Impact Of Chronic Venous Leg Ulcers On Health And Wound Healing Process

Physical Factors Affecting Wound Healing

Discuss about the Impact of Chronic Venous Leg Ulcers.

In the given case study, Mr. Bill Best stays alone as he is divorced and has two adult children who comes to see him once a month over dinner. As he stays alone and comes late from work, he is reluctant to cook at times and consume “fast foods”. As a result, he has put on weight resulting in a body mass of 120 kgs. He is leading a sedentary lifestyle as there is lack of physical exercise and extended periods of standing as his occupation demands. He smokes 20 cigarettes per day and has a past history of varicose veins. Six months ago, he bumped into equipment while moving things and that resulted in a small wound. Until recently, it has started to ooze pus with unpleasant odor, swelling and no healing. Despite of dressing, there is no healing and the condition has not improved.  

The leg ulcers are mostly caused by venous insufficiency. The initial assessment of the patient covers the medical history related to deep vein thrombosis or varicose vein treatment and the various physical and psychosocial factors. The various factors like nutrition, physical parameters and psychosocial factors associated with the physical health. The factors like stress, infection, age, nutrition, smoking and obesity affects the wound healing in the patient (O’Donnell et al., 2014). Bill Best physical factors like age, overweight condition, intake of “fast foods”, smoking and malnutrition affects the wound healing. He smokes 20 cigarettes a day, obese due to intake of “fast foods”, sedentary lifestyle, and old age greatly affects the wound healing process. The healing capacity is determined by the age-related changes in terms of platelet aggregation, delayed infiltration of macrophages, delay in angiogenesis and collagen deposition (Ashby et al., 2014). There is increase in pressure venous ulcers in obese patients, influenced by hypovascularity. The friction that is caused due to skin to kin contact in ulceration predisposes obese people to impaired wound healing (Nherera et al., 2016).

There is delay in wound healing due to smoking as there is increase in complications such as wound rupture, infection, wound necrosis, leakage and decrease in wound’s tensile strength. The carbon dioxide, nicotine and hydrogen cyanide that is emitted by smoke affects the wound healing process. Most importantly, nutrition is an important factor that greatly affects the wound healing process. The carbohydrate, energy, protein, vitamin, fat and mineral metabolism overall affects the healing process in terms of energy supply, capillary formation, collage synthesis and being the building blocks for tissue repair and wound healing (Norman et al., 2016).

Psychosocial Factors Affecting Wound Healing

The psychosocial factors also affect the wound healing process. The conditions like stress, depression and other behavioral factors also affect the healing process. Bill is worried that his ulcer will not heal and he is concerned that he will not be able to work in the future. In addition, he is divorced, stays alone and there is no one to take care of himself.  This also contributed to his wound healing as there is no one to take care of himself. Stress and anxiety has direct implication on the wound repair process as it promotes adoption of behaviors that damages health (Ylönen et al., 2014).

The TIME framework is an assessment and practical tool that is used to assess and manage patients with the wounds. It is a way to treat the whole patient and not just the wound. The TIME framework stands for Tissue Management, Infection and Inflammation control, Moisture imbalance and Wound edge advancement. It greatly identifies the barriers to wound healing and implement a plan of care to remove the barriers and promote efficient wound healing (Dolibog et al., 2014).

The tissue characteristics play an important role in the wound healing process. When the tissue is deficient or non-viable, the wound healing is delayed. It also focuses on infection, necrosis, slough and eschar also describes non-viable tissue (Green et al., 2014). In venous leg ulcers, the hypertension in the venous leg ulcer causes red blood cells leakage from the capillaries and its breakdown causes hyper pigmentation like tissue staining. There is yellow slough which is an adherent fibrous material from fibrin, proteins and fibrinogen, red granulation tissue and black necrotic tissue. There is moist, slough- yellow, fibrinous and loose tissue that is approximately 10%. Moreover, there is necrotic tissue that is thick, black and dead cells that are dehydrated approximately 50%. There is 40% granulated tissue that is healthy tissue, red in color indicating adequate flow of blood (Ousey, Rogers & Rippon, 2016).

The presence of infection in the wound causes pain and great discomfort for the patient. There is a presence of bacterial infection due to critical colonization to infection. The emphasis is given on bacterial burden, although host resistance plays an important role in fighting bacterial infection (Greatrex?White & Moxey, 2015). The behavioral factors like smoking and poor nutrition determine the host’s resistance to wound healing.  In the given case study, Bill’s wound has no signs of bacterial contamination or infection, though, there is minimal serous exudate. There is no biofilm formation and no rolling of the wound edges. There is no presence of redness or swelling in the surrounding skin. The assessment of the pain, odor and pyrexia needs to be assessed. The condition of the surrounding skin plays an important role in venous leg ulcers. The vulnerable skin is an important measure in assessing the condition of the surrounding skin as it can react with the excess exudate and cause excoriation, maceration irritant dermatitis.

Wound Assessment

The creation of moisture balance is an important parameter in the wound healing process. The exudate is produced in response of the body to tissue damage and the exudate amount produced greatly depends on the tissue’s pressure gradient. A normal wound healing would produce moisture to promote proliferation of cells and devitalized tissue removal. Over hydration or moisture imbalance may result in drying out of the wound or causes maceration. The exudate production is increased when there is dilation of blood vessels during the wound healing cycle. As there is minimal exudate in the wound, it will facilitate migration of cells and promotion of wound healing process (Powers et al., 2016). 

The migration of the epidermal margins of the wound across the bed of the wound, consideration is required for the review of the T, I, M phases. The epithelialization is the final stage of wound healing that involves division of the cells, migration and epidermal cells maturation from the margins of the wound across the open wound. The epidermis of the skin that surrounds the venous leg ulcers that is thicker than the normal skin that is highly keratinized. When the thickened, proliferative tissue is not removed from the wound, there is no epithelialization of the wound (Fletcher & CertEd, 2017). The surrounding skin is intact and healthy after the assessment of Best’s wound. The edges of the wound is not rolled or raised which promotes wound healing in Bill.

