Care Study

I recently completed a placement in the community, and decided it appropriate while there to focus my care study assignment on leg ulcers as I witness various chronic wounds being assessed and dressed and wished to acquire more knowledge on the subject. Chambers et al, (1996) suggests that chronic leg ulcers present a large problem to nursing today. My care study will focus on one particular lady who was suffering from a venous leg ulcer. For the purpose of this case study I will call that patient Miss. A, as a nurse has a legal, professional and ethical duty to protect all confidential information concerning patients by recognizing the primacy of the patient and practice in an ethical and legal framework (NMC, 2002). The patient gave informed consent and agreed to be involved with the care study after being given adequate information and given time to decide whether or not to agree to be written about. It was discussed and explained that the care study would involve the condition of the patient, assessments, prioritise the needs which arise and contribute and develop a plan of care. This would be done by assessment, planning, implementing and evaluating which is the constant cycle of the nursing process. (Alexander et al, 2000).

Miss A is an elderly lady who has lived with her sister for many years; she has limited mobility and relies on her sister for most of her care. Miss A is a very private woman and required encouragement from her sister for the nurse to attend to assess her wound which was thought to be a leg ulcer, she also felt generally unwell.

Leg ulcers cost the NHS approximately £400m per year and is estimated that at any one time 100,000 individuals will receive treatment for this condition in the community, which remains to be the most frequent encountered wound that community nurses are called upon to treat (Williams, 1996). A leg ulcer is defined as a loss of skin below the knee on the leg or foot which takes more than six weeks to heal, the occurrence of leg ulcers increases with age and is most common in women (Watson, 2002).

The underlying cause of a venous leg ulcer is poor venous return which can be recognized by oedema, skin pigmentation and are usually flat (Watson, 2003). It is important that this type of ulcer is assessed by the use of a Doppler test (Maylor, 2002). The nurse must check that the patient is complying with recommendations: elevation of the limb to prevent oedema and aid venous return, exercise and compression bandages/stockings. Chair bound patients are encouraged to strengthen the calf muscles by moving the feet up and down, this action also helps to pump the blood up the vein. On no account should the patient stand or dangle the limb for long periods without moving (David, 1986).

The management of leg ulcers is divided into three 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 sole responsibility for deciding which type of ulcer is present and what dressing to use (Pudner, 1997). Primary nursing care is when the nurse has total responsibility for the planning, delivery and evaluation of care for the duration of the patients care (Pearson, 1988).

The District Nurses I was working with used a care pathway which had been modified for community use; care pathways are holistic multidisciplinary plans which predict the course of events in the treatment of patient's problems. These events must be specified on a timescale, and all incidents, actions and interventions must be identified (Reinhart 1995). The Roper Logan and Tierney's Activities of living model of nursing was used as a basis for her assessment of the patient. This can be viewed as the first stage of the Nursing Process; assessment, planning, implementing and evaluating. This assessment sheet outlines the client's actual and potential problems with regard to daily activities; 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 effectively. (Gilling, 1996) However all information documented is confidential and nurses are accountable for any entries made by them (NMC, 2002) Documentation is often targeted by nurses because of the increasing amount of paperwork involved, which nurses feel is limiting the amount of time a nurse can spend with each patient (Brindle 1998). However nurses must always bear in mind the reasoning for this as litigation with regard to health care is not uncommon (McHale 1998). Any nursing document can become a legal document, if requested by a court of law therefore it is essential that medical staff follow legislation and good record keeping (Young, 1995). The NMC (2002) has a booklet entitled 'Guidelines for records and record keeping,' designed to guide nurses in their documentation. The NMC (2002) also has booklets on professional code of conduct highlighting the importance of responsibility and accountability. This gives nurses guidelines ensuring they understand the implications of their actions and working within their own limitations. Therefore whatever intervention a nurse is using she must be able to justify the rationale for its use, have evidence based knowledge about intervention and be able to react in a professional manner if adverse effects occur.
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Miss As initial assessment showed that she required support for her medical condition (leg ulcer), emotional support and encouragement of independence. It was also established at this point that Miss A had some years ago been admitted to hospital after suffering from a Myocardial Infarction, and continued to suffer from angina. Although this was not a priority at this point as her angina was stable I felt it appropriate to gain knowledge on this subject.

More than 1.4 million people suffer from angina and 300,000 have heart attacks each year, which makes Coronary heart disease (CHD) one ...

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