NURSING CARE OF VENOUS LEG ULCER

Introduction:

An effective as well as systemic nursing care plan is important for providing high-quality care to patients (Mościcka et al., 2019). For treating a venous leg ulcer, care professionals need to follow the systematic care pathway which is associated with proper assessment and diagnosis of leg ulcers, the history of patients with leg ulcers, patients’ genetic history, premedical history and current health status (Nursing and Midwifery Council (NMC), 2018). This assignment will first introduce a case study of venous leg ulcer. Next the study will give a brief discussion about the venous leg ulcer with its pathophysiology and the health implications of the venous leg ulcer in relation to the case study. Then the study will present a brief discussion on the care pathway of Venus leg ulcer that the patient in the case undergoes in which the overall treatment process, assessment tool and the pain management process will be discussed. This study will apply the Roper-Logan-Tierney assessment tool in terms of assessing the leg ulcer in the patient in the case study. Moreover, the study will present a critical discussion on why the particular clinical intervention process and pain management techniques are used over the others in the case study. Under NMC (2018), for maintaining the confidentiality of the patient identification and personal details, the real name of the patient in the case study has been changed.

Case study:

Mr Parks, is a 44-year-old gentleman, who had been admitted to hospital with leg ulcer. He had a four weeks history of cellulitis with swelling and severe pain in the left leg above the tribal crest and dorsum of the foot. This ulcer began with a small opening on his left leg above the lateral malleolus of the foot. In the case study, Mr Park’s medical history showed that he suffered from diabetes which can be one of the potential risk factors to develop the venous leg ulcer in him. Although he visited the general practitioner (GP), he did not complete the course of the antibiotics that was prescribed to him. He had neglected to take proper care of this wound which led to occurrence of cellulitis on the left leg that caused severe inflammation at the site of the venous ulcer. For the last 24 hours he had been suffering from severe pain and inflammation at the ulcer site with high fever due to the infection. His wife took the decision of admitting him to the local hospital. and then he was admitted to the emergency ward. The personal history of Mr Parks showed that he was a bank manager who dealt with an extreme workload at his office which made it difficult for him to take care of his health and wellbeing. He lived with his wife but had no children. His wife was the homemaker who took care of Mr. Parks’ nutrition and lifestyle.

Diagnosis:

The physical health condition of the patient assisted the care professionals to develop an effective care plan and implement appropriate treatment for the venous leg ulcer immediately after admission of Mr Parks. it is important for the nurse to implement a care plan with predictions of what outcomes are expected (Hopkins, 2020). The pathway followed by the nurses and doctors in terms of providing proper clinical support to Mr Park is: effective physical assessment, evaluation of the assessment results to check different physical conditions that impact on the healing of ulcer, development of an effective care plan based on the assessment and finally implementation of the developed care plan into the treatment process.

A leg ulcer pathway is the systematic care pathway in which an effective wound care assessment is done and a wound care treatment plan is developed based on the assessment report to prevent and manage the infection at the wound site (Nazarko, 2017). In case of Mr Park, a systematic leg ulcer pathway has been followed by the nurses in terms of assessing the tissue type and the depth of the infection at the wound side. An effective wound care assessment has been performed by nurses in case of Mr Park which enables the nurse to check the exude from the ulcer, the depth of the wound, the type of tissues at the wound site, pain at the wound region and colour of the surrounding skin (Mościcka et al., 2019). After the wound assessment is done then the wound treatment care plan is developed under which clinical assistance is provided to Mr Park to prevent the further bacterial colonisation at the wound site.

For assessing the severity of the cellulitis and the inflammation at the site, nurses carried out blood tests and a special immunological test. An immunologic blood test is the diagnostic test that is carried out to check the capability of the blood to produce immunoglobulin (antibody) against the microbes and bacteria that enter into the body (Nazarko, 2017). this is the test that is highly relevant to check the capability of body’s immunes system of Mr Parks to develop an autoimmune resistance against the bacterial colonisation at the site of ulcer. On the other hand, a Complete Blood Counts (CBC) is important in case of Mr Park which will assist physicians to check the blood sugar level, haemoglobin, white blood cells and red blood cells in the blood. If Mr Parks has high blood sugar, then there are chances of delayed healing of leg ulcer.

