Management of leg ulcer
There are no national competencies or standards for leg ulcer care, although the RCN leg ulcer guidelines (RCN 2006) and the SIGN Guideline 120: management of chronic venous leg ulcers (SIGN 2010) serves as a framework for the components of leg ulcer care. It is also imperative to use the nursing process which is assessment, planning, implement and evaluating care (Alexander et al 2000). It is essential that chronic venous leg ulcer is managed effectively as the consequences of mis management would be detrimental to the patient and cost the NHS more, in the United Kingdom venous leg ulceration costs the NHS 1.3% of the Health care budget including nursing hours in the community (Palfreyman et al 2007) and will be set to cost more to the growth of the ageing population (Van Hecke et al 2008).
Assessment
The management of leg ulcers is divided into 3 stages assessment, treatment and prevention, the most important being assessment, as it is a vital first step in treating all types of leg ulcers, as the district nurse is the primary nurse and has the responsibility for deciding on which ulcer is present and what treatment to use (Pudner 1997).
The nurse must have the knowledge and skills to identify a venous leg ulcer, and it is important that nurses look for the underlying cause of an ulcer (Dowsett 2007). The Royal College of Nursing suggests that professionals who are fully trained in leg ulcer management should only be able to identify an underlying cause as a wrong diagnosis could be given. If a diagnosis of an arterial leg ulcer was indicated instead of a venous leg ulcer, this could cause complications for the patient and the wound (RCN 2010).
The Roper Logan and Tierney’s activities of living is used as a basis for Joan’s assessment, this assessment sheet outlines the patients actual and potential problems with regard to jeans daily activities (Roper et al 2000) the assessment is also about collecting data and communicating with the patient. It is widely used as it is looked upon as a holistic model and suggested that it is not merely a checklist but a guide to enable a nurse to care for a patients needs (Alexander et al 2000).
Using this assessment determines that Joan’s mobility is not what it used to be and that she does not do any exercise, Joan also declared that she has socialised less since developing the ulcer as she is embarrassed about the wound. This showed that she needed emotional support and encouragement of independence. It was also established that Joan has had varicose vein surgery 20 years ago and has a long history of ankle swelling.
By also using the NATVNS assessment chart for wound management (Appendix) 1, which is used by the tissue viability nurses (Tissue Viability 2009), this determined that she had poor joint mobility in her left ankle, she suffers from oedema, which is a condition of abnormal large fluid volume in the circulatory system or in the tissues between the body’s cells (NHS 2010). Her leg ulcer was shallow with irregular edges and measured at 15cm x 10cm, there was a considerable amount of exudates although this was clean. There was also a little brown staining to the surrounding skin which suggested that hyper pigmentation was present, this condition is caused by an increase of melanin and is a symptom of a venous leg ulcer (RCN 2006).
Investigations
The next step in the assessment and treatment is to carry out a Doppler ultrasound. SIGN guideline suggest that all patients with a chronic venous leg ulcer should have an ankle brachial pressure index (ABPI) carried out prior to any treatment (SIGN 2010). The Doppler ultrasound uses sound waves, the hand held probe reflects sound waves off the moving red blood cells; the reflected waves are picked up by the probe and create an audible sound. The signal given off represents the blood flow through the vessel. The Doppler ultrasound measures the ankle and brachial pressure indices (ABPI’s). If used correctly the Doppler ultrasound can be an essential part in patient assessment (Morrison and Moffat 1994) and to help to ensure detection of arterial insufficiency (RCN 2006). To calculate the ABPI for each leg the highest ankle systolic pressure of each leg is divided by the higher of the two brachial pressures, any reduction in the ankle reading indicates a reduced flow (Moffat and Harper 1997). The SIGN guideline suggests that all patients with a leg ulcer will have a Doppler measurement carried out by a trained professional (SIGN 2010). The SIGN guidelines also advise that a patient with an ABPI of <0.8 should be assumed to have arterial disease and an ABPI of >0.8 should be classed as venous insufficiency (SIGN 2010). The ABPI is essential to rule out arterial insufficiency in the ulcer (RCN 2006).
