VOL: 98, ISSUE: 44, PAGE NO: 59
Janice Roberts, RGN, is a community nurse, Guildford and Waverley Primary Care TrustMr Hall is a 64-year-old man with extensive and painful leg ulceration. He was first seen by the district nursing team in March 1999 for the treatment of his leg ulcer.
Mr Hall is a 64-year-old man with extensive and painful leg ulceration. He was first seen by the district nursing team in March 1999 for the treatment of his leg ulcer.
He had a history of intermittent claudication dating from 1995 and had had arterial surgical intervention. In 2001 he was admitted to hospital for debridement of his ulcer in preparation for skin-grafting but he refused this treatment and was discharged.
Mr Hall's hospital discharge letter in October 2001 stated that four-layer compression bandaging was to be applied to his 'venous' leg ulcer. As a team we were not prepared to apply compression bandages until a full assessment, including a Doppler ultrasound, had been completed. This is supported by the RCN (1998) in its clinical practice guidelines.
Callum et al (1987) stated that the misdiagnosis of an arterial ulcer can have dire consequences if tight bandages are applied to a leg that already has reduced blood flow. It may lead to tissue death and even result in patients having a limb amputated. Considering Mr Hall's history it was important to completely reassess his leg ulcer, undertaking a holistic assessment as advocated by Moffatt and O'Hare (1995a).
The Doppler assessment was delayed until Mr Hall's pain control improved with analgesics so that an accurate ankle blood pressure reading could be obtained without causing unnecessary discomfort. The initial assessment was completed in February 2002 with his full cooperation. The Doppler assessment establishes the presence and extent of arterial disease (Moffatt and O'Hare, 1995b). However, diagnosis must not be made using Doppler studies in isolation (Gibson, 1995).
The majority of patients with leg ulcers are cared for by community nurses. A study by Callam et al (1985) found that 83% of these patients had nursing treatment for their leg ulcers in their own home. If this is the case and a Doppler assessment is a necessary part of the holistic assessment then we must expect community nurses to have the necessary skills. However, Moffatt and O'Hare (1995a) highlighted that many nurses perform Doppler assessments with limited or no training.
Although his ulcer was extensive, Mr Hall tolerated the procedure well. Despite his arterial insufficiency he was able to rest on his bed and have the blood pressure cuff inflated at his ankles. Hampton (2000) stated that pain usually increased with the limb elevated in patients with arterial disease. On reflection, the assessment was undertaken at the time when Mr Hall's analgesia was at its optimum efficacy.
Flanagan (1997) highlighted that infection and anxiety cause pain, and a wound swab indicated the ulcer was infected. It is important that any ulcer is covered in a plastic sheet as an infection control precautions to protect the sphygmomanometer cuff from contamination with body fluids (Herbert, 1997).
The Doppler assessment was completed, with Mr Hall lying flat for 10-20 minutes to ensure an accurate resting systolic blood pressure reading (Jones, 2000), with no pressure on nearby vessels (Vowden et al, 1996). The results showed that he had an ankle brachial pressure index (ABPI) of 0.48 on his ulcerated leg and 0.66 on the other leg.
In accordance with local policy guidelines, Mr Hall was referred immediately to a vascular consultant, as these readings indicate arterial disease. Williams et al (1993) report that with an ABPI of less than 0.6 the ulcer is possibly due to arterial insufficiency, and no compression bandages should be applied until further expert assessments have taken place.
The Doppler assessment results were discussed with Mr Hall's GP who wrote immediately to the vascular consultant and the team that had discharged him from hospital several months earlier.
As a result of the referral Mr Hall was seen at the vascular clinic and a repeat Doppler ultrasound was performed. A Duplex scan is to follow, but at present there is a waiting list.
The following day a return visit was made to Mr Hall to explain his referral to the vascular consultant and the reasons for this. It was explained in layman's terms that the blood was not getting down to his leg ulcer adequately and that we needed to find out why it was not. It was hoped that specialist referral and treatment would result in an increased blood supply to the lower limb, which would facilitate wound healing and pain reduction.
The Doppler assessment is an integral part of the holistic assessment of a leg ulcer. This was important in Mr Hall's case due to the incorrect information on the hospital discharge letter. Mr Hall's compression bandages were not applied and he was referred back to the vascular consultant for further investigation. His care has helped us to further appreciate that each patient is unique and assessment must be individual and holistic. By analysing the care he received the district nursing team are reviewing Doppler assessment procedures critically.
- This was written as part of the Principles of Wound Management course in part-fulfillment of a BSc Hons in Tissue Viability at the University of Hertfordshire.