Dora Margarida Ribeiro Machado1*, Manuel Alberto Morais Brás2, Assunção das Dores Laranjeira de Almeida3, Isabel Maria Pires Silvério1, Maria Isabel Mendes Rodrigues Pereira Domingos1 and Mafalda Beatriz Dias Ribeiro4
1ACES Grande Porto III Maia/Valongo, USF Pirâmides, Portugal
2Instituto Politécnico de Bragança, Investigador Integrado no CINTESIS e Professor na Escola Superior de Saúde de Bragança, Portugal
3Assistant Professor, Universidade de Aveiro, Portugal
4Escola Superior de Enfermagem, Porto, Portugal
*Corresponding author:Dora Margarida Ribeiro Machado, ACES Grande Porto III Maia/Valongo, USF Pirâmides, Portugal
Submission: March 01, 2021;Published: March 09, 2021
ISSN: 2576-8875 Volume8 Issue1
Family Health Nursing focuses its action on the user and family and, due to its centrality and proximity, it is the main responsible for monitoring chronic diseases, where leg ulcers stand out. Given the complications that they represent in the user and family, it is essential that the Family Nurse masters their characteristics, to distinguish their etiology, as well as the different treatments available, adapting them to the particularities and background of the user. Compressive therapy is a good alternative to apply to venous ulcers, if the essential criteria for its application are met. It is up to the Nurse to evaluate them and, when properly instructed, their application, to enhance health gains and cost adequacy.
Keywords: Leg ulcer; Family health; Therapeutics
Of the different nursing specialties is Family Health (Regulamento n.º 428/2018) which implies greater involvement with the user and family. It is the Family Nurse who will know you best and who, most assiduously, will accompany you in situations of chronic illness, such as leg ulcers. Its function is to promote health and prevent disease, through health education, management, coordination and evaluation of care, which must be centered on the person, as an individual inserted in a certain family system and social context.
In view of the need to define an adequate treatment plan, based on scientific evidence, it is essential that nurses identify the etiology of the leg wound and, therefore, master its characteristics.
Leg ulcers are included in the group of chronic wounds, due to their long durability - greater than six weeks - and high recurrence in a short period of time [1,2].
Studies [3,4] indicate that these injuries are impactful for both the user and their family. In the individual it affects (1) their physical and occupational function, by limiting the activities of daily living, pain, edema and difficulties in performing personal hygiene; (2) its psychological function, due to anxiety caused by the fear of visualizing the lesion and its odor, leading to a change in body image, shame, disgust and difficulty in social contact; (3) financial level, due to incapacity for work, which leads to absenteeism and dismissal, and expenses with treatments, whether with medication or transportation; and (4) their social interaction, due to limitations that the treatment itself invokes, namely in the performance of some sports and trips to the beach. All of them have implications for the family system due to the isolation and social restrictions they represent.
There is no consensual definition of leg ulcer, however, the most
comprehensive is the presence of “(…) continuity solution in the leg
that occurs in previously injured skin reaching the papillary dermis
and that leaves a scar” (Andriessen, 2002 quoted by Furtado [2]).
According to Morison [5] leg ulcers can have different causes,
namely: venous insufficiency, arterial occlusion, microcirculatory
disorders, physical or chemical injuries, neuropathies, infectious
diseases, hematological diseases, coagulation disorders, metabolic
diseases, neoplasms , ulcers secondary to drugs and ulcerative
dermatoses. About 80 to 90% of cases represent ulcers of venous
etiology [6].
A differential diagnosis is essential for the prognosis and
decision-making of the care plan to be carried out. Thus, it is
vital to assess the user holistically, paying special attention to
his or her background, personal and family, signs and symptoms. It
is also recommended to evaluate the Ankle Brachial Pressure Index
(ABPI) and in some cases the venous and arterial flow of the lower
limbs [2].