By performing the special immunological test that CBC, it is diagnosed that Mr Parks has Methicillin-resistant Staphylococcus aureus (MRSA) infection at the ulcer site which is the potential reason for inflammation at the ulcer site (Nursing and Midwifery Council (NMC) (2018). the MRSA infection occurs due to the colonisation of the Methicillin-resistant Staphylococcus aureus which leads to the risk of further infection at the ulcer cute thereby reducing the chances of healing of the site.

in case of Mr Park, nurses have followed the systematic process under the leg ulcer pathways which enable the health professionals to determine the status of leg ulcer based on which they develop an effective and highly relevant wound care plan (Mościcka et al., 2019). The aim of this leg ulcer pathways in case of Mr Park is to carried out the effective wound care assessment which is necessary for having clear information on the tissue type, status of the ulcer, the severity of infection at the ulcer site and the risk of further infection at the wound. On the other hand, this leg ulcer pathways aim to assist healthcare professionals to develop highly appropriate care plan for Mr Park which will provide his wound with the better treatment and care to prevent the further bacterial isolation at the wound site.

During this leg ulcer pathway first an initial wound assessment has been done. In this initial ulcer assessment nurses collect information on premedical history, genetic history and current healthcare complications of Mr Park. Here nurses record the information regarding the duration of the ulcer to check whether the ulcer is six months older or not, the pus or exude discharge from the ulcer, the severity of pain at the wound site, whether the patient has any genetic history of diabetes and if the patient has any additional complex health condition (Mościcka et al., 2019). After the assessment, the devitalised tissues is collected from the wound site to check the nature and types of the tissues. By assessing the nature of wound tissue, it is seen that wound is sloughy but it is not the local infection. After assessing the type of the infection at the wound site, the dressing is performed by using the urgoclean, hydrogel and absorbent pad. Hydrogel dressing is used to perform the appropriate compression at the wound site until the wound is properly cleaned (Oates and Adderley, 2019). Regular dressing is performed by nurses in case of Mr Park by using the aseptic techniques which ensure that there are no chances of further bacterial colonisation at the wound site. Then the reassessment is performed after every 6 weeks in which health professionals make the follow up of treatment in which they check whether there is any improvement at the wound site after implementation of care pathways. If these is no noticeable recovery at the wound site then health professionals make effective changes in the dressing such as changing the dressing elements to fastening the recovery.

Assessment by using Roper-Logan-Tierney assessment tool:

Under NMC Code (2018), while implementing any risk assessment techniques nursing professionals need to ensure that they work under the level of nursing knowledge and professional expertise that can ensure patients’ safety [NMC, 2018]. Under the care plan designed for Mr Parks, nurses followed the Roper-Logan-Tierney assessment tool. This tool is important in wound healing to determine the care needs of Mr Parks. The strength of this assessment tool is that it enabled nurses to determine the activities the of daily living of Mr Parks thereby assessing the causative factors of his leg ulcer, his holistic needs in relation to the would care and the associated risk of further inflammation at the ulcer site (Melikian et al. 2019).

Critics of this model mention that although this model assists nursing professionals to determine the ability of the patients in performing the activities of daily living, this model fails to promote the holistic wellbeing of the patients. On supporting this view Oates and Adderley (2019) criticise the Roper-Logan-Tierney assessment model by stating that, this model fails to emphasize on the other determinants of health in case of patients such as the social, biological, cultural, socio-economic and behavioural determinants. In this context, the use of Roper-Logan-Tierney assessment in case of treating the leg ulcer in Mr Park can avoid the other important determinants of health that are essential in terms of promoting positive health and wellbeing in patients (Heyer et al., 2017). Therefore, while implementing this, nurses need to also consider all the health determinants such as social, cultural and financial determinants in terms of promoting the holistic wellbeing of Mr Park.