The potential issue that is related to the wound is the delay in the healing process is the pressure ulcers that mediate shear tearing or friction of the tissue surrounding the wound that causes obstruction of the blood.

The type of wound is the venous leg ulcer or varicose ulcers as the wound is due to improper functioning of the venous valves in the leg called the leg ulcers.

According to Royal District Nursing Service (RDNS), the nursing expertise is recognized by wound management. The nursing interventions include type of dressings that reflects the long term promotion of health strategies by focusing on the nutrition of the patient. The trained nurses should assess the pain management with efficient decision making in the management of the wound and promote healing. The effective leg ulcer management also includes clinical expertise that greatly requires proper education and training of the nurses in wound management (Sandy-Hodgetts et al., 2016).   

Wound product	1.      Type of product 2.      Mode of action	3.      Rationale
Sorbsan	1.      Calcium salt of alginic acid, used as loose rope packaging 2.      Absorbing action	to remove exudates in the wound
Iodosorb	1.      Iodine products, cadexomer dressing 2.      Broad spectrum antimicrobial action	Desloughing action
Biatain	1.      conformable polyurethane foam dressing  2.      absorption action	Provides extra adhesion for extra fragile skin
Mesorb	1.      absorbent dressing 2.      absorbs large amounts of exudate	It prevents contamination of wound from external environment and serves as a secondary absorbent
Aquacel Ag	1.      silver impregnated dressing 2.      antimicrobial in nature	Cover acute wounds from antimicrobial infection

In patient-centered approach, Bill’s physical and psychosocial elements to be addressed. For the ulcer healing, Bill’s nutritional needs in terms of calorie intake, interventions to weight loss and control of smoking would promote fast recovery and healing of the wound (Gillespie et al., 2015). Moreover, the venous leg ulcers deteriorate the quality of life in the patient, so proper support is required for Bill that promotes normal wound healing in him. As Bill is alone, he should be provided with proper care and support that would help in the proper healing of the wound. His psychosocial needs should also be assessed as he is stressed and anxious about his leg and is worried about his future ability to go to work.

Infection or Inflammation Control

As Bill is alone, he needs additional support from the general practitioner and the nutritionist in order to reduce his weight and look into his diet so that he does not intake fast foods. He should be provided with a caregiver who would take care of him and assess his wound healing process also. He should be under the supervision of a general practitioner who would assess his healing process from time to time. Proper administration of dressing, proper medication and diet, treatment for associated symptoms is also required for Bill (Whitlock et al., 2014).

References

Ashby, R. L., Gabe, R., Ali, S., Adderley, U., Bland, J. M., Cullum, N. A., … & Stubbs, N. C. (2014). Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised controlled trial. The Lancet, 383(9920), 871-879.

Dolibog, P., Franek, A., Taradaj, J., Dolibog, P., Blaszczak, E., Polak, A., … & Kolanko, M. (2014). A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci, 11(1), 34-43.

Fletcher, J., & CertEd, P. G. (2017). Best Practice-Choosing an appropriate antibacterial dressing. Caring, 6, 00.

Gillespie, B. M., Kang, E., Roberts, S., Lin, F., Morley, N., Finigan, T., … & Chaboyer, W. (2015). Reducing the risk of surgical site infection using a multidisciplinary approach: an integrative review. Journal of multidisciplinary healthcare, 8, 473.

Greatrex?White, S., & Moxey, H. (2015). Wound assessment tools and nurses’ needs: an evaluation study. International wound journal, 12(3), 293-301.

Green, J., Jester, R., McKinley, R., & Pooler, A. (2014). The impact of chronic venous leg ulcers: a systematic review. Journal of wound care, 23(12), 601-612.

Nherera, L. M., Woodmansey, E., Trueman, P., & Gibbons, G. W. (2016). Estimating the Clinical Outcomes and Cost Differences Between Standard Care With and Without Cadexomer Iodine in the Management of Chronic Venous Leg Ulcers Using a Markov Model. OSTOMY WOUND MANAGEMENT, 62(6), 26-40.

Norman, G., Westby, M. J., Stubbs, N., Dumville, J. C., & Cullum, N. (2016). A’test and treat’strategy for elevated wound protease activity for healing in venous leg ulcers. The Cochrane Library.

O’Donnell, T. F., Passman, M. A., Marston, W. A., Ennis, W. J., Dalsing, M., Kistner, R. L., … & Stoughton, J. (2014). Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg, 60(2 Suppl), 3S-59S.

Ousey, K., Rogers, A. A., & Rippon, M. (2016). Hydro-responsive wound dressings simplify TIME wound management framework. British Journal of Community Nursing.

Powers, J. G., Higham, C., Broussard, K., & Phillips, T. J. (2016). Wound healing and treating wounds: Chronic wound care and management. Journal of the American Academy of Dermatology, 74(4), 607-625.

Sandy-Hodgetts, K., Leslie, G. D., Lewin, G., Hendrie, D., & Carville, K. (2016). Surgical wound dehiscence in an Australian community nursing service: time and cost to healing. Journal of Wound Care, 25(7), 377-383.

Whitlock, E., Morcom, J., Spurling, G., Janamian, T., & Ryan, S. (2014). Wound care costs in general practice: a cross-sectional study. Australian family physician, 43(3), 143.

Ylönen, M., Stolt, M., Leino?Kilpi, H., & Suhonen, R. (2014). Nurses’ knowledge about venous leg ulcer care: a literature review. International nursing review, 61(2), 194-202.