Management Of Venous Leg Ulcer

Discussion

Write an essay on “Management of Venous Leg Ulcer”.
 

A wound is an interference normal skin architecture and function. According to Bryant & Nix (2015), acute wounds are expected to heal under normal stages of wound healing while chronic wounds are physiologically impaired. To ensure fast and proper healing of wounds, the wound should be clear of infections, well vascularised, lacks devitalized tissues and is kept moist. There are many factors that delay healing of wounds and include diabetes, some drugs, nutritional problem, infections and tissue necrosis (Demidova-Rice, Hamblin, & Herman, 2012). The nurse should properly assess the patient with a wound in order to administer appropriate treatment. The patient, family, and the multidisciplinary team have a big role in the management of the patient wound.

Appropriate assessment of the leg ulcer is the initial step towards the healing of the patient. Myers, 2012 claims that Proper assessment of the patient ulcer is paramount in determining the exact etiology for the ulcer and exclude arterial disease in which compression is dangerous. Visual assessment of the ulcer alone is regarded as unsatisfactory, instead, ulcer diagnosis and skilled assessment supported by guidelines are required (Myers, 2012). The assessment of the venous leg ulcer takes three main steps.

The records of the patient should be taken which includes the gender, age, and occupation. The medical history of the patient is determined and followed by physical examination (Di & Clark, 2016). According to Starkey & Brown (2015), physical examination involves measurement of the patient blood glucose levels, blood pressure, urinalysis, and weight and ankle brachial pressure. These measurements should be taken regardless of whether it is a recurrent or first leg ulcer and continued thereafter. Regmi (2012) argues that, the past medical history of the patient include: Allergies to dressing or medication, the degree of mobility as state of mobility can affect efficiency of calf muscle pump, smoking history as it delays wound healing and is a risk for arterial disease, social support as lack of social support and depression prolong the healing of the wound.

medical history should also include a record of pain, as it can help to determine the ulcer pathology as symptoms that suggest the disease of the artery includes night pain which is lessened by hanging the leg downward from the bed, pain in the buttock and thigh while walking and reduced at rest, pain, when the limb affected is elevated, pain in the foot or limb when limb is resting (Regmi, 2012). The venous disease has symptoms of pain that include pain that improves on leg elevation but increases when the limb is dependent and night cramps that are relieved by walking. Thompson et al, 2014 asserts that obesity impairs venous return and reduces mobility while malnourishment can delay healing due to lack of vital nutrient; therefore it is important to determine patient’s nutritional status. The current medication of the patient should be noted as some medication delay healing including cytotoxic drugs and steroids. 

Assessment of The Patient

The ankle brachial pressure index (ABPI) should be measured by Doppler ultrasound to detect arterial insufficiency as the arterial disease result when ABPI

The ulcer should be assessed for size as small ulcer takes less time to heal compared to a large ulcer. The ulcer depth should also be determined by describing the tissue that is present as it will determine how the wound is progressing and the choice of dressing. The exudates color and quantity should also be recorded as can determine any sign of clinical infection (Ylönen, Stolt, Leino-Kilpi, & Suhonen, 2014). The location of the ulcer should be documented as can indicate the underlying cause. According to Ylönen, Stolt, Leino-Kilpi, & Suhonen (2014), the documentation of the patient ulcer  should also include the  edge of the ulcer appearance as it can indicate a sign of infection .The edge that is epithelializing  signifies that healing  is in the process.

The planning for nursing care for venous leg should be determined by the treatment goals which are gained from the overall assessment findings which include the family and client willingness to follow the care plan, the risk factor and patient concerns for wound heal ability, whether the wound is venous, arterial or mixed, peripheral circulation effectiveness and availability of supplies and resources (Regmi, 2012). Venous leg heals within three to four months when appropriate techniques are used in treatment.

The implementation of care involves advising the patient on what to do so that the ulcer heals more quickly and nurse treating the leg ulcer and the associated symptoms of the leg ulcer. The following are the techniques in caring and treating the patient with venous legs ulcer

The first step towards the treatment of the leg ulcer is removing any dead tissue and debris from the ulcer and then applying a dressing. The ulcer should be dressed in a nonsticky dress and should be changed on a weekly basis (O’Donnel et al, 2015).

Compression Therapy

A compression bandage should be applied on the leg to squeeze in order to reduce swelling and enhance vein circulation of blood in the leg (Mosti, 2014). (Harding, Vanscheidt, Partsch, Caprini, & Comerota (2014) explain that, the compression bandage facilitate blood to flow to the heart and faster healing of the wound. Different types of elastic stockings and bandage have been designed for the treatment of the leg ulcer.

