Chapter One *A Brief Overview of a Venous Leg Ulcer *and the Assessment Process The nurse must have the skills and knowledge to identify a venous leg ulcer. Dowsett (2005) believes that it is important that nurses and other health care professionals look for the underlying cause of an ulcer.
Whereas, the Royal College of Nursing (1998) has different views, and argues that, professionals who are fully trained in leg ulcer management should only be able to identify an underlying cause as it is easily mistaken that diagnosis of an arterial leg ulcer is made rather than venous which could cause serious treatment complications for the wound as well as the patient. There are major problems associated with a venous leg ulcer such as, pain, loss of mobility, financial implications and much more which will be discussed in chapter 3.
Leg ulcers appear as shallow holes or craters in which the tissue underneath is exposed. They can vary in size, discolouration and depth (National Health Service Direct 2008) (NHS). The clinical factors of a venous leg ulcer are, lipodermatosclerosis (champagne bottle shaped leg) ,which is cellulites affecting the dermis and subcutaneous tissue (Finlay & Chowdhery, 2007), hyperpigmentation, derived red blood cells extravagated from dilated, leaky capillaries which produces areas of brown discolouration (Brown & Burns, 2007).
Atrophic Blanche, where interspersed by visible engorged capillaries seen as tiny red dots just below the surface of the skin (Moffat et al, 2007). However before looking at the patients wound it is the nurses role to look at the patient holistically and find out past medical and family history as well as personal factor that could contribute to the condition (Moffat et al, 2007). There are essential details that the patient can tell the nurse about their ulcer and the factors that may contribute to this.
Such factors are their full medical history these details should include varicose veins, diabetes, Deep Vein Thrombosis (DVT), previous leg surgery and any family history of leg ulceration (Dougherty and Lister 2004). The importance of this is that if a leg ulcer is diagnosed incorrectly, such as a venous ulcer being mistakenly diagnosed as an arterial one can have serious complications for the patient and causing further delays in the healing of the wound. Also the nurse must undertake baseline observations this includes, the patient’s weight, height, blood pressure (BP), oxygen saturations levels, temperature nd respiratory rate, and also the patient’s nutritional intake, urine samples and routine blood tests such as glucose and haemoglobin levels must be gained, as diabetes is present in approximately 5% of patients with leg ulcer (SIGN 1998). Murray (2004) also agrees with Dougherty & Lister (2004) & Bolton et al (2004) stating that that hyperglycaemia can have an effect in the wound healing process, as this can be linked with infection and decreased oxygen levels in the haemoglobin will slow down the healing process and go onto starve tissue. These factors are important to know as it plays a big part in the wound healing process.
In clinical practice thesebasic observations are a vital part of information gained to ensure safer patient care and early recognition of deterioration. The key factor in order to gain a thorough assessment it is essential that the nurse must have is communication and listening skills not only for this purpose but also for a nurse patient relationship. Dealey, (1994) believes that fear is one of the most common experiences a human can feel and a patients illness release many fears, in which health care professionals are unable to identify when not allowing the patient to express their needs freely.
If the patient has a full understanding of their condition they are more likely to comply with treatment regimes and have a more productive relationship with healthcare professional’s (Anderson 2006). The RCN (2008) states, that the nurse-patient relationship is founded on trust. The nurse patient relationship allows the conversation to flow easy in order to gain a holistic approach to the patients care. The Code (2008) also agrees that as nurses ‘we must listen to people in our care and respond to their concerns and preferences’.
Much research has taken place regarding nurse patient relationships, McCabe (2002) carried out a study which aimed to explore and produce statements relating to the patients experiences of how nurses communicate. A qualitative phenomenological approach was used. This focuses on individual’s interpretations of experiences and ways in which they express them (Parahoo 1997), followed by unstructured questionnaires which were tape recorded and lasted for approximately thirty minutes. The results found that four themes emerged, these were, lack of communication, ‘attending’, empathy and friendly nurses.
Therefore the conclusions were that in contrast to the literature, nurses are not good at communicating with patients, however nurses can communicate well if the task undertaken was a patient centred approach. Although research has taken place the limitations were that only eight patients participated, therefore this could reduce the validity and reliability of the study. Also with such a small sample the study could be used as a pilot study which could be replicated in the UK as this study was undertook in Ireland.