It is also recommended that blood pressure be taken to monitor cardiovascular disease, as this is associated with leg ulcer (RCN 2006, SIGN 2010). It is also imperative that a urinalysis is also undertaken to detect any undiagnosed diabetes and weight should also be taken on assessment as this is used as a baseline, should the client be overweight (SIGN 2010). Certain blood tests may also be done to rule out conditions such as anemia, diabetes, kidney problems and rheumatoid arthritis which may cause or aggravate certain types of skin ulcer.
Treatments
Ulcers are costly, debilitating and painful (Tissue Viability Online 2010: RCN 2006), it is important that an effective assessment is carried to plan effective interventions to remove or reduce the risk of ulcers. The grading is imperative as it establishes the extent of damage and therefore assists the correct choice of treatment (Tissue Viability Online 2010).
Clinically the most effective way of resolving these conditions is admittance to hospital for continual leg elevation (Heinen et al 2003). Palfreyman et al (2004) suggests that leg elevation in hospital enhances healing. This would appear to be the preferred option for Jean. However the article goes on to discuss the fact that this is no longer an option as it is not deemed to be cost effective, hence the need to push this out to community nursing services. A recent consultation conducted argued that most patients would prefer not to go into hospital; they also suggest that people recover more quickly when they are in familiar surroundings (NHS Wales 2010). At a time when the NHS is to find savings of up to £20bn by 2014 (BBC 2010) Joan’s condition must be managed in a most cost effective way.
Compression bandages encourages and enhances the blood flow in the veins, it acts as the calf muscle pump by providing a skin in which the muscle can expand, which increases venous return (Moffat and Harper 1997). There are many types of compression therapy some of the most used are the multi layer bandage system, which is a 3 layer or 4 layer compression bandage and a short stretch bandage, placed over a dressing. The choice of bandaging also is based on the patient’s ankle circumference (O’Meara et al 2009).
Short stretch compression bandages are more widely used in Europe and Australasia (SIGN 2010). It consists of an initial layer of orthopedic wool and then a further one or two layers of short stretch bandage. They apply high pressure only when the patient is active (Moffat and Harper 1997, SIGN 2010). The Royal College of Nursing suggest that this should only be used if patients are ambulate (RCN 2006). The four layer bandaging is most commonly used in the United Kingdom. These consist of an initial layer of orthopaedic wool, a crepe bandage to smooth the wool layer, an elastic bandage and an elastic cohesive bandage as the outer layer. The four layer bandage can sustain high pressure for a considerable time this allows for a weekly change of dressings (Enoch et al 2006). A trial from St Thomas' Hospital, London compared 3 layer paste bandages with the conventional 4 layer system (Meyer et al 2003). In this study the 3 layer system was found to be more effective at healing than the 4 layer system. However a systematic review was carried out by O’Meara et al (2009) who found that patients treated with a 4 layer bandage experienced faster healing than those treated with short stretch bandage.
It needs to be noted however that compression bandages can leads to skin necrosis. The combination of compression bandages used to achieve compression of 40 mm Hg at the ankle will depend on ankle circumference according to Laplace's law (Mears and Moffat 2002). A combination of bandages achieving ideal pressures in the average ankle will produce ineffective pressures in a large oedematous limb and dangerously high pressures risking skin necrosis over bony high points in small or narrow ankles. This is why it is important that Compression therapy should always be applied by a healthcare professional trained in venous ulcer management (RCN 2006, SIGN 2010). A survey on community nursing conducted by the RCN in 2010 showed that a quarter of nurses had not received leg ulcer training in the past 3 years, and that this is a great concern as this is half of community nurses caseload (RCN 2010). This information was also agreed by a survey conducted by Van Hecke et al (2008) and recommendations were made that more training and funding needed to be made.
If compression bandages were not seen to be cost effective the use of drugs to treat the ulcers could be considered. Pentoxifylline is a drug that improves blood flow through the blood vessels. It is used to treat problems with blood circulation in the arms and legs (Colleridge-Smith 2009). There are some side effects of the use of this drug: loss of appetite, nausea and constipation occur at first, as patients adjust to this medication, however evidence suggests that healing rates are improved (Enoch et al 2006).
