“Ulceration of the lower limb has been an affliction of the human race since the time of Hippocrates, it is almost certainly the price we pay for having emerged from the ocean and learnt to stand erect” Burnand (1990).

United Kingdom leg ulcer management is largely nurse-led. Cornwall et al (1986) report that It is estimated that over 80% of leg ulcers are cared for in the community by district nurses. Taylor et al(1998) suggest that district nurses spend some 50% of their time treating leg ulcers.

In preparation for this assignment searches have been conducted using the following databases: Cinahl, Pubmed and Medline search terms: Wound care, Venous leg ulcer, Wound healing, Healing process. Nutritional status and smoking were used singularly or in combination. Manual searching of relevant nursing journals and publications have been performed. Articles published in English in the last 10 years were reviewed. This assignment will examine the issues of holistic care to obtain wound management and healing

In order to comply with the Nursing and Midwifery Code of Professional Conduct Council (NMC (2008); any names used will be pseudonyms to protect identification, confidentiality and dignity will be maintained at all times. The patient chosen for this case study assignment has been given a pseudonym to protect his identity and to maintain confidentiality he will be known as James. Permission was sought to allow access to James’s Community Records Data Protection Act (1984).

The patients’ main medical condition will be focused upon, along with the identification of health and health care needs. The need to include the biological, psychological and social aspects, which will briefly be discussed.

The rationale for choosing this patient and his family is the rapport and trust gained from this client whilst under the care of the district nurse in the Community setting in collaboration with the input from the Multi Disciplinary Team (MDT).

The district nurse has the role of managing a patients’ health and health needs in the community, whether it is in the patients’ own home, a clinic setting or residential home. The district nurse also has the role of teaching patients’ how to look after themselves along with contributions from other members of the family if appropriate. The district nurse will look after the health care needs of the family too if this appropriate. The district nurse will work to keep the number of admissions and re-admissions to hospital to a minimum. Department of Health (2001)

James is sixty-nine years old and he resides in a one bedroomed, local authority owned property. James has been a widower for 3 years, his wife died from cancer. James has a daughter; Victoria and two grandsons Joel aged 7 and David aged 9 years. They live approximately 20 minutes drive away.

His General Practitioner (GP) had referred James to the district nurse service (DNS) for the provision of care for Venous Ulceration. James has attended the ulcer clinic regularly for the last eighteen months.

Victoria often attended the ulcer clinic with her father and with her father’s consent she has been involved with contributing to James’s health care provision. Victoria takes James shopping on a weekly basis and she cooks him a meal daily.

Dealey (1999) suggest that venous leg ulcers affect up to 1 per cent of people at some time in their life. Venous ulcers usually are found in the medial gaiter area of the lower extremity. Briggs and Nelson (2003) suggest that these ulcers are often painful and some clinicians choose dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes. Bosenquet (1992) suggests; estimates that the cost of treating leg ulcer patients varies from £230 million to £400 million yearly in the United Kingdom; with a high percentage of these costs spent on dressings and district nurse spending

James had a holistic assessment, which was of the utmost importance so that an appropriate plan of wound management could be implemented.

Morison (1992) argues, accurate assessment and holistic care are essential, because failure to treat the patient as a whole and identify any problems that might adversely effect the wound could lead to delayed healing.

In order to facilitate a holistic assessment Burnand (1989) reports that the establishment of a good therapeutic relationship with the patient is paramount towards achieving compliance as it gives the nurse leverage to apply skills and procedures.

According to Ross and Mackenzie (1996) assessment are a key part of professional practice and the first most important stage of the nursing process. The nursing assessment should not only focus on the wound exclusively; but must take a holistic approach.

Whilst conducting a clinical assessment of James’s health needs it was reported that his leg ulcer was from trauma due to an accident on the bus. The rational behind a full clinical assessment is to identify the underlying cause of the ulcer and any associated diseases that will influence the decisions about the management and referrals.

