Overview
Ulcers of the lower leg are common incapacitating wounds amongst the elderly in the United States. For women over 65 years, there is relatively 1.43 percent. These ulcers can be broadly split into two main types with the ones originating from poor arterial perfusion occurring less times and the ones taking place due to venous problems making relatively 70 percent of the presented cases. The etiology of the ulcer is identified through measurement of the ankle/brachial pressure index (ABPI). The ulcers that have an ABPI of more than 0.8, are perceived to be appropriate to be treated with compression treatment. The compression therapy is what is widely known to be the standard treatment for venous leg ulcer. This paper gives a case study of Bridie, a 82 year old with a venous ulcer on her left foot over the medial malleolus. The ulcer indicates uneven edges and the it has a significant amount of red granulation tissue.
Wound Assessment for Bridie
In the management of the venous ulcer, determination of the etiology is a critical step (McIlwaine 2008). The distinguishing features in the clinical presentations and physical examination findings can assist in the differentiation of venous ulcers from other lower edge ulcers. The venous ulcer assessment is generally clinical; nonetheless, tests like plethysmography, color duplex ultrasonography, ankle-brachial index and venography.
Bridie O’Shea is 82 years has a venous ulcer on her left foot over the medial malleolus. The edges of the ulcer are uneven and have a considerable amount of granulation tissue. In the assessment, the wound is approximately 1.8 cm at the longest edge. It is notable that Bridie has been admitted severally to the Acute Aged Care Ward. This patient lives alone in a small pension flat, is overweight, and finds it hard to perform some tasks, specifically maintenance of hygiene and nutritional needs. Bridie as well suffers from depression and has a history of abusing alcohol. The condition of his venous ulcer is affected by the fact that she is overweight, and unable to maintain cleanliness in her house. Additionally, her habit of alcohol abuse makes the venous ulcer condition worse.
Wound Assessment Chart
Pathophysiology of Venous Ulcers
The venous ulcer pathophysiology is not out rightly clear. Venous incompetence together with associated venous hypertension are considered to be the basic mechanisms for the formation of the ulcer. Factors which may result to incompetence of venous comprises of ineffective pumping of the calf muscle, immobility, and venous valve dysfunction from congenital absence, venous thrombosis, trauma, or phlebitis (de Araujo et al 2008). Consequently, chronic venous stasis may lead to blood pooling in the circulatory system of venous that would trigger further damage in capillary and inflammatory process activation. Endothelial damage, leukocyte activation, platelet aggregation, and intracellular edema contribute to development of venous ulcer as well as impaired healing of the wound (Etufugh & Phillips, 2008). Limb immobility, dependency, and oedema are major contributors to hypertension in venous ulcers. Limb elevation lessens oedema and enhances microcirculation flow, reducing sequestration, trapping and for white cells activation. This is a vital first step in the ulceration pathophysiology. Elevation of leg in hospital boosts curing.
Comparison of Characteristics of Venous and Arterial Ulcers
(Newton, 2011; & Carville, 2012)
Physiological Processes of Wound Healing in Relation to Bridie’s Present Wound
The physiological processes linked with healing of a wound are categorized into four stages: vascular response, proliferation, inflammatory response, and maturation. Granulation characterizes the proliferative stage of wound healing. The resulting granulation tissue in the wound is red in color and normally described as grainy or granular in appearance. Next, there is epithelialisation, which is illustrated by proliferation and migration of epithelial cells across the surface of the wound (Deborah Francis & Charles 2008). There is a cell migration that stops after the epithelial cells from opposite wound margins come together, and this is referred to as contact inhibition. For the granulating tissue to be identified accurately, the wound healing method that is primary or secondary needs to be established (Etufugh & Phillips 2008). Wound healing process through secondary intention call for a greater level of granulation tissue. Epithelialisation does not take place until the granulation tissue levels with that of the surrounding skin. New epithelial cells drift from the margins of the wound, sebaceous glands, and hair follicles across the granulation tissue until the close of the wound.
Factors that may Impact on the Healing of Bridie's Wound
Venous ulcer healing is affected by various factors. Some of these factors will affect the healing of the venous ulcers of Bridie. The first factor would be her age, which is at 82; at this age, the healing process is slow. The other factor is that Bridie is overweight; this neuropathic factor will affect the healing of Bridie’s wound. The fact that she has difficulties in maintaining her personal hygiene will affect the healing process. This is because poor hygiene would make the wound be dirty and infested with bacteria. These bacteria would worsen the wound by making it even larger and probably resistant to medication. The cleanliness of the wound needs to be maintained to ensure that it heals within a short period and that it is responsive to medication. Other factors that will affect the healing of this wound is her history of drug abuse and the fact that she at times from depression (Carville 2012). Her forgetful nature may make her fail to take medication as required, which would affect the healing. Additionally, her aggressive tendencies may hurt the wound and make it fresh hence affecting the healing of the wound.
Wound Management Products Bridie
Iloprost is a synthetic prostacylin, which inhibits aggregation of platelets. A study by Ferrara et al (2008), they used intravenous iloprost combined with elastic compression therapy and it considerably reduced the venous ulcers healing time compared with placebo.
Aspirin just like pentoxifylline, when used with compression therapy is known to increase the healing time of ulcers and reduces the size of ulcers. Generally, addition of aspirin therapy to compression bandages is suggested for venous ulcers treatment, unless there it has side effects. Zinc on the other hand is known to be a trace metal that has a potential anti-inflammatory effect. The oral zinc therapy is known to lessen time of healing in patients who have pilonidal sinus.