Arterial ulcer
Patients with arterial leg ulcers have the most advanced
form of peripheral arterial disease, the most common underlying
pathological process of which is atherosclerotic disease. It is
associated with an ABPI <0.5-0.7, an age over 65 years and several
comorbidities, such as: smoking, hypertension, dyslipidemia,
hyperhomocysteinemia, inflammatory markers, hyperviscosity and
hypercoagulability states, renal failure chronic and diabetes mellitus
[7].
These ulcers usually appear in bony prominences of the foot
and are the result of minor trauma. Peripheral pulses are weak or
absent. There is a deficient capillary filling time, the skin is cold,
shiny and with diminished hair follicles, due to weak peripheral
perfusion, loss of subcutaneous tissue (due to weak perfusion and
decreased muscle exercise due to functional limitation of the leg) ),
there may be necrosis of the foot or toes, mostly associated with
trauma, and pain at rest, enhancing intermittent claudication [2].
Venous ulcer
Venous ulcers represent the most advanced stage of chronic
venous disease, so its approach implies an understanding of the etiological
mechanisms of Chronic Venous Insufficiency (CVI), which
very briefly result from a vicious cycle between chronic venous hypertension,
heart failure valve system and the structural and functional
modification of the walls of the veins to which an inflammatory
response that promotes skin changes is associated. The veins
of the lower leg are divided into perforating, deep (carrying most of
the blood) and superficial (just below the skin). The evidence explains
“(...) that the fragility of the vein wall conditions dilation with
secondary enlargement of the valve ring, preventing adequate coaptation
of the valve leaflets”. The perforating veins may also become
incompetent in a primary way, however the most common is the
coexistence of the incompetence of the perforating veins and the great saphenous vein. Hence, some authors defend the reestablishment
of the valve competence of the perforators by removing the
saphenous vein system [8]. In more detail, and according to Escaleira
[8], “(…) the perforators act as safety valves allowing the escape
of blood under high pressure, which is conducted to the superficial
veins promoting the dilation of capillaries and leakage of contents
intravascular in the interstitial space ”.
In venous ulcers, the patient experiences pain and swelling of
the legs, and the symptoms are accentuated at the end of the day and
with the leg hanging, relieving with the elevation of the same. Mostly,
they are located 2.5cm above the malleolus to the prominence of
the twin (gastrocnemius muscle). The edges are generally sunken,
irregular and rounded, there is abundant edema and exudate, there
is reference to pain, history of varicose veins, varicose eczema,
white atrophy and lipodermatosclerosis and hyperpigmentation of
the adjacent skin [2].
Venous drainage of the lower limb
Draining venous blood from the legs to the heart needs to
overcome gravity. It is the muscles surrounding the thigh, leg and
foot and the compression of the network of veins on the plantar
surface of the foot that favor venous return. The twin (gastrocnemius
muscle) appears as the most important muscle of the leg, staying
active during gait and with the movement of the ankle. However,
due to the increase in age and the consequent inactivity, its function
decreases [9]. In the process of transition from horizontal to
vertical, the pressure of the venous system, due to the accumulation
of blood in the lower extremities, increases. As the person moves,
the pumping effect of the muscles reduces this pressure and forces
the blood flow to the heart. Immobility will increase this pressure
again. In a healthy individual, during exercise the venous pressure
drops to about 30mmHg, however, in the presence of venous disease
the reduction is much less expressive, so rest and elevation of the
leg help in the relief of symptoms [9].
On the other hand, when muscle relaxation, it is the valves
in the veins that prevent blood reflux. The valves are found in the
perforating and superficial veins. Chronic venous insufficiency
occurs when these valves do not work properly, due to weakening
resulting from varicose veins, deep vein thrombosis, venous
obstruction or trauma. This results in blood reflux, preventing the
reduction of venous pressure and resulting in venous hypertension
[9]. Negative chest pressure during inhalation also helps venous
return [9].
