1. Leg Ulcers

2. Introduction Define Leg ulcer Introduce the scenario Identify the main causes and conditions Assessment and planning of scenario Discuss the implementation and evaluation of care given

3. Causes of leg ulceration Venous Arterial Rheumatoid Arthritis Diabetes

4. Scenario Anna Jarvis is a 72 year old retired shop assistant. Anna has lived alone since her husband Harry died of heart disease 3 years ago. For the past 18 months, Anna has had sores on her legs which never quite seem to heal. She has tried to manage these sores herself with limited success. On a recent visit to her doctor, it was suggested that she make an appointment with the practice nurse for further management. On inspection, both ankles show signs of oedema, which leave a mark when pressed. She has 2 ulcers on her left leg (1 x 1.5 cm diameter and 1 x 1 cm diameter), both of which seem to be shallow and quite clean. She also has one ulcer on her right leg ( 2 x 3cm diameter and about 0.25 cm deep) which is quite mucky with a sticky greenish brown exudate. The edges of the ulcer are flat and irregular. Foot pulses are just palpable and her ABP is 1.1 Anna complains that the ulcers are very uncomfortable and unsightly and that her legs ache and that she doesn’t go out much as she is embarrassed by how they look. Discuss the assessments you will undertake with Anna and outline the appropriate management of these leg ulcers.

5. Patient Background Patient has venous leg ulcers Her previous occupation as a shop assistant meant that she was standing all day As a result of her husband dying 3 years ago, she may be suffering with depression, hence isolation and lack of nutrition All these factors can prevent healing

6. Venous Leg Ulcer A venous leg ulcer is the most commonly encountered group of leg ulcers. This mainly occurs in elderly female patients. Damage to the veins deep in the calf causes incompetence of the perforators (the vein which links the deep and superficial veins to the calf) drainage to the skin in the lower leg is affected, leading to oedema in duration and pigmentation. Fibrin is laid down around the capillaries in this area, which interferes with the oxygen diffusion into the tissues. Following this any knock or minor injury to the lower leg leads rapidly to break down of the skin and ulceration

7. Assessment From using a doppler it has been established that Anna has sustained a venous ulcer A doppler is an ultrasound which is used to assist a diagnosis of the aetiology of a leg ulcer by helping to determine the presence or absence of compromised arterial flow to the lower limb. It is also used to support care decisions. The systolic readings are taken from the arm and the leg to give an ankle brachial pressure index. This index indicates the arterial flow to the lower limb. The doppler procedure needs to be accurate in order for it to be correct.

8. Care Plan In this Assessment these factors will be looked at: Nutrition Physical activity Personal hygiene Pain management Wound care

9. Implementation Types of dressings used on a venous ulcer good and bad outcomes of using dressings Reasons for compression

10. Evaluation-Prevention Venous leg ulcers reoccur after they have healed. To prevent this the patient should wear a support stocking during the daytime for at least the next 5 years after the ulcer has healed Encourage the patient to keep active Encourage patient whenever they are sitting or laying down to try and elevate their legs to reduce oedema. Be careful not to injure the infected leg in any way and to wear only comfortable and well fitting shoes. Individual education regarding wound management can have a dramatic effect on progress. This area of care is particularly appropriate for Anna and her venous leg ulcer. If Anna does not know the cause of the ulcer she may not comply with her treatment, such as leg exercises, leg elevation and the need for sufficient compression are the key factors to success. Leaflets were provided to Anna with the education of wound management. From monitoring Anna’s nutritional intake, her weight has increased healthily over the past few weeks and has helped towards tissue repair.