Through using this assessment tool, nurses were able to determine the environmental, physical and communicational needs, breathing condition, drinking and eating needs (recommended foods for faster recovery of ulcer), personal cleaning needs such as dressing of the ulcer site and physical health needs of Mr Park. As argued by Guest et al. (2018), the Roper-Logan-Tierney model is best suited in the case of patients with complex health conditions but not in the case of patients with ulcer or venous infection. This is because the assessment tool focuses more on the overall activities of daily living of patients rather than focusing specially on the effective infection control measures and venous pressure management at the site of the venous ulcer (Melikian et al., 2019). In this context, nurses could use the Roper-Logan-Tierney tool along with implementation of effective medication system and relevant clinical intervention techniques that enabled the care team to take a person-centred approach to provide the effective wound care to Mr Parks.

Pathophysiology of leg ulcer:

While it comes to assess, treat and manage the symptoms of a venous leg ulcer it is important for the nursing professionals to have good understanding on the pathophysiology of this health condition (Oates and Adderley, 2019). Venous leg ulcer is common in middle age and older people. Although the actual cause of venous leg ulcer is not properly known, the pathophysiology shows that in case of older people there is limited blood supply to the lower parts of the legs which enhance the risk of the venous ulcer. On the contrary Heyer et al., (2017) argued that, venous leg ulcer can also be developed in middle-aged people in which different health conditions act as the causative agents for this wound such as osteoarthritis, high blood sugar, lymphoma, malignancy and comorbidities. The primary mechanism that is associated with venous leg ulcer is the venous reflux in which there is an increased venous blood pressure that leads to development of venous hypertension. Microcirculation is associated with the venous hypertension in which the blood pools to the area of the extremities thereby enhancing the chances of developing an ulcer at the site. The exudate can be minimum to heavy based on how effectively the oedema management is carried out.

Improving lifestyle behaviours of Mr Parks:

For improving the lifestyles behaviour of Mr Parks, it is important to implement the effective risk assessment tool that will assists nurses and care professionals to determine the risk associated with the wound while Mr Park perform activities d daily living. Waterlow risk assessment tool is generally used in detecting the risks associated with pressure ulcer (Oates and Adderley, 2019). As mentioned by Nazarko (2017), the Waterlow risk assessment tool was developed and designed by Judy Waterlow to determine the risk of the pressure ulcer on the skin. In this context, nurses followed the Waterlow risk assessment score card that have different categories. Nurses need to relate to the information gathered from the patient regarding the ulcer to the given categories on the score card and then analyse the severity of risk of the ulcer. If the score is 10-14 then there is risk of the ulcer, if the score is within 15-19 then the patient is under high risk of ulcer and if the score is beyond 20, then the patient is under very high risk of ulcer. In this case of Mr park, the score of water low risk assessment tool was 18, which indicated that he was under the high risk of the severe inflammation and infection at the venous ulcer (Heyer et al., 2017). Therefore, in case of Mr Park, effectiveness of the waterlow risk assessment depended on how effectively nurses determine the different risk associated with the venous leg ulcer. The strength of the waterlow model is it assisted nurses in the case study to determine the risk of inflammation at the ulcer and the further deterioration of the infection (cellulitis). Nurses chose this tool above the Braden Risk assessment tool, because as compared to only six criteria in the Bradon score card, the Waterlow score card provides a greater number of categories and subcategories of determining the severity of risk of venous ulcer. Therefore, the waterlow tool had been proved to be effective tool in the case study for nurses to match the ulcer related information to the categories in the score card thereby designing the effective treatment process for Mr park. There are many arguments regarding using the water low risk assessment tool. As argued by Bianchi et al., (2018.), the waterlow scorecard is associated with only determining the risk of the pressure ulcer but fails to determine the associated risk factors that can raise with the devilment of any venous ulcer such as comorbidity, further deterioration of cellulitis and risk of malignancy. The limitation of the water low tool in the case study is that it failed to provide nurses with additional information regarding the characteristics and genetical history of the venous ulcer of Mr. Park.

