VOL: 98, ISSUE: 08, PAGE NO: 51
Anita Kilroy-Findley, RMN, is tissue viability nurse, mental health, and ward manager, Welford Ward, The Bennion Centre, Leicestershire and Rutland Health Care NHS Trust
Carolyn Wheatley, RGN, is community tissue viability nurse, Leicestershire and Rutland Health Care NHS TrustAnita Kilroy-Findley, RMN, is tissue viability nurse, mental health, and ward manager, Welford Ward, The Bennion Centre, Leicestershire and Rutland Health Care NHS Trust
Leg ulcers are costly, both in human terms, as patient quality of life is reduced (Charles, 1995; Franks, 1998), and in financial terms, with reported costs estimated between £400-800m a year (Morison, 1993). The greatest proportion of this cost is to fund nursing time.
Approximately 1.5-3 per 1,000 of the general population has active leg ulcers, but this rises to 20 per 1,000 over the age of 80 (RCN, 2000). Leg ulcer management has had a higher profile in recent years, possibly due to changing health care strategies and realisation of the high care costs associated with them.
Full assessment of the patient's vascular status is crucial and should be undertaken by an experienced health care professional with a sound knowledge of the relevant anatomy. Holistic assessment is also essential, as well as assessment of the wound (Collier, 1994), as thorough assessment reveals factors that must be simultaneously addressed if nurses are to avoid applying inappropriate treatments.
Where venous disease is indicated following Doppler ultrasound assessment, graduated multi-layer high compression bandage with adequate padding, capable of sustaining compression for at least a week, should be a first line treatment for uncomplicated ulcers (Cullum et al, 2000; RCN, 2000). In the UK, compression bandages are normally applied by nurses. Well trained, experienced bandagers have been found to obtain better, more consistent results than inexperienced nurses who have not had training in applying the bandages, and tend to apply inappropriate, widely varying pressures (Logan, 1992; Nelson, 1995; Stockport, 1997).
Margaret Castle was admitted to a psychiatric unit for elderly people with mental health problems during a hypermanic episode at Christmas 1999. She had no history of mental illness but presented with auditory and visual hallucinations of Princess Diana and auditory hallucinations of God. After a recent domiciliary visit the district nurse had queried whether Mrs Castle had personality problems.
Mrs Castle was a methicillin-resistant Staphylococcus aureus carrier. Her legs were oedematous and dressed with Actisorb Plus and a crepe bandage. She used a frame to walk short distances and needed assistance to stand. Her euphoric mood caused lack of awareness of her urinary incontinence, mental and physical problems.
Mrs Castle's previous medical history included congestive cardiac failure, atrial fibrillation and severe arthritis in the hips. In 1969 she had undergone stripping of her varicose veins and she had had leg ulcers for 31 years. In January 1999 she developed a large haematoma (15.5x11cm) on her left calf, which resulted in a skin graft in April 1999.
Mrs Castle was seen by vascular services in August of that year, and a duplex scan confirmed deep venous disease which would not be helped by surgery. Three-layer compression bandage treatment was prescribed, and Mrs Castle was told that if this did not work she would need to consider amputation. She had a real fear of this, as her father had been an amputee due to extensive leg ulceration.
Compression treatment proceeded in the community but was discontinued by the district nurse due to Mrs Castle's urinary incontinence and the fact that her mental state was deteriorating and she was not cooperating with her treatment.
Earlier in 1999 a mental health nurse from the psychiatric unit had been seconded to tissue viability to assume the role of tissue viability nurse mental health (TVN/MH). This nurse was on ward duties only over the Christmas period due to staff shortages and was unable to assess Mrs Castle. Ward staff therefore contacted the community clinical nurse specialist (CNS) and tissue viability nurse (TVN) for advice on how to manage Mrs Castle's wounds.
A leg ulcer assessment was carried out which identified extensive bilateral ulcers and black necrotic heels. The ulcer wound beds were a mixture of healthy granulation tissue and slough. There were large amounts of serous fluid exuding and they were slightly offensive. The surrounding skin was oedematous and dry with lipodermatosclerosis.
The left heel displayed a hard, black eschar. The necrosis on the right heel was softer and starting to lift. A repeat Doppler assessment was performed, as three months had elapsed since the duplex scan. The ankle brachial pressure index (ABPI) on the left leg was 0.93 and on the right 0.83, indicating that Mrs Castle did not suffer from arterial insufficiency. Three-layer compression was therefore continued.
The surrounding skin needed rehydration, malodour and bacterial colonisation required control and management of exudate. Wound swabs were taken to ascertain Mrs Castle's current MRSA status.
The community tissue viability team recognised that mental health nurses were not trained in leg ulcer management and were ill equipped to meet the treatment needs of chronic leg ulcers. As a result, the TVN/MH received intensive training in leg ulcer management and compression bandaging from the community CNS and TVN before being assessed as competent to undertake Mrs Castle's leg ulcer care. Without this collaboration Mrs Castle would not have received the first-line treatment option for venous leg ulcers, and mental health staff would have struggled to cope with the wound challenges facing them.