It was also revealed that James smoked between thirty and forty cigarettes a day. The district nurse could have encouraged Jack to re- think his smoking habit and offered advice and support if he wanted it. She was mindful of his mood at this initial assessment and decided she would wait for the appropriate time to talk to James about his smoking habit.

Research clearly shows that smoking inhibits wound healing and smoking should be discouraged.

Mosley and Finseth (1977) first reported the detrimental effects of smoking as they observed impaired healing of a hand wound in a smoker with arteriosclerosis. There have been several studies into the effects of wound healing amongst smokers in comparison to non-smokers Siana et al (1989, Sherwin and Gastwirth (1990).

There has been research into the effect smoking has on acute wounds and the results have been conclusive in showing the detrimental effects smoking has on wound healing. (Siana et al1992, Slavin J 1996, Whiteford L 2003), however further research is needed to confirm the detrimental effects smoking has on chronic wounds. Moreover patients who smoke have to cope with the withdrawal form the addiction to the nicotine and should be thoroughly supported.

It had been noted in the patients’ records that James’s priorities were for the ulcer to be healed as quickly as possible. Warren and Alstrom (2000) argue that, often leg ulcer assessments focus on the ulcer alone other factors such as body image are often overlooked. James concerns were that of body image and how having his leg dressed he couldn’t interact with his grandsons as much as he would have liked. James felt the bandages got in the way and the ulcer was smelly. Collier (1997) argues “any wound assessed as being offensive in smell by either patient, practitioner or both is a malodorous

wound “. According to Edwards (2000) main causes of odour are, “dead tissue, infection and exudate”.

Body image is closely associated with self-esteem. Snipes (1987) suggest self-esteem can be defined as the sum total of all we believe in about ourselves. James expressed he felt like an old man with bulky bandaged legs and he felt that this had a negative impact on his ability to enjoy a game of football with his grandchildren.

To help to promote the care plan and the proposed treatment of James’s leg ulcer the district nurse involved James and Victoria in discussing the available treatment and the best treatment appropriate for James.

As accountable practitioners, nurse and doctors; clinical interventions should be based on evidence rather than custom and practice or tradition. (NMC2004).

The building of a trustworthy relationship between James and the district nurse will help to achieve concordance. Working with patients to reach their health goals is important if concordance is to be achieved Marinker (2000). Whereas Jones (2004) argues that effective treatment and assessment help to achieve concordance. Furthermore Marinker (2000) suggests the main barrier to concordance for patients can be an unequal balance of power in the encounter between patients and health professionals, and the fear of not being taken seriously.

James has been having his ulcer assessed on a weekly basis, he had been had been informed of the benefits of the four layer bandage in relation to the healing process and having been commenced on this course of treatment for several months; James became frustrated at the length of time the healing process was taking and he explained ” the bandages were uncomfortable and he feels they restricted his mobility”.

The district nurse suggested a consultation with the tissue viability sister (tvs); after discussions between James, Victoria, the district nurse and the tvs; it was determined the venous leg ulcer would be treated using the short stretch bandaging (SSB) system. Thompson (2000) suggests, in practice, the study of ethics provides a means of evaluating personal views and choices and how they shape our lives and also helps to appreciate the choices others make.

According to Ellis (2004) SSB is effective in the treatment of venous leg ulcers and demonstrates many benefits over other compression systems; however many practitioners are still unaware of SSB as an alternative to multi-layer system.

James understood the benefits of the four-layer system but insisted the SSB system was tried instead. Flanagan (1997) argues it was important to consider alternatives to the four-layer system, in order to promote the moist environment that facilitates the formulation of granulation tissue angiogenesis and epithelialisation.

According to Williams (2002) the advantages of the SSB system are: Most people have an ankle circumference of less than 25 centimetres, so only need two layers applying thus avoiding some of the problems associated with multi layer bandaging; therefore the patient will not be as hot, bulky and sweating.

Hawkins (2001) suggests It was thought that the SSB only worked effectively if the patient was mobile; however they can also be used on the less mobile patient.