Treatment:

Actiformcool dressing:

After assessment of the leg ulcer, nurses followed the treatment process that was designed for treating the leg ulcer on Mr Park. Dressing is important treatment for any ulcer to eliminate the chances of any further infection at the site (Bianchi et al. 2018). In case of Mr. Park, actiformcool dressing was used to reduce the pain in the ulcer site and eliminate chances of further inflammation at the site. Actiformcool is smoothing dressing that is widely used by modern care professionals to treat any wound such as venous ulcer (Heyer et al. 2017). The actiformcool is the hydrogel sheet that would improve the condition of the ulcer in Mr Park.

Antibiotics:

Antibiotics are also used by the modern care professionals for treating venous leg ulcer. Venous ulcer has high risk of bacterial infection in which there are chances of contamination with different bacteria such as Streptococcus spp., Proteus mirabilis and Staphylococcus spp. In case of Mr Park, the effective and routine administration of systemic antibiotics minimised the chances of bacterial colonisation at the ulcer site. As Mr Parks is diagnosed with the Methicillin-resistant Staphylococcus aureus (MRSA) infection had been administered with povidone-iodine, ethacridine lactate, chlorhexidine and mupirocin which are evident to reduce the pain and changes of further infection as well as inflammation at the ulcer site (Melikian et al. 2019).

VTE risk assessment:

VTE or Venous thromblism is the condition in which the blood clots or thrombi develops within the deep vein thereby reducing the blood supply to the lower extremities of body. Therefore, VTE is one of the potential causative factor of venous leg ulcer. In case of Mr Park, the risk assessment of VTE was carried out to determine whether there were risks of the VTE. As argued by Bianchi et al. (2018), VTE assessment not only assist the care professionals to determine risk of VTE but also enable them to assess the risk of deterioration of inflammation and further infection at the ulcer site due to lower blood supply to the leg. In case of Mr Park, the using of VTE risk assessment was proved to be highly effective to examine different health aspects such as mobility, bleeding risk and thrombosis risk at the ulcer site. For avoiding the risk of further infection at the ulcer site regular dressing would be carried out that will eliminate the chances of bacterial colonisation at the wound (Moini et al. 2020). In this context acniformcoll dressing would be highly relevant to Mr Park for healing MRSA infection at the ulcer site. Nurses would maintain the sterile environment surrounding Mr Park and use aseptic techniques while dressing the wounds (Nazarko, 2017). aseptic technique will minimise the chances of the further bacterial infection at the ulcer site and also reduces the chances of spreading of the infection from the patient to the other people.

Pain management:

Under NMC (2018), while treating leg ulcer effective pain management is important for fast recovery of the patient. In the case study, administration of aspirin and paracetamol was performed for reducing the pain at the ulcer site in Mr Park. On the contrary Heyer et al., (2017) argued that while going for effective pain management, nurses must ensure that the techniques or medicines that are used as the pain reducer would not pose adverse impacts on patients’ health and wellbeing. Aspirin is widely used in medical science to reduce the pain, inflammation and infection in the body. In case Mr Park, aspirin administration is high appropriate to his age and health condition which will reduce his pain at the ulcer site and also eliminate the chances of bacterial colonisation. On the other hand, the acniformcoll dressing was highly useful for Mr park to reduce the pain in the ulcer site. A Numeric rating scale (NRS) with a standard of 1-10 can be used in case of MR park in terms of detecting the severity of his pain at the ulcer site. Behavioural pain scape (BPS) can also be used for MR Park to check his facial expression and behavioural changes to understand the severity of pain. in this context, care professionals can check Ventilator dyssynchrony, limb reflection and facial grimacing of Mr Park.

Improving mobility:

Furthermore, mobility was a key ADL (Roper et al., 1996) that impacts on sustaining positive progress in health and welfare. Effective mobility ensures ease, comfort and efficiency for the patient and results in improved manoeuvrability with basic everyday actives such as food preparation, walking and doing tasks that help improve the health and welfare of the individual (Medicine Net, 2018). An analysis of Mr. Parks’ background and lifestyle revealed that his obesity did not only impair his mobility, but it also affected his confidence, his social interaction and behaviour. As his nurse, working towards redressing his obesity and thus his mobility, helped in restoring Mr. Parks' life. The person-cantered care provided aided the treatment plan for getting him back to normal. On some occasions aiding in Mr. Parks’ mobility was not always successful as Mr. Parks would experience pain, this was due to his venous leg ulcers as Briggs (2012) states that venous leg ulcers are often painful, which lead to reduced mobility.

