of specialised training & expertise in wound assessment as it forms the basis of wound care & management and their efficacy. Incorrect diagnosis costs the NHS greatly in wasted resources and extended pain & suffering for CVLU sufferers.  Assessment should not only be about the wound. It should take into account the individual’s co-morbidities, their health beliefs and capacity for healing (Benbow, 2011). The assessor must be knowledgeable in the healing process and factors that affect healing (Hess, 2011).

Full medical history ruled out peripheral arterial disease (PAD), rheumatoid arthritis and diabetes as these conditions affect healing and require specialist referral (Scottish Intercollegiate Guidelines Network, SIGN 2010). It’s good practice to check blood pressure, urinalysis and blood to rule out conditions such as cardiovascular and renal disease, diabetes, anaemia and check nutritional status (SIGN, 2010).

Familial history of leg ulcers was noted. Agnes also suffers osteoarthritis in both knees, a degenerative condition that causes inflammation to joints, cartilage impairment & bone abnormalities around the joints (NHS Choices, 2012b).  Being overweight, with a body mass index of 31, increased burden to her knees causes her pain walking, which has latterly seen her mobility reduced. Hess (2011) claims that obesity can impair wound healing through comprised blood supply due to superfluous adipose tissue or protein malnutrition, suggesting nutritional status is biochemically tested as patient appearance is not reliable. Obesity also increases risks of cardiovascular disease, diabetes, atherosclerosis & hypertension according to Lazarou and Kouter (2010).

Prescribed tramadol & paracetemol, Agnes doesn’t complain about pain. On the surface, she appears stoic however does suffer low spells. Benbow (2011) insists individual’s health beliefs must be considered as barriers to concordance and healing. This is corroborated by Agnes’ non-concordance with compression stockings. Agnes watched her mother suffer and believes nothing will work. She has no issues with continence & has never smoked or drank alcohol. The nurse completed her assessment, based on Roper et al. activities of living model of nursing. Described by Mooney and O’Brien (2006) as assessment of twelve different areas, providing a picture of how individuals manage their daily life and identifying areas that require assistance. With reduced mobility highlighted, a Waterlow assessment was completed. With Agnes at risk of developing a pressure sore, a pressure-relieving cushion was supplied. The assessment identifies incontinence, reduced mobility, and malnutrition as risk factors of developing pressure sores (Healthcare Improvement Scotland, 2009a). With patient assessment complete, the wound was examined.

Hess (2011) suggests ulcer assessment should include site, appearance of wound bed, description of shape & edges, exudate, surrounding skin and pain. According to Whitehurst (2007), underlying causes must be investigated as this dictates a safe & effective choice of treatment. Closs et al. (2008) claims CVLU tend to be shallow, superficial, moist & granulating with irregular borders, found on the lower leg. Agnes ulcer measured six centimetres long by five centimetres wide. It appeared superficial with a red granulating base and moist with low exudate. Benbow (2011) insists standardised data from wound assessment reduces personal interpretations, providing baselines to measure efficacy of treatment and evaluate healing. The general wound assessment tool was used to document & evaluate Agnes’ wound and treatment (HIS, 2009b). Tang et al. (2012) found consistent & on-going wound assessment documentation provides a basis for increased healing.

With no signs of infection, there was no need to swab the ulcer however Agnes was informed of the associated symptoms such as increased pain, exudate or swelling, pain, malodour or temperature. Cooper et al. (2009) advise that most wounds contain some level of bacteria & there is no impact on healing. Unless classic signs of colonisation occur, there is no value in swabbing for infection.

Agnes lower left leg presented with unilateral peripheral oedema and hyperpigmentation, due to hemosiderin deposition, which is common in CVLU. (Hess, 2011). The leg was initially macerated and excoriated which according to Stephen-Haynes (2011) is caused by high exudate levels. This had now improved through application of absorbent dressings initially. Both ankles showed signs of reduced mobility, an indicator of calf muscle pump function which according to Shiman et al.(2009), points to a venous aetiology, compression therapy being the gold standard treatment. O’Meara et al. (2009) found that compression therapy is better than no compression in treatment of CVLU. Keen (2008) advises high compression may be damaging where blood supply is already compromised, so ABPI assessment must be performed before compression is commenced.

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According to Young (2011), ABPI cannot diagnose CVLU however it is a reliable tool for identifying PAD. Due to complex interpretation, it must be undertaken by trained practitioners. The measurement is calculated by measuring the highest pressure recorded in the ankles divided by the highest recorded brachial pressure in the arms. SIGN (2010) recommend compression therapy for measurements >0.8, with readings <0.8 referred to vascular specialists. Agnes ABPI measurement 1.0 demonstrated her safe for compression.

Compression provides pressure against the venous leg pump, prevents backflow by increasing valve sufficiency & promotes reabsorption of oedema, effectively improving venous return and ...

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