Key learning points:
- The role of the specialist nurse prescriber in improving patient outcomes
- The importance of team approach to wound management
- Introduction to the causes of this type of wound
The aim of this case study is to demonstrate how non-medical prescribing, continuity of care and team work can improve patient outcomes and provide quality evidence based care.
Venous Leg Ulcers
Leg ulceration costs the NHS up to £600 million per year1 and 3% of the population may suffer from leg ulceration, with 70% of leg ulceration being venous in aetiology.2
Venous leg ulcers are primarily caused by chronic venous insufficiency (CVI).2 CVI is caused by faulty valves in the superficial and deep veins of the leg. The main role of the venous system is to carry blood back towards the heart via the calf pump. The presence and function of valves within veins is to prevent back flow of blood. These valves can become damaged, for example from thrombosis, in either the superficial or deep veins. This can cause venous blood to pool in the lower leg. When this happens, it can cause increased pressure within veins as the blood travels back towards capillaries. This results in the release of fibrinogen and haemoglobin from the capillary and causes hemosiderin staining, which in turn leads to fibrosis of the tissue (known as lipodermatosclerosis) and induration.2
The Sign Guidelines3 define a chronic venous leg ulcer as “an open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease.”1-3
Case Study: Tom
Tom is a healthy 71-year-old man with chronic venous ulceration. Tom has been cared for by the vascular department in the acute trust on and off for over 20 years. In the past, Tom has been treated for pancreatic and prostate cancer and is now in remission from the disease; part of the treatment for the cancer was to remove most of the pancreas, leaving him with unstable blood sugars requiring daily testing, however he is not classed as having diabetes.
Part of the role of the Wound Prevention and Management Service (WPMS) in the community is to support practice nurses with leg ulcer management. At the time the nurse met Tom, he was requiring daily dressings, and she agreed to see Tom weekly to help with his care.
Tom had expressed to the clinician that his quality of life had been seriously affected by the condition of his legs – mainly because he couldn’t wear normal shoes. His ability to get out with his wife and lead a normal life was important to him.
Tom’s ulceration was extensive to his right leg. He presented with deep, sloughy ulceration to his medial and lateral malleoli (typical of venous ulceration) and to the dorsum of his foot and his toes (more prevalent in diabetic foot ulcers and arterial ulcers). The ulceration was present also around the gaiter area of his leg extending up the leg (venous). The surrounding skin was red, inflamed and macerated, due to the high exudate levels coming from the ulcers. Tom was being treated with the advice from the vascular team, who had carried out a doppler assessment, gaining a reading of one bilaterally, which is indicative of venous disease.4 However, as Tom’s ulceration was also pointing towards an arterial element, the vascular team had arranged an magnetic resonance angiography (MRA) to look at the arteries for evidence of narrowing or blockages. For this reason, Tom was not in compression therapy of any kind during that time.
It was clear from the appearance of Tom’s leg and ulcers that the treatment he was receiving was not promoting wound healing. This decision was made by the medics for good clinical reasons; however Tom required intervention to speed the healing process along.
The main aim of Tom’s treatment was to promote wound healing while improving and protecting the surrounding skin.1 As Tom’s condition was not new to him, he knew that the process would be a long one and involve specific treatments. With this in mind, the treatment plan was undertaken jointly.
Gathering information from Tom and the vascular department was essential in order to plan the next step in Tom’s care plan. As identified previously, a doppler assessment was carried out and revealed that Tom was safe to have compression therapy, which is ‘gold standard’ treatment for venous leg ulcers.5 The results from the MRA showed clear vessels to below his knee; however the picture below that point wasn’t clear enough for the radiologist to be absolutely sure that the vessels to the lower leg and feet were normal. The vascular consultant was almost certain that the ulcers were venous in origin, but without a clear picture, a final diagnosis could not be made until the MRA was repeated. The nurse discussed this with her manager and a joint visit was undertaken to ensure the best treatment was decided upon.
The pedal pulses were present and strong and the doppler signals were biphasic, which indicates arterial flow to the foot. The Royal College of Nursing Leg Ulcer Guidelines (RCN)1 report that the pulses should be taken in to account during the initial assessment of the patient but should not be used solely as an indicator of the presence of arterial disease. In Tom’s case assessing the pedal pulses and the sound of the Doppler signal were helping the nurse to decide, along with all the other evidence, that Tom was in fact safe to receive compression therapy.