There are many homeopathic solutions that could be used to promote the healing of ulcers one of these Manuka honey (Conforth 2009) which has been used in patient trials and the results showed that there was a positive effect; however SIGN Guidelines do not recommended honey dressings in the routine treatment of patients with venous leg ulcers as the evidence was inconclusive on patient trials (SIGN 2010; Jull et al 2008).
To combat the pain associated with leg ulcers EMLA cream could be used. EMLA (Eutectic mixture of Local Anaesthetic) is a local anaesthetic for topical application, developed to anaesthetise intact skin. EMLA is used to prevent pain associated with needle insertion and it can also be used to relieve and prevent pain associated with the cleansing and treatment of leg ulcers (SIGN 2010).
As Joan has a considerable amount of exudate in her wound, it is important that the correct dressing is applied (White and Cutting 2006). Exudate is essential to healing chronic wounds (White 2001) it is a fluid produced by the tissues surrounding the wound and provides the moisture to heal the wound. It can prove problematic in chronic leg ulcers as it can saturate the wound and surrounding areas which can cause maceration, which could enlarge the wound (Jones et al 2001). A cadexomer iodine dressing was applied to jeans ulcer, it is an antiseptic, which kills bacteria and is effective in treating chronic venous leg ulcers with moderate amounts of exudate (Enoch et al 2006; SIGN 2010).
Joan’s ABPI is greater than 0.8, so she is suitable for compression bandaging (RCN 2006; (SIGN 2010). As Joan is not very active, the 4 layer compression bandage was used in conjunction with the iodine dressing this is to reduce the exudate and help improve the healing time. The nurse will assess the ulcer in 24-48 hours to ensure there are no complications (SIGN 2006). The dressing should be changed every 4 days (RCN 2006), and bandaging re-applied. The nurse will constantly review and assess the wound and document the changes of the wound (SIGN 2010). A re assessment of the wound will be made in 3 months, and if not healed alterative treatments should be considered.
Prevention
As stated before, it is noted that Joan avoids exercise, this is compounding her ulcers. To manage this situation, when the present ulcers have healed I would recommend that Jean joins an aqua aerobics class at her local pool. The exercise will help the mechanics of her veins, heart and circulatory system. There are many activities like this offered to women of Joan’s age, so Joan’s modesty should not be an issue. Alternatively, to get this process started Jean could be referred to the physiotherapy department for rehabilitation. Other preventative measures are to use below the knee compression stockings when the ulcer has healed (SIGN 2006) again this should be reviewed three monthly. Keeping mobile and evaluating legs when resting should be encouraged (Leg Ulcer Forum 2010). In certain circumstances the possibility of surgical treatment should be considered. (RCN 2006; SIGN 2010). The prevalence rates of re occurrence in chronic leg ulcers are very high unless prevention is maintained (Nelzen et al 1994).
Conclusion
There are many different aspects included in the management of a patient with a leg ulcer, all of which are vital in order to plan a sufficient recovery. Chronic leg ulcers disrupt patient’s lives and restrict their social lives, which could lead to social isolation and depression. Nurses should better understand the impact of symptoms such as odour, oedema and exudate leakage on patient’s mental health, physical health and healing.
The nurse must not assume that all patients with a venous leg ulcer, can receive the same treatment, and the patient should receive holistic, individualised care. It is also important that the nurse works in multi-disciplinary team as the nurse may wish to contact the vascular surgeon for severe vascular ulcers, the physiotherapist for advice on mobility, the dietician to assess nutritional deficit, and other nursing colleagues. Once the patient and their wound have been assessed, a choice of dressing will have to be made. If the wound has been accurately assessed, then the nurse can decide which treatment is most suitable to their patient. The dressing choice must be documented in the care-plan and be re-assessed at three monthly intervals until healing has been achieved, it is also suggested that data is collaged to help gather evidence of treatment, diagnosis and other significant information to promote healing and prevention in others with venous leg ulcer. It is also imperative that prevention is the main result and the nurse should offer health promotion to prevent re occurrence.
In Joan’s case an individual approach was taken and appropriate guidelines were adhered to, this gave Joan an accurate assessment, the appropriate investigations to ensure Joan’s ulcer is treated and managed in an effective way.
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