Consider the Choice of Product
Short-stretch compression bandaging has been shown to be equally efficacious when compared to other compression systems in healing venous ulcers independent of associated factors (Scriven et al, 1998; Nelson, 1996; Vowden, 1998). This has directed a trend towards the use of short-stretch bandaging as a cost-effective and proven method of reversing venous hypertension and enhancing the wound repair process in some patients (Charles, 1998).
Short-stretch compression bandages are fairly inelastic because the weave allows for minimal stretch and recoil (Charles, 1998). When applied to a leg at 90-100% stretch with a 50% overlap the inelastic nature of the bandage allows it to form a firm 'tube'. When the muscle of the calf contracts, it reflects or 'rebounds' from the wall of the tube, which increases the action of the calf muscle pump, thereby promoting venous return to the heart. It also has an effect on the microcirculation with an overall improvement in the function of the skin (Klyscz et al, 1997; Coleridge-Smith, 1997).
The combination of increased calf muscle pump activity and an improved microcirculation as a result of short-stretch compression therapy therefore has the potential to correct venous incompetence and promote healing in venous disease.
Non-compliance is a recognised problem in the use of compression therapy (Mayberry et al, 1991; Taylor, 1992). There are a number of reasons why this is the case, including factors such as forgetting instructions, difficulty managing the bandages and discomfort caused by the bandages - for example, finding them too hot (Samson and Showalter, 1996).
Mr X had experienced leg ulcer in the past and had not felt happy with four layer bandaging as he had complained of them making his legs ‘too hot’ and also they felt bulky.
Negotiate a Contract
To ensure concordance it is important that the patient plays a central role in the decision-making process (NPC, 1999). If the patient is not consulted and does not understand the rationale for dressing choice, compliance with the treatment may be affected (Cole, 2004). A nurse prescriber has to balance dressing cost with nursing time, together with patient acceptability and concordance (Edwards, 2000). Mr X had experience of other wound care products used on his leg in the past, and had strong opinions about which ones he was willing to accept the use of. It is important to be aware of influences that may affect the way treatments are prescribed however, such as patient pressure or drug companies’ promotional advertising (Brew, 1994). Autonomy is grounded in respect for patients' ability to choose, decide and take responsibility for their own lives (Randers and Mattiasson, 2004), but had his decisions been inappropriate, unsafe or not based on best evidence, agreeing to prescribe them could be deemed maleficent (Pridmore, 1998). Providing information on the benefits of the treatment proposed, in addition to the drawbacks enabled him to make an informed choice. Ultimately, negotiation ensures that the patient receives the most appropriate evidence-based care, which is safe, and which he agrees on.
Review the Patient
Twice weekly visits were agreed with Mr X to monitor the effectiveness of the bandaging and ensure that it was not causing a reaction, was helping to debride the slough, reduce the localised infection and absorb the exudate. Mr X was informed of the signs of an adverse reaction to the dressing, such as itching, increased localised pain and irritation at the site of the dressing, and advised to ring the DN if at all concerned. If the dressing used caused a reaction to Mr X’s leg and it was not picked up soon enough and the dressing removed, the effects could be deemed maleficent (Pridmore, 1998).
Ongoing evaluation of the prescribed treatment should always be undertaken, as modifications may need to be made if conditions change (Morison et al, 1999). Once the primary objective has been achieved, the assessment process needs to be repeated in order to identify the next treatment objective until the wound has healed (Collier, 2002). After one week the inflammation surrounding the ulcer had gone and there was evidence that the slough was beginning to lift. Mr X had not reported any discomfort or irritation to the ulcer or surrounding tissue, which suggests that the dressing prescribed, was suitable for him.
Record Keeping
As a registered nurse one has both a professional and legal duty of care, therefore all nurses have a responsibility to keep accurate and up-to-date records that should be an accurate account of treatment, care planning and delivery that provides clear evidence of the decisions made (NMC, 2002a). This form of communication ensures that all members of the healthcare team involved in the care of the patient are fully informed, and ensures changes in the patient’s condition are detected at an early stage (NMC, 2000b). Details of the prescribed treatment were entered into Mr X’s assessment notes with a clear rationale for the choice of treatment. The trust has a specific form to complete that informs the GP of the treatment prescribed, which was completed and handed to Mr X’s doctor.
Reflection
Utilising a structured model of reflection by Driscoll (2000) has provided a useful means of reflecting on the incident described and analysing the decisions made. Although Mr X had expressed strong opinions about the choice of treatment he was willing to accept on his ulcer, negotiation had enabled a decision to be made that was safe, appropriate and cost-effective, in addition to being acceptable by him, thus ensuring concordance. Using the prescribing pyramid (NPC, 1999) provided a systematic, structured method of decision-making in relation to the choice of treatment, therefore ensuring that all essential aspects that needed to be considered were included.
Conclusion
Many district nurses have expertise in the different causes and manifestations of leg ulceration and wound care, thus most GP’s tend not to interfere in the treatment, preferring to take advice from the experts in this field. So it makes sense that district nurses should be able to prescribe the most appropriate choice of dressing themselves. A good knowledge of wound healing mechanisms in relation to venous ulcers, in addition to a knowledge of treatment choices that reflect local policy, their suitability, contradictions and adverse reactions based on evidence not influence, ensured that Mr X received a dressing that proved successful in reducing the bacterial load, healing of the ulcer and comfort. The dressing did not cause any reaction or deterioration, therefore was safe and effective.
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Appendix 1
Critical Incident
Mr X was referred to the district nursing team by the practice nurse to assess a wound on his leg, which was not showing any signs of healing after six weeks of treatment. He had received the wound by accidentally colliding with a iron fire guard and this originally caused the injury, despite different wound care products and a course of antibiotics for a clinical infection, the wound did not improve. The practice nurse did not have the skills to perform a leg ulcer assessment including Doppler ultrasound, therefore referred Mr X to the team for advice and guidance on future care. There was no evidence of oedema in the limb, and the skin was showing signs of talangectasia around the ankle and brown staining to the gaiter area of the leg. The wound measured 3cm in length and 2.8cm in width, with approximately 0.3cm depth, and it had an irregular appearance with sloping edges.