Urinary incontinence constantly soaking Mrs Castle's legs led to clinical infection of the ulcers and bilateral cellulitis. It also meant that her dressings needed to be changed more than four times a day. However, she refused to wear a pad, stating that she knew when she needed the toilet. On the occasions that she did allow staff to take her to the toilet Mrs Castle was unable to sit on it due to a combination of severe arthritis of the hips and gross oedema. Urethral catheterisation was the only option if compression treatment was to proceed, but Mrs Castle refused this, and treatment was postponed.
Mrs Castle was started on trifluperazine to see if this controlled her hallucinations and enabled her to have more insight into her problems. It was explained to ward staff that it would be futile to start compression bandaging on her legs until her incontinence was resolved, because to be effective they needed to be in situ for up to a week. Three days after starting the trifluperazine mental health staff were able to rationalise this with Mrs Castle and she agreed to catheterisation.
Three-layer compression bandaging was started at the end of January 2000. After two months the wound edges of Mrs Castle's ulcers had become more defined, with evidence of epithelialisation.
The catheter produced only limited success, with leakage around it causing Mrs Castle's bandages to become wet. She was referred to a urologist and put on the waiting list for a suprapubic catheter. While at the psychiatric unit Mrs Castle's mood level had become increasingly low as she realised she would be unable to go home and would have to be discharged to a residential facility. She was therefore started on antidepressants. Although she received weekly physiotherapy to encourage mobility Mrs Castle lacked the motivation to move and as a result her legs became more oedematous.
Mental health staff worked with Mrs Castle to help her come to terms with the move to residential care, and her mood level improved. She walked daily round the ward using a frame and would spend short periods of time elevating her legs. She also began to knit again.
Mrs Castle was discharged to a residential home in March 2000 and her leg ulcer care devolved to the district nursing service. The TVN/MH liaised with the district nurse to fully inform her of Mrs Castle's treatment plan and history to ensure continuity of care, and maintained three-monthly joint visits to Mrs Castle at the residential home with the district nurse to facilitate follow-up.
On admission to the residential home, granulation tissue was visible on the outer aspect of Mrs Castle's left foot. Although slough was still evident on all the wounds, it was now a coating rather than deep filling. Maceration was evident on the outer aspect of the foot, indicating that the dressing was not managing the exudate. All the wounds were epthelialising, and scar tissue was evident where they were contracting.
Mrs Castle did not like the hoist used at the home to get her into bed and refused to go to bed for two months. Her legs became extremely oedematous. Due to the physical care needed to meet her needs she was transferred from the residential to the nursing side of the home.
Mrs Castle was upset by the move, as she felt she had no one to talk to in her new home. The move also meant that all her nursing needs were to be met by qualified nurses at the home rather than by the district nursing service. However, no one at the home had been trained in compression bandaging.
The district nurse, who was a key leg ulcer nurse, taught the aetiology of leg ulcers and the art of compression bandaging (theory and practical) to the nurses at the nursing home. Once she confirmed they were competent she was able to discharge Mrs Castle from her caseload.
A reclining chair was ordered for Mrs Castle, as she was adamant that she would not use the hoist to get into bed. The TVN/MH discussed her psychological needs with nursing home staff. They were endeavouring to meet these by taking her across to the residential side for activities, socialisation and outings. It was also suggested that they spend time with Mrs Castle to allow her to express her feelings about the turn her life had taken.
Mrs Castle's suprapubic catheter failed due to a lacerated bowel, which meant she had no urinary catheterisation. She was frequently admitted to an acute hospital over the next few months and her mental state deteriorated. She refused to go to bed, could be resistive to intervention and was frequently wet. She was later admitted to an acute hospital with a grade four sacral pressure ulcer and died there in March 2001.
The ageing population is likely to lead to increased incidence of co-morbidity, resulting in people requiring treatment from several different specialties. As Mrs Castle's case demonstrates, physical ill-health does not preclude people from having mental health problems; indeed, the latter can exacerbate the former.
If equity and continuity of health care is to be achieved for older people with physical and mental health problems, professionals working in different disciplines need to share their skills. The high prevalence of leg ulcers among older people makes it advisable for professionals working in settings where older people are cared for to receive training in leg ulcer management so that they can adequately care for this high-risk group.
Mrs Castle's treatment was carried out in five different settings - her own home, an acute hospital, a mental health unit, a residential home and a nursing home (Box 1). The treatment regimen was started in a mental health unit with the support of tissue viability nurses from the community trust and, where necessary, nurses were given training in leg ulcer care in the other settings.
Attempts to increase training and knowledge of appropriate leg ulcer management in the mental health sector is hampered by the inability of RMNs to gain ENB status in leg ulcer care. If patients receiving care in different settings are to receive optimal treatments, all health care professionals need to be able to gain recognition for their extra training and knowledge.
Liaison and cooperation between tissue viability nurses, mental health nurses, community nurses, residential home staff and nursing home staff resulted in continuity in this case, with the provision of appropriate training and monitoring. In the present climate of severe time constraints and nurse shortages this may not always be possible, but it is an objective to aim for.