The (NMC 2004) states, “As a registered nurse you must respect a patients’ and clients’ autonomy -their right to decide whether or not to under go any health care intervention”. 3.2 it also states, ” You must recognise and respect the role of patients’ and clients’ as partners in their care and the contribution they can make to it. This involves identifying their preferences regarding care and respecting these within the limits of professional practice, existing legislation resources and the goals of the therapeutic relationship”.2.1

The district nurse removes the dressing and reassesses the wound; documenting what she found in James’s Community Nursing Records, (NMC 2004) states, “Health care records are a tool of communication within the team”.4.4 It is paramount that health care records are completed and that they are as precise as they can be this is crucial for continuous care to be maintained.

After the district nurse removed James’s dressing and looks at the progress of the wound; she uses tap water to cleanse the leg. Flanagan (1997) argues that prior to the use of saline, tap water had been used for centuries in the cleansing of wounds. Hollinworth and Kingston (1998) found the use of tap water acceptable especially in the community for the cleansing of Chronic Leg Ulceration. Young (1995) and Pudner (1997) agree, adding there are numerous benefits in using tap water to cleanse chronic wounds in community practice.

The next stage in James’s treatment was to use an emollient to soothe, and hydrated the skin Aqueous Cream, BP is chosen for this, it was gently rubbed over the unbroken skin from foot to knee. BNF(2004). A Telfa, non- adherent absorbent, perforated plastic film dressing was applied. BNF (2004). A cotton wool bandage is then applied to cover any bony prominences, followed by the first bandage, which is applied toe-knee with a fifty percent overlap; this bandage can be pulled to full strength. The second bandage is applied ankle-knee in the opposite direction from the first and this too can be applied at full strength; however patents’ can find this intolerable and it should be noted that the second bandage can therefore, be applied using less tension providing it still conforms to the leg without dislodging easily.

The district nurse utilized this assessment of James’s Leg Ulcer to broach the subject of James’s smoking habit, offering to give Jame’s information on the smoking cessation classes available at the clinic. Because quitting smoking improves health it would be unethical not to help smokers who wish to quit. James said” he would look at the information and he would like to have a go at giving up”. It has been reported in the Nursing Standard (2006) that smoking cessation nurses are being urged to offer nicotine replacement therapy (NRT) to their patients’ before the quit.

The district nurse has been implementing and evaluating this practice for several months with no significant improvement. There has been research into the use of static magnets promoting chronic leg ulcer healing. The district nurse had consulted James, Victoria, Tissue viability service and James’s GP. The decision was made to use this treatment for James. (NMC 2004) states” You have a responsibility to deliver care based on current evidence, best practice and, where applicable, validate research when it is available”.6.5

Nyjon (2006) reports that the use of the 4UlcerCare static magnet device (Leg wrap) that is designed to be placed on the leg in conjunction with the multi-layered bandage was shown to significantly expedite healing of chronic wounds. This study was published in the Journal of Wound Care in February 2005.

The National Health Service (NHS) has approved the use of this product, for use. Magnopulse (2006) reports 4UlcerCare is the first static magnet product available through the doctor and paid for by NHS. This treatment is currently being implemented in the provision of care for James’s venous leg ulcer.

In conclusion the paper has identified an individuals health status encompassing the management of a wound, the need for concordance and a holistic view of the overall health status of the individual; that required the process of decision-making with the role of the district nurse being a multifaceted role. The district nurse had addressed assessment and treatment of the health status enveloping the psychological and sociological aspects.

It was palpable that the role of the district nurse is crucial in identifying and delivering appropriate care to patients and their families in the community setting. The management of chronic wounds is complex; it requires skill and is best undertaken using a multidisciplinary team. Access to specialist service is on the increase; which will impact on the delivery of wound management. The role of the district nurse was fundamental in promoting James’s health and education along with the information given to empower James to assert his needs and take direction of his life.