Critical Analysis and Thinking about Wound - Essay Example

Running Head: CRITICAL ANALYSIS AND THINKING ABOUT WOUND: OPTION 2 Critical Analysis and Thinking about Wound: Option 2 Name Tutor Date Critical Analysis and Thinking about Wound: Option 2 Introduction The initial step in managing Mr. Owen is performing a complete physical examination incorporating assessment of Mr. Owen’s venous system. Several diseases as well as clinical conditions are capable of impairing the venous system and this results into venous ulcers. Therefore, the history of Mr. Owen is supposed to be thoroughly documented as a part of the initial assessment. In this case, the history that ought to be recorded includes Mr. Owen having suffered from varicose veins, being hypertensive lately, being overweight as well as having diminished mobility after scrapping his leg (Ruckley, 2009). During a normal functioning of the venous system, the blood usually flows through the superficial veins to deep veins in a unidirectional manner. Within the legs, the usual action of the calf muscles assists in pumping the blood back to the heart, normally without any complication. In case the venous system gets impaired by disease, the deep veins develop venous hypertension (Kammerlander, 2007). With time, the weight of blood backflow into the superficial veins may result into fluid and protein leaking into the tissues and this can cause edema which causes the crater like appearance in Mr. Owen’s wound, in addition to ulceration. Mr. Owen’s ulcer began as a very minor injury which was expected to heal. However, because of the underlying disease in the veins, it did not heal and as a result the ulcer deteriorated (Criqui, 2007). In the assessment, Mr. Owen has numerous of the distinguishing “markers” of venous disease. First, according to the image, is the location of the ulcer. The ulcer is located on the medial lower leg on top of the medial malleolus. The wound is beefy red as well as granular in appearance. Furthermore, the margins of the wound are irregularly shaped and the unbroken periwound skin is a darker color when compared to the rest of his leg and is indurated and erythematous. This lipodermatosclerosis is characteristically found with venous disease. Hemosiderin deposits, typically known as hemosiderin staining, are what cause this condition. Still, according to the image, the skin of Mr. Owen lower leg is dry and scaly. Mr. Owen wound also has a crater like appearance and has an unpleasant smell as a result of the exudates from the wound. The unpleasant smell also indicates presence of an infection on the ulcer (Gohel, 2007). During the examination, the main focus will be on the ulcer itself as well as on venous systems within the leg. The appearance of the edge of the ulcer will be used in establishing any possible suspicions of skin can and will also be used in establishing if the ulcer is starting to heal or if it is deteriorating. During the management of the wound, very specific changes like violaceous border, may point out the presence of uncommon conditions like pyoderma gangrenosum (Ebbeskog, 2006). I will use the ulcer base to establish if the ulcer will heal. For example, exposed bone or tendon, presence of dead tissue or healthy granulation tissue will all be vital during the entire care. Discharge, as said before more so if smelly may indicate that there is an infection. Furthermore, discharge can be secondary to swelling within the leg and continuous of fluid across the ulcer bed will slow down healing of the wound. Evident varicose veins will be recorded and the pulses will be felt throughout the leg and the blood circulation will be examined using the color in addition to the warmth of the limb (O'Brien, 2008). When measuring Mr. Owen’s blood pressure, it will be measured at the ankle by using hand held Doppler. Doppler is extremely sensitive is examining the blow of the blood within the leg, which will be then compared against the flow of the blood in the arm. This will enable me to calculate the ankle: brachial index (ABI). Normally, blood flow within the arms and legs is equivalent and the index is nearly 1.0. As a result, in case there is an impairment of blood circulation within the legs, then the index will be lowered to less than 1.0 (Hawkley, 2003). Nevertheless, the quality of the Doppler signal is significant and hence the tool should be in good working condition while being used. What is more, Mr. Owen’s veins on the affected limb can be assessed using color flow ultrasound. This examination will provide detailed information regarding the anatomy of the system of veins as well as the blood flow direction within the veins. There is nothing unusual regarding the appearance of Mr. Owen’s ulcer and hence there is no need for any biopsy (Trent, 2008). In regard to the management of the wound, the earlier diagnostic results will be reviewed as well as the medication, treatment and medical history in addition to the physical assessment findings. The edema which is causing the crate like appearance on the wound will be controlled before the healing of the wound; therefore Mr. Owen will be placed on the bed rest with his legs elevated above heart level. Compression therapy will be the basis in reducing and eliminating Mr. Owen’s hypertension (Trent, 2008). Since the wound has been diagnosed as venous ulcer, compression treatment will start. Nevertheless, this is supposed to be applied only after assessing the arteries through measuring the ankle-brachial index. This is so since in case compression is applied and the Mr. Owen’s arteries turn out to be badly diseased, this will damage the ulcer as well as the leg and hence make matters worse. Still, it would also be very painful for Mr. Owen (Gohel, 2007). Before application of the compression, the leg and the ulcer will be thoroughly cleaned. After this, a simple, dry, non-adherent dressing will then be applied to the ulcer itself. The ankle circumference will then be measured and thereafter the compression system will be selected. The formal compression bandage will be applied by a nurse proficient in bandaging techniques. Basically, the first layer is inclusive of a soft wool bandage to protect the bony points at the ankle as well as the shin bone. After this, a crepe bandage will be applied as the second layer while the third layer is an elasticated bandage that will apply compression on the wound. Finally, the fourth layer will be applied and this is important in applying additional compression and will maintain all the bandages in place (Bergan et al, 2007). These bandages can be left in place for even up to seven days but in case the fluid from the ulcer soaks through the bandages, they will be changed. If it possible, the bandages will be left for like seven days before changing since every dressing change has the likelihood of damaging