Chronic venous leg ulcers

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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.

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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