Nursing Process: The Patient Who Has Leg Ulcers

NURSING PROCESS: THE PATIENT WHO HAS LEG ULCERS

Assessment

A careful nursing history and assessment of symptoms are im-portant. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and comparisons are made of the pulses in both legs. The legs are checked for edema. If the extremity is edematous, the degree of edema is determined. Any limitation of mobility and activity that results from the vas-cular insufficiency is identified. The patient’s nutritional status is assessed, and a history of diabetes, collagen disease, or varicose veins is obtained.

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, major nursing diagnoses for the patient may include:

·        Impaired skin integrity related to vascular insufficiency

·        Impaired physical mobility related to activity restrictions of the therapeutic regimen and pain

·         Imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include:

·        Infection

·         Gangrene

Planning and Goals

The major goals for the patient may include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications.

Nursing Interventions

The nursing challenge in caring for these patients is great, whether the patient is in the hospital, in a long-term care facility, or at home. The physical problem is often a long-term one that causes a substantial drain on the patient’s physical, emotional, and economic resources.

RESTORING SKIN INTEGRITY

To promote wound healing, measures are used to keep the area clean. Cleansing requires very gentle handling, a mild soap, and lukewarm water. Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is arterial insuffi-ciency, the patient should be referred to be evaluated for vascular reconstruction. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. A decrease in edema promotes the exchange of cellular nutrients and waste products in the area of the ulcer, promoting healing.

Avoiding trauma to the lower extremities is imperative in pro-moting skin integrity. Protective boots may be used (eg, the Rooke Vascular boot, Lunax Boot, Bunny Boot); they are soft and pro-vide warmth and protection from injury. If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations. When the patient is in bed, a bed cradle can be used to relieve pressure from bed linens and to prevent any-thing from touching the legs. When the patient is ambulatory, all obstacles are moved from the patient’s path so that the patient’s legs will not be bumped. Heating pads, hot-water bottles, or hot baths are avoided. Heat increases the oxygen demands and thus the blood flow demands of the tissue, which in this case are al-ready compromised. The patient with diabetes mellitus suffers from neuropathy with decreased sensation, and heating pads may produce injury before the patient is aware of being burned.

IMPROVING PHYSICAL MOBILITY

Generally, physical activity is initially restricted to promote heal-ing. When infection resolves and healing begins, ambulation should resume gradually and progressively. Activity promotes arterial flow and venous return and is encouraged after the acute phase of the ulcer process. Until full activity resumes, the patient is encouraged to move about when in bed, to turn from side to side frequently, and to exercise the upper extremities to maintain muscle tone and strength. Meanwhile, diversional activities that interest the patient are encouraged. Consultation with an occu-pational therapist may be helpful if a prolonged period of limited mobility and activity is anticipated.

If pain limits the patient’s activity, analgesics may be prescribed by the physician. The pain of peripheral vascular disease, whether it is arterial or venous, is typically chronic. Analgesics may be taken before scheduled activities to help the patient participate more comfortably.

PROMOTING ADEQUATE NUTRITION

Nutritional deficiencies are determined from the patient’s report of usual dietary intake. Alterations in the diet are made to remedy these deficiencies. A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged in an attempt to promote healing.

Many patients with peripheral vascular disease are elderly. Their caloric intake may need to be adjusted because of their de-creased metabolic rate and level of activity. Particular consideration should also be given to their iron intake, because many elderly people are anemic.

After a diet plan has been developed that meets the patient’s nutritional needs and promotes healing, diet instruction is pro-vided to the patient and family. The nurse and patient design the diet plan to be compatible with the lifestyle and preferences of the patient and family.

PROMOTING HOME AND COMMUNITY-BASED CARE

The self-care program is planned with the patient so that activities to promote arterial and venous circulation, relieve pain, and pro-mote tissue integrity will be used. Reasons for each aspect of the program are explained to the patient and family. Leg ulcers are often chronic and difficult to heal; they frequently recur, even when patients rigorously follow the plan of care. Long-term care of the feet and legs to promote healing of wounds and prevent re-currence of ulcerations is the primary goal. Leg ulcers increase the patient’s risk for infection, may be painful, and limit mobility, ne-cessitating life-style changes. Participation of family members and home-health providers may be necessary for treatments such as dressing changes, reassessments, and evaluation of the plan of care. Regular follow-up with a primary health care provider is necessary.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Demonstrates restored skin integrity

a)     Exhibits absence of inflammation

b)    Exhibits absence of drainage; negative wound culture

c)     Avoids trauma to the legs

2)    Increases physical mobility

a)     Progresses gradually to optimal level of activity

b)    Reports that pain does not impede activity

3)    Attains adequate nutrition

a)     Selects foods high in protein, vitamins, iron, and zinc

b)    Discusses with family members dietary modifications that need to be made at home

c)     Plans, with the family, a diet that is nutritionally sound