My role as Student Nurse played an important role in the improvements in Mr Parks’ mobility, through moving and handling, such as Mr Parks’ moving from bed to the chair. During the moving and positioning of the patient, it was important for Mr Parks to carry out these tasks with minimal assistance, as Lister et al (2020) believes that moving and positioning is an important aspect of patient care, as it has a major impact on a patient’s rehabilitation. Lister et al (2020) goes on to say that moving and positioning of patients is one aspect of patient management where the optimum goal is for the individual to gain independence.

Impacts of pain management in increasing mobility:

Through effective pain management, it is possible to improve the mobility of patients with leg ulcer (Heyer et al., 2017). In case of Mr Park, the above-mentioned pain management techniques were highly useful in improving the ability of moving his leg thereby improving his mobility. As argued by (0 pain management through medicines is not very effective for increasing patients’ mobility rather the lifestyle changes such as regular leg exercise, proper dressing and recommended food consumption can improve the blood supply to the leg thereby improving mobility (Bianchi et al., 2018). In case of Mr. Park, along with pain killers, the hydrogel dressing was highly useful in eliminating the chances of bacterial contamination at the ulcer site thereby contributing to the fast healing of the ulcer which could increases the ability of Mr park to move freely. On the other hand, he was trained by the psychotherapist to do regular leg exercise that would improve the blood supply to the leg and lower extremities thereby providing more energy to leg muscle to improve the mobility. On the other hand, Mr Park was recommended to take nutritious and protein enriched food with low carbs (as he was diabetic) which could provide the body enough energy to maintain the leg muscle activity thereby contributing to the effective mobility.

Nutrition:

Nutritional supplements were introduced to Mr. Parks’ diet for him to lose weight, a key element for getting complete mobility back in his life. A healthy intake of food was planned to improve his resistance to the ulcer and more importantly, improve his health reduce the fat in his body so as to develop strong muscles and healthy bones that could support his mobility (Southern NHS, 2014; Bishop et al., 2018).

Effective communication:

Effective communication between the patient and team members in multi-disciplinary work helps to accelerate the healing process and enables an appropriate discharge plan for a positive transition that will benefit both sides (Ryan, 2008; Musich et al., 2018). Discharge planning allows nurses and health professionals to measure and assess the assistance the patient will need when on his own or what agency help, he may require for his recovery process (O’Brien, 2002).

Multidisciplinary approach:

The Multidisciplinary approach allows every member of the health care professional team involved in Mr. Parks’ care plan to give suggestions and design a plan for his discharge, living independently and helping the patient to get back to normal life without relapsing or having to be re-admitted or having a delayed discharge process (Stewart, 2000 cited in Dougherty et al., 2015). Infectologists are specially involved in the treatment of MRSA infection at the wound of M Park. The resulting plan for the patient in having a discharge process will ensure that care continues from his home with bandage changing, monitoring progress and an effective care package that will ensure positive progress to the recovery plan (Kusek et al., 2004). The referral opening was made available through the district nurse, as she reviewed the healing rate in line with clinical procedures that have been tried on the patient (O’Brien, 2012).

Conclusion:

In conclusion, this case study addressed the processes involved in the patient’s admission, stay, and return from hospital. His leg ulcer needed medical attention and the ensuing treatment package helped him towards recovery with a focus on reinstating mobility. This can only be costly, time consuming and intense, it must be worthwhile as it focuses on improving and restoring health and welfare of the patient. There are key guidelines aimed at assisting the health professionals deliver the best and effective treatment package befitting the patient, considering among other things, his medical background history as well as the presenting condition. The treatment package reviewed the best possible approach for venous leg ulcer and the nursing intervention addressed his mobility. This recognises the need for underlying subsidiary approaches that enabled Mr. Parks to have a more effective and safer recovery plan for regaining his mobility and self-confidence. He was introduced to nutritional supplements to help in healing the wounds and ulcers and allow for his independence to bring back hope and confidence to him emotionally and physically.

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