In a resting individual the venous pressure of the lower limb is
determined by the distance between the ankle and the heart. Venous
hypertension is related to the maintenance of high mean venous
pressure in the ankle. This hypertension causes abnormalities in
the capillaries of the leg tissues, making them more permeable
and, therefore, allowing blood cells, proteins and fluids to escape
into the tissues. In addition, it may be related to an increased
inflammatory response, changes in the microvasculature and
reduced oxygenation of the skin and tissues. Venous hypertension causes changes in subcutaneous tissues and skin, such as edema,
lipodermatosclerosis, varicose eczema, white atrophies and
hyperpigmentation, contributing to skin fragility and an increased
risk of leg ulceration and delayed healing [9].
ABPI (Ankle-Brachial Pressure Index)
The ABPI is an internationally validated, non-invasive measure.
It is the ratio between the systolic pressure obtained in the lower
limb and the highest value of systolic pressure obtained in the upper
limbs. The interpretation is made with the aid of reference value
tables, where an ABPI> / = 1 is normal and “(...) lower values reveal
arterial compromise, the greater the closer to zero”. It takes between
10 and 15 minutes, can be performed by a Nurse or Doctor, and
needs as instruments of a sphygmomanometer and a stethoscope
or, for greater precision, an Ecodopler [10].
The calculation of this Index is essential for decision making
in the treatment of a leg ulcer. It is important to mention that in
patients with venous ulcers, due to the frequent presence of edema,
palpation of the pulses can be difficult, so that, if other evaluation
strategies are not used, decision making is limited [10].
Treatment of leg ulcers
The treatment of a leg ulcer implies a constant review of the care
plan, with systematic assessments and appropriate prescriptions
for the stage of the wound, considering the patient’s background
and available resources [6]. In arterial ulcers, referral to vascular
surgery is essential for eventual revascularization. The control of
symptoms, namely pain, and the use of dressing material agreed
with the principles of ulcer treatment is a priority. Compressive
therapy is contraindicated.
In venous ulcers, treatment must respect four elements: (1)
venous stasis, by rest and compression therapy; (2) topical therapy
with cleaning the wound bed, with warm water for irrigation
or serum, eventually debridement, maintaining a clean, humid
environment and exudate absorption; (3) control of possible
infections, namely associated with the duration of the wound, where
some studies demonstrate that the use of the drugs pentoxifylline
and purified flavonoid micromized have a very positive effect on
healing; (4) patient education about signs, symptoms, wound
complications and hygienic-dietary measures [6,8].
In addition, in the treatment of venous ulcers, to improve
venous return, circulation activating exercises can be performed,
from which stand out:
a) supine position, place the lower limbs elevated, above the
level of the heart, for about 2-3 minutes
b) sitting, with the lower limbs hanging down, doing
dorsiflexion and plantar flexion of the foot and toes, for 3
minutes
c) supine position, place the lower limbs supported at the
level of the heart for 5 minutes.
The importance of keeping the perilesional skin clean and
hydrated is emphasized, in order to prevent infections in the
injured tissue. In venous ulcers, proper compression is essential for
the healing process, as it allows the reduction of superficial venous
pressure, facilitates venous return, increases the speed of flow in
deep veins and reduces edema [2].
Compression therapy
Compressive therapy is called the application of compression of
the lower limb, using specific bandages, compression stockings or a
pneumatic device, to prevent reflux, by promoting the reabsorption
of fluids from the interstitial to the intravascular space [11]. Its
main objective is to correct complications of chronic venous
insufficiency, so the use of external compression systems on the
lower limbs is used to increase pressure on the skin and underlying
structures. In this way, it counteracts the force of gravity, acts on the
lymphatic and venous systems, redistributes fluids, reduces edema
and pain and promotes ulcer healing [8,9].
The most used compression therapies are compression
stockings and bandage components around the leg (full leg or up
to the knee), the former being more suitable for preventing ulcer
recurrence and the latter for ulcer treatment [8,9]. Compressive
therapy systems are categorized in particular by the pressure they
produce, being less than 20mmHg considered gentle, moderate
20-40mmHg, 40-60mmHg strong and 60mmHg very strong
[8,12]. Compression systems can contain inelastic and/or elastic
materials, most of which function as inelastic, even if they contain
elastic components [8,9].