Tom was consulted on the predicament the nurse and her manager faced, and it was decided jointly between the team and Tom that compression therapy would be applied and Tom would be monitored closely by the WPMS. Following the RCN Leg Ulcer Guidelines,1 Tom’s ankle was measured and the appropriate bandages were prescribed.
The skin to Tom’s leg also required intensive treatment. The condition appeared to be inflamed venous eczema exacerbated by the ulcer exudate. Local trust guidelines state that emollients are first-line therapy for atopic eczema but in cases of flare-up, a topical corticosteroid is the first-line treatment, in conjunction with regular emollient therapy. This is supported by the National Institute for Health and Care Excellence (NICE) guidelines, Frequency of application of topical corticosteroids for atopic eczema.6 In this case we were treating what appeared to be venous eczema, related to chronic venous insufficiency. There are no clinical guidelines to support the treatment of venous eczema, however NICE clinical knowledge summaries of good practice recommendations based on current literature report that venous eczema responds to topical corticosteroids.7
It was decided that a topical corticosteroid was required to treat the surrounding skin. Due to the severity and the distribution of the inflamed skin, the decision was made to prescribe a potent steroid rather than a mild or moderate one. Elocon (Mometasone Furoate) 0.1%, a potent topical corticosteroid and a prescription-only medicine, was prescribed to treat this condition. The British National Formulary (BNF),8 states that Elocon can be prescribed for “inflammatory skin disorders such as eczemas unresponsive to less potent corticosteroids.”8 Local trust guidelines for the treatment of eczema,9 advise that Elocon cream as opposed to an ointment should be prescribed for wet eczema as this promotes absorption and eases application.9
The BNF8 states that “corticosteroids suppress the inflammatory reaction during use; they are not curative and on discontinuation a rebound exacerbation of the condition may occur.”8 There are side-effects associated with using a potent steroid, namely thinning of the skin, contact dermatitis, perioral dermatitis, acne, or worsening of acne and rosacea, mild depigmentation which may be reversible.8 The BNF continues to advise that to minimise the side-effects, apply a thin layer to the affected areas only no more than twice daily, suggesting prescribing one fingertip unit of corticosteroid per area that is twice that of a flat adult palm (approx 500mg); this appears to be easier to follow than “apply thinly”.8 The BNF has a table on quantities of corticosteroid preparations.
The plan was for Tom to have treatment every second day, having input from the practice nurses, the district nursing team and the Wound Prevention and Management service (WPMS). The clinician planned to review Tom weekly, at this point the legs could be reviewed and treatment changed accordingly.
After just two weeks of steroid treatment and four layer compression therapy, the skin had improved and the ulcers reduced in size. There was no evidence of maceration to the surrounding skin as the exudate levels were being managed with the frequency of dressing change. The initial concern over commencing full compression to the leg was alleviated as the ulcers were responding well to the treatment.
Over a three-month period, having received intensive treatment from the WPMS the leg was showing remarkable improvement. Tom was now seeing his practice nurse once a week and was self-caring with leg ulcer compression hosiery. The impact this had on Tom’s activities of daily living was immeasurable; he was more mobile, more active and most importantly, Tom was now able to wear shoes.
The role of the specialist wound prevention and management nurse as a non-medical prescriber is a valid one. The skill enables the clinician to prescribe treatment effectively and without delay, eliminate the cost of inappropriate prescribing and provide sound rationale for the prescribing decisions they make, using a robust evidence base.
1. Royal College of Nursing. Clinical Practice Guidelines: The Management of Patients with Venous Leg Ulcers. London: Royal College of Nursing; 2006.
2. Anderson I. Aetiology, Assessment and Management of Leg Ulcers. Wound Essentials 1:20-37;2006.
3. Scottish Intercollegiate Guidelines Network. A National Clinical Guideline: The Management of Chronic Venous Leg Ulcers. Edinburgh: SIGN; 2010.
4. Marston W, Vowden K. Compression Therapy: A Guide to Safe Practice in European Wound Management Association (EWMA) Position Document: Understanding Compression Therapy London: MEP Ltd; 2003.
5. Harding K, et al. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd; 2008.
6. National Institute for Clinical Excellence. Frequency of Application of Topical Corticosteroids for Atopic Eczema London; 2004. Available at: www.nice.org.uk/TA081guidance.
7. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Venous eczema and lipodermatosclerosis. London: NICE; 2013.
8. BNF. British National Formulary: No 62 - September 2011. London: BMJ Group; 2011.
9. Fallon J. NHS Leeds Community Healthcare – Guideline for the Treatment of Adults with Atopic Eczema Including use of Topical Corticosteroids. Leeds; 2010.
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