When assessing the general population, it is observed that 27% or 3.2 million of the adult population in the United States has venous disease. Of this group, 2% will develop a leg ulcer. Approximately 500,000 people are treated for leg ulcers each day. Venous stasis ulceration can be chronic and is often recurring, with 65-70% of those who have had one leg ulcer eventually developing another.1
More than 60% of the population is considered to be overweight. Thirty percent are considered to be obese, defined as a body mass index (BMI) equal to or greater than 30.2 Numerous systems are affected by increased weight, with the risk of developing weight-related complications directly correlated to the degree of obesity and the distribution of that weight.2 Diabetes risk increases with the degree of obesity, those with a BMI equal to or greater than 30 being 3 times more likely to develop this disease.3 Also with obesity comes the risk of hyperlipidemia and heart disease, and with extreme obesity comes the risk of lower extremity edema, thromboembolic disease, skin compression, intertrigo, fungal infections, and venous stasis ulcers.2 In addition to obesity, risk factors for venous stasis ulcers include varicose veins, occupation, history of obesity, and pregnancy. Much of the difficulty in preventing venous ulcers is the inability of the patient to perform proper foot and skin inspections and perform adequate hygiene.
Contributing Factors
Chronic hypertension and edema restrict flow, thus impairing venous return. The resultant venous stasis leads to extravasation of fluid into the surrounding tissues, with the resulting characteristics of venous insufficiency (Figure 1). Although the exact mechanism of ulceration is unknown, all theories suggest inflammation and ischemia at the capillary level as the ultimate cause.4 Typical findings for venous ulcers are listed in Figure 2.
The following 3 case studies all illustrate venous ulcer disease complicated by comorbid conditions and morbid obesity.
Case Study 1
This patient was a 46-year-old female who worked as a cashier in a grocery store. She typically spent between 10 and 12 hours a shift sitting on a stool with her legs dependent. She was also obese, weighing 384 lb. In addition to being diagnosed in her early 40s with type 2 diabetes, the patient had suffered for years with lower extremity lymphedema. Her laboratory work was done preoperatively with unremarkable results; her albumin was 3.5 mg (normal 3.0-5.0 mg). She had developed an ulceration to her leg, which began in a pattern that indicated venous stasis ulceration (Figure 3). The wound began when she bumped against her workstation. The wound was shallow with diffuse edges, and it drained constantly. The base of the wound was essentially clean, although healing did not progress with the initial courses of wound treatment. Venous Doppler studies were done, which revealed failed valves in the perforating veins. No changes were made in her work schedule, nor did she agree to compression therapy. To complicate matters, she missed appointments for care at home and follow-up care with her physician, so her adherence with wound care was limited. The wound failed rapidly, with infection and necrosis to the tissue. A diagnosis of necrotizing fasciitis was made. The wound was debrided, with a resulting deep wound that measured approximately 23 x 30 cm. Numerous dressing modalities were trialed, including silver sulfadiazine cream, calcium alginates, growth factors, and collagen. A skin graft was ultimately performed. Her comorbidities played a significant role in her healing potential.
On recommendation from the wound care team, the patient purchased a pair of open-toe sandals that had expandable straps to permit size changes during the day. Despite regular education on the role of compression in wound healing for venous stasis disease and lymphedema, she nonetheless persisted in her refusal to wear compression, which unfortunately impeded the healing process. She maintained that they were too hot and unattractive for wear. Leg elevation was advised. She either sat on her work stool or in a standard chair with her legs dependent. Because of her weight and height, she could not independently cause her chair to recline, so a footstool was provided, which permitted her to elevate her feet while sitting. The skin on her legs and feet was dry, so she had a family member assist her in applying lotion to her skin. The home health nurse also applied lotion during her visits for wound care.
Nutritional status was assessed, and the patient had an albumin of 2.4 mg. Dietary consultation addressed nutritional supplementation, food and beverage restrictions, and recommendations to improve her condition. Water intake was also poor, and the patient was advised to increase her fluid intake. Approximately 90% of the graft took, leaving about 10% of wound along the lower edge to be resolved. There was drainage and odor from the wound. The most effective approach to the wound protocol was silver and charcoal dressing, applied 3 times per week. The dressing provided some inhibition to new bacterial growth, while the charcoal eliminated the odor improving her quality of life at home and in public.
Case Study 2
Mr G. is a 54-year-old man with chronic venous stasis disease, lymphedema, congestive heart failure, morbid obesity, and estimated weight of 400 lb, and type 2 diabetes. His blood sugars ran between 185 and 210 mg/dL. He had resolving ulcerations improved with multilayer compression wraps. When the author assessed this patient, he had healed skin ulcerations though the skin, which was thick and dry with areas over the ankle area with friable skin (Figures 4 and 5). Some areas would occasionally develop blistering and weep, as shown in Figure 6.
For this patient, the focus was skin care education and prevention of further ulceration, as well as management of edema. To accommodate the circumference and the length of his leg, 11/2-compression wrap kits were used initially, reserving the other half of the kit for the next dressing change. The goal was to reduce as much edema as tolerated and then move to a management compression strategy. Skin care was provided before wrap application.