Systemic and Topical Therapy

Antibiotics should be administered to a patient with leg ulcer to prevent systemic infections as a result of the ulcer. Pain killers should also be given to the patient to relieve pain. Most of the people usually develop scaly and itchy skin due to leg ulcer. According to Wang, Armstrong & Armstrong (2013), Corticosteroid cream and emollient are suitable for driving away the itchiness of the scaly skin and inflammation but when corticosteroids drugs are taken orally they can delay healing of the wound. 

Skin grafting involves shaving skin from one site of the body and transferring it another site. Lazarus et al (2015) explains that, skin grafts aid in healing the ulcer as it create new blood supply

Assessment of The Leg

Varicose Vein Surgery

Myers (2012) argues that the surgery of the varicose vein can also be used in the management and treatment of venous leg ulcer.

Role of the Client and Family in Management of Venous Leg Ulcer

The patient and the family have a significant role to play for the patient to recover from the venous leg condition.  According to Myers (2012), the role of the patient and the family in management of the venous leg includes:

Washing Hands

The client and the family members should always wash hands before touching the wound. The hands should be washed using alcohol based techniques or soap and water. The washing preventing transmitting the microorganism to the wound and hence allow healing kept clean- the patient and the family have the obligation of ensuring that the dressing is keeping Dressing Clean

 The dressing is kept clean prevent entry of microorganism onto the wound. The dressing protects injury on the wound and keeps out germs.

Taking Care

The wound should be taken care of injury and trauma. The wound heals more rapidly when there is no trauma or further injuries.

 Balanced Diet

The family should provide the patient with a balanced diet as the healing of the wound requires nutrients. The body of a patient demands more nutrients than a healthy person for it to heal the wound.

Quit Smoking

The patient should quit smoking as smoking delays the healing of the wound. The nurse has a role in advising the patient on the need to quit smoking for wound to heal more quickly

Exercise

Exercise has been shown to increase the rate of healing of a wound as calf muscle pump function is increased through exercise

Social Support

The family has the role of providing social support to the patient with a venous leg to improve the healing process. Depression due to lack of social support has been shown to delay the healing process. 

The evaluation of the leg is of great importance to determine if the ulcer is healing. Active management process should be put into place. The evaluation should be carried out at regular basis to monitor the progress of the ulcer. The evaluation is to determine whether the ulcer is healing, the presence of new comorbidities, need for ulcer biopsy, confirmation of etiology of the ulcer and compliance of the patient to treatment (Lazarus et al , 2014). The nurse should take an appropriate action after evaluation.

Factors That May Impact Proposed Nursing Care and Therapeutic Wound Management.

Patient Preference

The nurse has the role in informing the patient of the nursing care and therapy that he/she is to administer to him. The nurse should present all the options for the patient and the patient chooses the treatment that suits him/her best (Regmi, 2012). The Patient choice of treatment will determine the nursing care and the therapy that the nurse provides to the patient.

Availability of Resources and Cost

The nurse may change the proposed nursing care and therapeutic wound management if the hospital does not have enough resources for treatment (Regmi, 2012).The hospital may lack the equipment necessary to undertake the treatment of the patient and hence the nurse will be forced to take another option of treatment. The financial status of the patient can also influence the choice of therapy and nursing care that the nurse would use in wound management.

Assessment of The Ulcer

Patient Medical History

The patient medical history will influence the choice of treatment that the nurse provides to the patient (Di & Clark, 2016). The patient who is allergic to dressing and some drugs will make the nurse administer other options of treatment. The nurse may decide to offer nutrition advice to the patient who is malnourished and give him/her nutrition supplement. The patients who have a history of smoking will be advised to stop smoking to enhance the healing of the wound.

The Type of Wound

The assessment result will be able to determine the type of wound that the patient is having which will determine the therapy and nursing care that he/she will be provided by the nurse (Augustin et al, 2015).The different types of wounds are venous, arterial or mixed, each type requires a specific care and management.

Patient Current Medication

The patient current medication can influence the nurse choice of medication.  According to Wang, Armstrong & Armstrong (2013), the anti-inflammatory drugs like steroids and the cytotoxic drugs can cause delayed healing of wounds. The nurse should, therefore, find alternative treatment for inflammation other than using steroids if the patient has a wound.

The role of Multidisciplinary Team in Improving the Care of the Patient with Venous Leg Ulcer.