Colonization of bacteria and superimposed bacterial infections are commonly found in venous ulcers are result to poor healing of wounds. Studies comparing antiseptics and topical antibiotics like ethacridine lactate, peroxide-based preparations, povidone-iodine solution and mupirocin, have established some evidence supporting use of topical antiseptic agent cadexomer iodine. However, data of higher quality was needed for better evaluation of effectiveness of topical preparations. Oral antibiotics can be recommended for treatment of venous ulcers only in events of suspected cellulitis. When there is suspicion of ostemyelitis there would be a justification for evaluation of arterial diseases and consideration of intravenous antibiotics for treatment of fundamental infectivity (O'Meara Al-Kurdi & Ovington 2008).
Nursing Care Plan for Bridie and its Rationale
Patients who have venous ulcers like Bridie can be best managed at the community due to these reasons. The patient number may overwhelm the services a hospital can offer, and maintenance of mobility and independence is essential for the elderly population. Nonetheless, direct access to the suitable specialized services in hospital is needful for examination of probable vascular disease and for dermatology, histopathology, and for microbiology. In the treatment of venous ulcers, the fundamental causes should be determined first. There are many pathologies to be used, however, for patients who have diabetes, they may have simple venous ulcers which can be healed easily (Ferrara Meli Raimondi et al. 2008).
Dressing Materials: Bridie is prone to contact sensitivity, specifically from topical antibiotics, wool alcohols, cetylstearyl alcohols rubber mixes, and parabens, which are commonly found in the majority of creams, ointments and dressings. The role of the majority of dressing materials, have indicated that modern designer dressing materials do not have additional effect in the healing of wounds over the one attained by simple low adherence dressing under multilayer compression bandaging.
Compression treatment: Compression surmounts the effect of venous hypertension through reduction of venous stasis and for prevention or for treatment of tissue oedema. The pressure found in veins when one stands is mostly hydrostatic, and the external pressure level required for counteracting this lessens gradually up the leg (Abbade & Lastória 2008).
Compression treatment is a viable method of treatment in terms of stockings and bandaging. Compression treatment encourages ulcer healing. Higher compression systems heal ulcers more than lower compression systems. The most effectual compression level for overcoming venous hypertension was established to be approximately 40 mm Hg at the angle. Appropriate bandage application would be necessary for avoidance of pressure ulceration along the anterior border of the tibia and over bony high points. For this pressure to be achieved in a range of limb diameters, regimens of bandaging need to be adjusted in accordance to ankle circumference. Higher compressions can reduce recurrence.
Limb elevation: Limb immobility, dependency and oedema are contributors of venous hypertension. The elevation of limb lessens oedema, improves microcirculation flow, and reduces sequestration, trappings and white cells activation.
Skin grafting: Split skin grafting is a technically demanding and calls for admission in hospital. The venous ulcer surface discharge tends to dislodge continuous sheets of split skin and this leaves a choice between pink and mesh skin grafting.
Prevention of Recurrence of Venous Ulcer
Venous leg ulcers commonly recur following their healing. This can be prevented by wearing compression stocking for not less than five years following the healing of the ulcer. This would counteract the raised pressure in the veins, which causes venous leg ulcers. Bridie should adhere to this and get a new stocking approximately after every six months, since the elastic lessens after some time. These compression stockings can be bought at pharmacies or be prescribed. They usually come in diverse sizes and the pharmacist would advise Bridie. Normally compression stockings for venous leg ulcer prevention are below knee in length instead of thigh length (Nelson et al 2008). There exists various categories of compression stocking; categories 1,2, and 3. Nonetheless, class 3 stockings are perceived to be too tight and uncomfortable, though class 2 might be the appropriate one.
There are other measures, which Bridie can take to avoid recurrence of her venous ulcer. She should avoid some habits like drugs such as alcohol as these would cause harm to her. If she is given medications, she ought to adhere to them and in case of underlying medical conditions, she should control them. She should constantly be using neutral or dependent positions for legs. Since blood viscosity is known to be a common cause of venous ulcer, she should maintain sufficient hydration to for reduction of the blood viscosity. The skin and feet should be inspected daily. This would ensure that maximum hygienic condition is maintained. Considering that Bridie has been in ability to maintain self-hygiene, she can find someone who shall take care of that condition. The skin should be moisturized frequently for avoidance of cracking. Additionally, routine professional foot care for toenails, calluses and corns should be used. Bridie is to wear protective footwear that is well fitting. Bridie is to avoid crossing of legs, exposure to trauma as well as constructive clothing. The extremities should be kept warm and avoid excessive moisture or going bear footed. In terms of nutrition, Bridie should consult a dietitian in regard to her intake of balanced, consistent diet that need to include individually determined amounts of minerals, calories, protein and fluids to maintain nutritional status and for prevention of malnutrition (McIlwaine, 2008).
References
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Ferrara, F Meli, F, Raimondi, F, et al. 2008, ‘The treatment of venous leg ulcers: a new therapeutic use of iloprost. Ann Surg. Vol. 246 no. 5 pp. 860–865.
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Nelson, EA Harper, DR Prescott, RJ, Gibson, B, Brown, D, Ruckley, CV 2008, ‘Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. Journal of Vascular Surgery, Vol. 44. No. 4: 803-808.
Newton, H 2011, ‘Leg Ulcers: Differences Between Venous and Arterial,’ Wound Essentials, Vol 6 pp. 20-28, viewed May27, 2013, http://www.wounds-uk.com/pdf/content_10001.pdf
O'Meara, S Al-Kurdi, D Ovington, LG 2008, ‘Antibiotics and antiseptics for venous leg ulcers’, Cochrane Database Syst Rev. (1): CD003557.