Compression therapy works by creating a closed system that
allows for uniform distribution of internal leg pressures and
by varying interface pressures according to the tension of the
applied bandage and the shape of the limb. Compression bandages
maximize the effect of muscle movement, reducing the diameter of
the veins inside the leg, favoring venous return. Thus, the volume of
local blood is reduced, helping to produce a more adequate venous
pressure, and edema, by decreasing fluid output from capillaries
and reabsorption of the vascular and lymphatic systems [8,12].
It should be noted that the incorrect application of the bandages
can cause damage to the tissues, namely pain, due to pressure, in the
bony or tendinous prominences, this is because, imagining circles
in the limb, the pressure will be greater the smaller the circle. Hence
the importance of padding in pressure risk areas [8].
Studies [13,14] show that, compared to conventional
treatments, healing rates increase when adequate compression is
applied and that it is less expensive.
In ideal compression therapy there are factors to consider, they
are:
a) incorporate an inelastic component. which will produce
a greater variation in interface pressure during gait (massage
effect), being more effective in venous return, compared to elastic systems, as it produces higher pressure peaks during gait
and lower peaks at rest; hence the importance of encouraging
the user’s gait [8]
b) be comfortable, particularly at rest; Compression therapy
is effective in different sizes and shapes of the limbs, and can
be used even in deformed limbs, since its cohesive properties
allow the bandage to mold to the limb and restart in any part of
it, after cutting, with subsequent filling of any gaps; as a rule, it
is tolerable to high pressure during movement, however at rest
it can become uncomfortable and therefore unsafe; discomfort
can cause poor adherence, reducing the rate of healing and
increasing the time for healing [9].
c) allow functionality and movement, and the system must
be as adapted and as thin as possible, allowing the continuation
of usual activities so that, as already mentioned, it enhances its
action.
d) be easy to apply and adaptable.
e) be durable and non-allergenic; some users may develop
skin allergy if the system used contains latex, which is why,
whenever possible, it is essential to collect a detailed medical
history that warns of allergic history in order to make the most
appropriate material possible [8,9]
Having ensured these factors, it is still vital:
a) examine the patient globally, with an assessment of the
peripheral blood supply, his neurological and cardiac status, the
condition of the skin, the presence of edema, allergic history,
level of mobility and shape of the limbs; eventually, request an
opinion on vascular surgery.
b) inform about the treatment plan.
c) follow the manufacturer’s instructions, namely, the
application of bandages with maximum ankle dorsiflexion.
d) ensure compression on the calf muscles, as, as mentioned,
the pressure will decrease the greater the circumference and
it is vital to ensure sufficient pressure in the twin muscle to
provide venous return.
e) resort to the use of padding, when necessary, to ensure
the adjustment of the bandage and protect areas from pressure
damage or to manage excessive exudate; nevertheless, it is
necessary to remember that when increasing the circumference
of the limb with the padding, compression will be reduced
and therefore the compression therapy system; some systems
already incorporate textiles in bandages to prevent this volume.
f) use elastic stockings after healing to prevent recurrences
and teach the patient about appropriate placement and
importance of use.
g) systematically update and reassess the care plan and
records of interventions.
h) ensure good skin care and ask the user to lift the limbs
when at rest.
i) promoting the user’s adherence to treatment, namely
through the discussion of possible options and the method of
application [9,15,16].
After consultation with the above topics and confirmation of the presence of a patient with venous ulcers, ABPI>0.8 and tolerance to compressive therapy, this treatment may be used.
The leg ulcer has multifactorial implications for the patient and family. It is therefore essential that the Family Nurse, due to its centrality in the health of the patient and family, effectively distinguishes the different types of chronic leg ulcers and the most appropriate treatments for each of them, respecting the personal and hereditary antecedents. In addition, he should know and make use of compressive therapy, whenever it is considered the most appropriate, to prevent the use of differentiated care, reduce the cost and duration of treatment and avoid possible hospitalizations and associated morbidities. In this way, it will increase health gains and will be responsible for the reduction and adequacy of costs associated with health care.
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