The multidisciplinary team work together to treat and assess the patient so that the patient can reap enough benefits from the treatment (Kim, Evans,Steinberg, Pollard,  & Attinger, 2013). The multidisciplinary team facilitate referral of the patient to a different specialist and hence promotes positive outcomes. According to Quinlivan, Jones,  Causby & Brown (2014), the multidisciplinary team in wound management includes:

Client- the client is part of the multidisciplinary team in the management of venous leg ulcer. The patient should ensure that he adheres to the therapy and embrace practices that promote the healing of would like quitting smoking, exercise, and intake of a balanced diet. The multidisciplinary team should hear the patient wishes and guide him/her accordingly.

Physician- The physician has a role in the management of the patient by monitoring his/ her health status

Nurse- the nurse has a role in applying compression bandage and to optimize the wound care to the patient

Enterostomal Therapist Nurse -he/she has the role of assessing the patient, plan for treatment and implementing the treatment plan.

Dietician-The dietician will help reduce the weight of the patient if they are obese and optimize the nutritional intake to the malnourished.

Physiotherapists-To monitors the lower leg exercises and teach the patient on how to exercise his/her feet.

Infection Disease Specialist-has the role of assessing and monitoring the identified disease infection.

Compression Stocking Specialist- He/she teaches the client on how he/she is supposed to apply the stockings. He/she chooses the permanent stocking fittings for the patient once healing has occurred. 

Conclusion

The management of the wound should first involve assessment of the patient. The proper assessment of the patient with venous leg ulcer involves three main procedures which include patient assessment, leg assessment, and ulcer assessment. The appropriate assessment gives the guideline to the nurse on the appropriate management to administer to the patient. The patient, family members, and the multidisciplinary team should coordinate to fasten the healing of the venous leg ulcer. 

References

Augustin, M., Blome, C., Goepel, L., Protz, K., Baade, K., Heyer, K., … & Herberger, K. (2015). Patient-reported outcomes as diagnostic tools and clues in chronic wounds: Considerations for practice. Wound Medicine, 8, 6-14.

Bryant, R., & Nix, D. (2015). Acute and chronic wounds. Elsevier Health Sciences.

Demidova-Rice, T. N., Hamblin, M. R., & Herman, I. M. (2012). Acute and impaired wound healing: pathophysiology and current methods for drug delivery, part 1: normal and chronic wounds: biology, causes, and approaches to care. Advances in skin & wound care, 25(7), 304

Di, W. & Clark, R. (2016). Comparison of guidelines for venous leg ulcer diagnosis and management.

Harding, K., Vanscheidt, W., Partsch, H., Caprini, J., & Comerota, A. (2014). Adaptive compression therapy for venous leg ulcers: a clinically effective, patient-centred approach. International Wound Journal, 13(3), 317-325. 

Kim, P. J., Evans, K. K., Steinberg, J. S., Pollard, M. E., & Attinger, C. E. (2013). Critical elements to building an effective wound care center. Journal of vascular surgery, 57(6), 1703-1709.

Lazarus, G., Valle, M. F., Malas, M., Qazi, U., Maruthur, N. M., Doggett, D., … & Zenilman, J. (2014). Chronic venous leg ulcer treatment: future research needs. Wound repair and regeneration, 22(1), 34-42.

Myers, B. (2012). Wound management. Upper Saddle River, N.J.: Pearson.

Mosti, G. (2014). Compression in leg ulcer treatment: inelastic compression. Phlebology: The Journal Of Venous Disease, 29(1 Suppl), 146-152. 

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. Journal of Vascular Surgery, 60(2), 3S-59S.

Quinlivan, E., Jones, S., Causby, R., & Brown, D. (2014). Reduction of amputation rates in multidisciplinary foot clinics-a systematic review. Wound Practice & Research: Journal of the Australian Wound Management Association, 22(3), 155.

Regmi, S. (2012). Best practice in the management of venous leg ulcers. Nursing Standard, 26(32), 56-66.

Starkey, C., & Brown, S. D. (2015). Examination of orthopedic & athletic injuries. FA Davis.s

Thompson, K. L., Leu, M. G., Drummond, K. L., Popalisky, J., Spencer, S. M., & Lenssen, P. M. (2014). Nutrition Interventions to Optimize Pediatric Wound Healing An Evidence-Based Clinical Pathway. Nutrition in Clinical Practice, 29(4), 473-482.

Wang, A. S., Armstrong, E. J., & Armstrong, A. W. (2013). Corticosteroids and wound healing: clinical considerations in the perioperative period. The American Journal of Surgery, 206(3), 410-417.