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 reducing venous hypertension. Compression must be applied by skilled practitioners. Incorrectly applied, compression can cause skin and leg damage, however more commonly, causes pain & discomfort. It should be used in caution in cardiac or renal disease to avoid cardiac overload Todd (2011).
Bandaging systems and hosiery deliver varying levels of compression and according to Todd (2011) hosiery is most effective in prevention of recurrence. The most common bandaging systems for treating active ulcers are described as short-stretch and multicomponent. Before deciding which compression is suitable, practitioners should consider dimensions of the limb, application frequency, patient’s lifestyle, choice and likely concordance (Anderson & Fernandez, 2008). With short-stretch suitable for more mobile individuals, the multicomponent 4-layer system, most commonly used in the UK was decided suitable for Agnes due to its success in the past. O’Meara et al. (2009) found that multicomponent systems are currently the most effective treatment for CVLU with a simple primary dressing.
Under Agnes’ compression, a non-adherent dressing was used as recommended in SIGN (2010). Hess (2011) suggests a moist wound environment as optimal however wound healing maintains a balance between over-hydration and too dry. Whilst Cutting (2010) recommends routine washing with normal tap water is not required at every change, maintenance debridement of slough & necrotic tissue should be removed if observed to stimulate the wound to promote healing (Tang et al., 2012). This was observed on visits when required as well as moisturising the surrounding skin with emollient to protect skin integrity (Royal College of Nursing, RCN, 2006).
At present, Agnes continues to receive weekly visits where evaluation of the wound is performed and leg redressed with a goal for complete healing within twelve weeks. Focus continues to be around wound healing with the care plan aimed at providing optimal conditions for healing & management of complications (Hess, 2011). Anderson (2012) suggests changing the focus from wound healing to priorities of care aimed at relieving symptoms the patient finds most debilitating. Interventions to educate & advise health promotion should be considered as this increases patient satisfaction & improves outcomes.
There was no assessment or management of psychological well-being or quality of life indicators as is mentioned by Palfreyman et al. (2010). Briggs and Flemming (2007) concur with Anderson (2012) that the social & psychological impacts are commonly pushed aside by nurses, making physical healing the priority. They suggest a change is required for both patients and professionals to see this condition as chronic, with the emphasis shifting from traditional nursing care to empowering individuals to self-manage their own long term condition. Better communication, allowing patients to be part of their own care and collaboration with other multidisciplinary teams (MDT) will go a long way in meeting the aims of the Healthcare Quality Strategy for NHS Scotland (Scottish Government, SG,2010) to deliver safe, effective, patient-centred care to every individual requiring healthcare in Scotland.
The Quality Strategy drives the implementation of the National Action Plan: Improving the Health & Wellbeing of People with Long Term Conditions in Scotland (SG, 2009). It refers to long term conditions (LTC) as those lasting over a year. With over 2 million individuals living with LTC in Scotland, due to an aging population the amount of people living with LTC will increase by 23% over the next 25 years increasing further demand on NHS resources. Although CVLU can heal and are not mentioned in the list of LTC (SG, 2009), the list is not definitive. The underlying cause is commonly a chronic condition, with palliative interventions based on managing the continuous cycle of skin healing and breakdown over decades.
The LTC Action plan aims to empower & support individuals to self-manage their condition which means a shift in roles where the professional no longer dictates care. Throughout visits with Agnes, no patient education was observed with the nurse suggesting Agnes lacked the capacity to self-manage. Van Hecke (2011) claims that CVLU sufferers in the community receive less than adequate education about their condition. RCN (2006), make patient recommendations such as leg elevation, weight-loss, exercise which have been proven beneficial in the treatment of CVLU. Practitioners also must consider alternative solutions in cases of non-healing ulcers such as referral to MDT where required. With reduced mobility, such as in osteoarthritis, Brown (2012) implies collaboration with physiotherapists & occupational therapists would be beneficial to suggest safe techniques to enhance physical capacity, to improve calf muscle pump function and ankle movement or elevation of feet to reduce oedema to enable individual’s capacity for self-management.
