Wound Management - Management of bilateral leg ulcers

Fegan, Marianne (2002) Wound Management - Management of bilateral leg ulcers, World of Irish Nursing, 10 (4) April pp 35-36.

Marianne Fegan outlines the management of a case of chronic bilateral circumference exudating leg ulcers 

Molly’s medical history
  • Hypertension despite medical management
  • Unstable cardiac rhythm
  • Acute renal impairment and inadequate urine output
  • One episode of confusion
  • Non-insulin dependent diabetes
  • Venus leg ulcers
Procedures/investigations
  • Insertion of central line for dialysis
  • Haemodialysis x 2
  • CT Brain: showing general atrophy
  • Reviewed by vascular surgeons

Molly, a 77 year old woman, had chronic bilateral circumference exudating leg ulcers. She had been an inpatient for two months with a complicated medical history (see Table 1) prior to being referred to the dressing clinic.

While in hospital she developed acute renal failure and was transferred to another hospital for dialysis. It was at this stage that her leg ulcers worsened. The legs required twice daily dressings, and even with this intervention her slippers became sodden with exudate.

The medical notes stated that Molly’s  compliance and adherence had been a problem in the past. Prior to admission Molly had often removed the dressings or refused to have them in place at all. Alternatively grape seed oil and talcum powder were used at her own discretion.

As an inpatient Molly had a duplex venogram of both legs. The right side showed there was evidence of some incompetence in the long saphenous vein near its junction with the common femoral vein. No deep venous incompetence was noted, nor was there incompetence in the short saphenous vein.

The left side showed incompetence at the junction of the short saphenous vein and the popliteal vein, but no evidence of incompetence in the long saphenous vein, nor evidence of deep venous incompetence (see Table 2). Molly’s leg ulcers came into a category of mixed arterial venous leg ulcers. After discharge from the ward Molly was referred to the dressing clinic.

Nurse assessment in the dressing clinic

Molly needed the assistance of a wheelchair to get to the dressing clinic. She was accompanied by her son and husband. Her base line condition was assessed:

  • BP: 170/80mmHg
  • weight: 103.5kg
  • urine showed no abnormalities
  • blood sugar: 7.7mmol/l (non-insulin dependent diabetic)
  • a swab was taken of both legs for culture and sensitivity.

Exudate from Molly’s leg ulcers was copious, she said: "It feels like water running out of me". Molly avoided crowded areas "as her legs might get knocked" and this was particularly difficult for her as her family were very involved in acting and the theatre in general.

Management – phase 1

While an inpatient the vascular surgeon had examined Molly and considered skin grafting. A regimen had been agreed between the nursing and medical staff (see Table 3 – Phase 1).

On February 23, 2001 a decision was made to continue treatment with Intrasite gel and Kaltostat. Wound pads were changed to Lyofoam C to deodourise and aid absorption. Netelast was changed to bandages. (Molly was reluctant to change to bandages, as they were reminiscent of previous bad experiences with pressure bandaging.)

A wound swab was taken of both legs, which showed that the ulcers were infected (see Figure 1). This was treated with ciprofloxacin (see Table 2).

Molly’s mobility was assessed, she used a wheelchair and two sticks for transferring. For pain she took dextroproxyphene hydrochlor (Distalgesic). Daily dressings were necessary for one week, after which they were done on alternate days.

Management – phase 2

On examination on April 24, 2001 the percentages of infection free areas were increasing and over-granulation was becoming a problem (see Figure 2). The decision was taken to change Molly’s primary dressing from Intrasite gel to Aquacell (dry). 

Prior to this the main problems had been:
  • maceration around the ulcer
  • slough decreasing but still evident
  • strike through on bandages
  • dressing every alternate day
  • dressings taking 40 minutes to change.

With the introduction of Aquacell we could increase the layers of dressings without her bandages being too bulky or changing the shape of her leg. Macerations and strike through decreased. The dressing time took 25 minutes rather than 40 minutes.

Aquacell acts by absorbing fluid into the fibres which increases the fluid handling capacity of the dressing per unit weight of dressing material, therefore reducing lateral wicking and encouraging vertical wicking. The benefits of vertical wicking ensure that moisture is retained immediately on the open wound in line with the principles of moist wound healing.

With the new treatment, Molly’s mobility improved and with the noticeable increase in her strength, a physiotherapy referral was suggested. By this stage the wheelchair had been discarded and she was walking with one stick. We thought it important to have her heel-toe foot action checked.

At this point Molly stated that she did not wish to have skin grafts. Her pain was not an issue and the odour had decreased significantly.

The family continued to be supportive and insisted that her legs be elevated while resting. Her bed-end had been raised by nine inches; her son did her shopping while her husband cooked daily.

Swabs were sent for culture and sensitivity as her dressings were blood stained, but the results returned moderate flora and no infection.

Management – phase 3

This phase began on May 16, 2001. Molly attended the vascular surgeon who recommended commencing Profore Lite bandages. This was commenced as Molly’s adherence and compliance were not now an issue. Aquacell was used to absorb exudate. Molly did not complain of pain or discomfort and by the second week her bandages were changed every five days. She bought herself a pair of ‘Ecco’ shoes and now enjoyed shopping and theatre going (see Figure 3).

Management – phase 4

June 29, 2001 was the cut off point for the case study. At this point Molly was waiting to see the vascular consultant to consider discontinuing Profore Lite and commencing compression hoisery. Management continued as in Phase 3 except that her dressings were changed once a week. Molly was eager to try compression hosiery (see Figure 4).

Wound assessment and treatment
 
Phase 1 (base line)
Phase 2
Phase 3
Phase 4
 
Right leg
Left leg
Right leg
Left leg
Right leg 
outer/inner
Left leg 
outer/inner
Right leg 
outer/inner
Left leg 
outer/inner
Slough  
Granulation  
Epithelisation
60% 
30% 
10%
50%
40%
10%
5% 
30% 
65%
15%
40%
45%
5%/5% 
60%/55% 
36%/40%
nil/nil 
30%/30% 
70%/70%

Marianne Fegan is nurse specialist in wound care and tissue viability at St. Michael's Hospital, Dun Laoghaire.

Acknowledgement

The Author wishes to thank Geraldine Regan, Director of Nursing, St. Michael's Hospital for her support.


All rights reserved by INMO. Please don't use without permission