some of the ulcer tissue that is trying to heal (Porter, 2005). This system is called 4 layer compression, and it is appropriate since it can be tailored to some extent to suit the particular shape and size of leg. It will be ensured that Mr. Owen gets enough bed rest as this will assist in reducing swelling in the leg and hence reduce the amount of fluid passing across the ulcer bed. Compression can normally then be applied to sustain the effect when Mr. Owen is eventually discharged (Bergan et al, 2007). On the other hand, as long as the supply of the blood to the tissues is good and compression is applied, if suitable, it won’t be an issue which dressing is placed on the ulcer bed. It just needs to be clean, dry and non-adherent and the ulcer is expected to respond (Phillips et al, 2006). According to latest studies, changing the dressing type regularly normally does not have any values and can in fact do harm because the patient can develop allergic reactions, for example dermatitis. The latest review of dressing for venous ulcers indicated that the kind of dressing applied beneath compression does not have an effect on the healing (Trent, 2008). Daily measurement of the circumference of Mr. Owen’s lower leg will be ordered. To achieve this, landmarks on the leg having the wound will be identified: for instance, four inches (10 cm) below the patella base. This site will be used for each and every measurement and also the same unit will be used in measuring every time, for example inches or centimeters, to make sure there is uniformity. The marker will be important to me as the RN in evaluating the effectiveness of Mr. Owen’s therapy (Kline, 2007). Since the wound produces an unpleasant smell, a swab should be taken and examined to establish if there is any infection more so a bacterial infection. Antibiotics will therefore be prescribed for the ulcer basing on the swab result having grown bacteria (Franks et al, 2008). However, it will be important to make sure that antibiotics are only used if there is an evident infection. This normally means that Mr. Owen should only be administered with antibiotics if his leg turns out to be hot, red and tender. Since we are all covered with bacteria, a swab from any body part regardless of an ulcer or not will grow bacteria, yet they do not need any treatment (Michel, Y. (2006). They are a usual body part flora and the presence of these normal bacteria is known as colonization.  Consequently, care should be taken since even over treating using antibiotics can result to problems whereby antibiotic resistance develops within the present bacteria and hence making future treatment of infection even more complex (Bergan et al, 2007). According to the image, the wound has heavy drainage and hence a product that is absorbent, for instance an alginate or foam will be the most appropriate choice for topical wound management. An alginate pad will be ordered as the principal dressing while a foam devoid of an adhesive border will be ordered as the secondary dressing. Additionally, a hydrating cream will be ordered in the treatment of Mr. Owen’s dry, scaly periwound skin (Simon, 2006). Controlling of Mr. Owen’s primary chronic condition which were uncovered during the physical assessment such as hypertension, overweight as well as diminished mobility are supposed to give the required clues in the management of the disease process. Understanding how the primary disease process affects Mr. Owens condition will enable me to initiate the interventions to assist in reducing venous hypertension as well as in decreasing edema to the lower leg (Sheridan, 2006). Furthermore, I will reevaluate the plan care regularly, particularly noting the quantity of the wound exudates as well as edema. After Mr. Owen’s ulcer has healed, I would ensure that he wears Class 2 below knee compression stocking as this will lower the probability of the ulcer recurring (Trent, 2008). Mr. Owen is a 68 year old male. He is well educated and well off considering he is a retired officer. As a result, I expect to comply with the treatment since he knows the benefit of receiving appropriate care for his treatment. Moreover, he had attended himself when he initially got injured and this implies his willingness and readiness to receive treatment (Epstein, 2007). Still, judging from Mr. Owen’s background, he can afford the required medical products for his treatment and also he can observe hygiene and hence there is no risk of having his wound contaminated. Nevertheless, since he lives alone he needs a lot of monitoring to ensure that he categorically follows the medical instructions. Again Mr. Owen is very active and hence he should be discouraged from engaging in rigorous activities. However, movement should not be restricted since this will assist him in regaining his mobility and plays a big role in facilitating wound healing (Patrick, 2004). In regard to bio-psycho-social needs, Mr. Owen is old and hypertensive and hence a comfortable environment should be created to avoid aggravating his hypertension. It is important to make sure that he engages in behaviors that promote health and treatment, for instance I will make sure that he takes his medication, takes proper diet mainly due to his hypertensive condition and actively engages in physical activities as this will improve his mobility (Johnson, 2004). Taking proper diet will involve avoiding a lot sugars in his diet as this will assist in improving his hypertensive condition and reducing weight since he is overweight. Furthermore, exercises will also be of importance in managing his weight (Lown, 2004). Conclusion Chronic venous insufficiency is the term used in referring to the changes that may occur within the leg tissues, because of longstanding high pressure within the veins and this can be attributed to Mr. Owen’s ulceration. The high pressure within the veins normally takes place due to the fact that the blood flow within the veins is not normal, secondary to valvular incompetence and this causes reflux within the veins (Hareendran, 2005). In several patients, varicose veins will also be present and this can be seen in Mr. Owen’s case whereby he has had a history of having suffered from varicose veins. The extended high pressure within the varicose veins as a result caused low level chronic inflammation within the surrounding tissues and ultimately produced the clinical changes observed in Mr. Owen’s ulceration. There are some factors that predisposed Mr. Owen to chronic venous insufficiency and they include, being overweight, being physically inactive since he is a retired office worker as well as age since he is relatively old at 68 years (Kline, 2007). References Bergan J et al. (2007). Chronic venous disease. N Engl J Med. Vol. 355: 488-98. Criqui MH. (2007). 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