Self-management, according to Brown (2010) is defined as increased knowledge of one’s condition, coping strategies, concordance & management of symptoms. For the patient, it may involve managing their condition, maintaining normal daily routines & management of psychological impacts. Some of the earliest trials in self-management were done with arthritis sufferers of various ages (Marks et al., 2005). Through various interventions including support for individual self-management achievements, social persuasion, reinterpretation of symptoms, action-planning & feedback, mastery of new skills & problem-solving strategies, they reported a reduction in physical symptoms & increased psychological wellbeing. Nicholson-Banks (2009) discusses The Expert Patient Program which is a self-management course currently running in the UK. With similar interventions to earlier trials including building self-efficacy, similar positive benefits are being reported. Lorig and Holman (2003) describe self-efficacy, the confidence in one’s self to fulfil behaviours to reach desired goals, as the most essential component in behaviour change.
Marks et al. (2005) claim self-efficacy is linked to past experience and predicts future behaviour, suggesting individuals with low self-efficacy less likely to engage in self-management behaviours. As it’s modifiable and impacts wellbeing, motivation & concordance, there is room for interventions to enhance self-management in chronic patients. Before embarking on patient education, professionals require an understanding of health-related behaviour. Using a health education model provides a framework to begin (Marks et al., 2005).
Crumley (2011) describes Rosenstock’s Health Belief model as a patient perception model. Using this model could challenge some of Agnes’ barriers to self-management, examining individual’s perceptions & severity of their condition. Agnes witnessed her own mothers suffering and believes nothing can help. Although she suffers reduced mobility, she believes it’s not life threatening so doesn’t take it seriously. The model also focuses on the individual’s need to believe a positive behaviour will reach a desired goal and builds self-efficacy. Individual barriers to change tend to be the biggest indicator of success. If Agnes feels the effort is not worth the benefit, success will be limited. To overcome these barriers, identifying what motivates Agnes, as described as internal or external cues to action must be achieved. However motivating the patient is not enough.
Empowered practitioners, suggests Drinkwater (2012) are required for this cultural transformation, claiming insufficient support from qualified staff in promoting the values of self-management. Education programmes to support staff in enabling self-management are needed. Whilst aims to train staff at earlier stages in the hope of it filtering down continue, it’s apparent that this will take time so education for current practitioners is required. Meanwhile, community nurses are best placed to commence support individuals in the community, according to Wrixon (2010) as they are already engaging with people in their own environment. By spending time educating and promoting the benefits of self-management, it may save years in the long run.
Yarwood-Ross and Haigh (2012), suggest that if more patients were provided with the right information they would take a more active role in managing their condition. Ward-Smith (2012) argues that information is not enough, stating that Health Literacy, (HL) must also be addressed. HL is described as the level at which patients have the ability to acquire, process & comprehend health information and services required to make relevant health choices.
In England, 1 in 3 adults over the age of 65 had difficulty comprehending basic health material, according to Bostock and Steptoe (2012). They found low HL is linked to higher mortality rates, with individuals doubling the risk of dying within 5 years, compared to those without HL limitations. As individuals are living longer and expected to manage their own conditions, better communication tailored to the individual’s needs and information delivered in different formats must be considered to provide individuals with the information & skills required to be true partners in their own care.
This essay examined the nursing care of one lady suffering from CVLU in the community. Following the nursing process from assessment through to evaluation, application of theory to practice was observed in line with national guidelines and clinically, care was delivered safely and was evidence-based. However in light of new Government policy promoting patient engagement and self-management of LTC, the care was not patient-centred, didn’t consider psychological needs and made no attempt of health promotion. If patients are dying earlier through a lack of comprehension of basic health advice, nurses have a duty of care to provide patient education, tailored to individual understanding to enable patients to be shared partners in their own care. Going forward, patient education should be considered every bit as important as choosing the correct dressing.
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