He was moved in to compression wraps that had adjustable straps. He used a long gripper device to grasp the Velcro straps. On the follow-up visit to assess his ability to manage the system, dry skin with flaking was observed, as seen in Figure 7. It was clear that part of his problem rested with his inability to reach his leg or foot to apply the lotion. To facilitate this, a long-handle dish sponge was used, covering the sponge with a piece of plastic wrap. Lotion was applied to the wrap and thus applied successfully. The wrap was smooth, so it eliminated any risk of scratching the skin.
This patient wore a Velcro strap shoe purchased through a mail-order catalog for $12. They had no-skid soles, could be adjusted throughout the day, and had a soft-top collar that did not apply any pressure around the ankle area. Although he was limited in his ability to exercise because of shortness of breath, he was willing to do an aquatic program through a local hospital. He tolerated a 30-minute program without stress or trauma to his joints or legs. He was able to continue with the compression wraps and keep lower extremity swelling to a minimum. He was discharged from the program after several weeks of care.
Case Study 3
Ms A. is a 37-year-old female with severe lymphedema, chronic venous hypertension, diabetes, severe morbid obesity, and chronic recurring ulcers to the lower extremities. This patient's last documented weight was 421 lb when she was 32 years of age. She was not mobile and used a wheel chair to move about. Her feet were constantly dependent and she used her feet to propel the chair. She did not wear shoes because she could not find a pair to fit, nor could she reach down to put anything on. Thus, her feet were dry, cracked, and deeply callused. Moreover, she was unaware that she had developed any wounds until a family member noticed drainage on her chair cover. It was determined that these wounds had occurred because of Ms A's repetitive hitting against the leg pad on the footrest (Figures 8 and 9).
The wounds exuded yellow serous drainage and were negative for odor. Initial laboratory work revealed a white blood cell count of 189/L (normal: 5-109/L) and an albumin of 2.3 g/dL (normal range: 3.5-5.0 g/dL). The patient's blood sugars were monitored by home health, and her values were consistently greater than 250 mg. She had cellulitis, and was placed on IV antibiotics followed by oral antibiotics. The focus of wound care was to reduce bacteria in the wound and provide protection. A silver dressing was applied to the wounds, and each leg was wrapped with 2 multilayer compression wrap kits. This was initially done every other day and gradually was decreased to once a week. An antibacterial moisturizing cream was applied to the skin before the wrap application.
Aside from lying on the bed, this patient could not elevate her legs because of their size, her general strength, and her wheelchair design. A short series of steps was set up so that she could wheel in front, then walk her feet up 3 steps, and then rest her legs on the top step, which was padded. It took some practice for her to perform this but worked well once mastered.
Podiatry was consulted to evaluate and treat the deep calluses on her feet and to manage her toenails. A pair of slippers was located, which were easy to slip on without having to bend over; she was encouraged to use the slippers to improve foot health and prevent additional wounds from developing in the deep fissures. Education was done to ensure she understood the risk of more wounds should her feet crack or become more damaged. The patient did not complete follow-up blood work, however, nor did she keep appointments once discharged from home healthcare. This case thus demonstrates the benefit of ongoing homecare designed to motivate the patient with encouragement in compliance with wound care and prevention.
Discussion
Often in the early stages of venous disease, legs may feel tired or heavy when dependent. Numerous preventive measures can be taught to the patient with edema, venous stasis disease, or ulceration. These include keeping the patient's legs elevated as much as possible to decrease venous hypertension and swelling or edema. Properly fitted support hose or stockings are critical in minimizing the trauma to skin. Tight socks may impede circulation or become embedded in the skin similar to a rubber band, leading to increased edema and possibly ulceration. Correctly fitted shoes that allow for changes in the size of the patient's foot and ankle are also vital in preventing breakdown at the joint area. To ensure that adequate compensation can be made for limb size changes during the day, the patient's foot should be professionally measured before each shoe purchase.
To determine if there are any breaks or skin damage needing to be addressed, good visual assessment of the patient's lower extremity and foot is critical. For the patient who cannot bend over to see his or her feet, placing a standing cosmetic mirror on the floor with the lighted magnified surface up can allow the patient to see. Regular visits to the podiatrist are recommended to ensure that a medical evaluation is done and ensure that the patient's nails are trimmed to prevent digit injury.
Excess weight does not correlate with good nutrition. Obese patients may suffer from malnutrition. As such, blood work should be performed to determine if the patient has adequate dietary status for prevention and healing. Dietary consultations may benefit the patient, not only for weight loss but also for improving intake to maximize well being.
Compression
Compression wraps are the most important treatment for patients with lower extremity edema. These wraps help reduce swelling and improve venous return. Appropriate wound care, with absorbent dressings under the compression wraps, is essential to the healing process. Evidence suggests that multilayer wraps are more therapeutically effective, because they can sustain a higher level of compression over a longer period of time.5 Leg elevation assists with venous return and may assist pain management.
Inadequate compression can prevent wound healing, increasing the risk of infection. Establishing realistic goals for care between the WOC nurse and the patient are necessary to determine services and expectations. For numerous reasons, some patients are unable to make major lifestyle changes that the WOC nurse believes are in their best interest. This can lead to a situation of conflict and resistance, which must be resolved in some mutually agreed way to allow care.
References