A venous leg ulcer is a skin condition that occurs when an area of the skin breaks down to a critical extent whereby the underlying flesh are exposed. These mainly occur above the ankle and are most common in older people. Females are mostly affected. The venous leg ulcer represents the top commonly experienced chronic wound problem noted in general practice. Just as other chronic illnesses and medical conditions, these venous leg ulcers significantly impact the situation of the health system and also the individual. Frequently, these conditions are managed in the community, which makes it imperative for the community based practitioners to possess some specific clinical skills, expertise and professional judgment. These will ensure that these professionals are better placed to make informed decisions regarding the ulcer etiology, the appropriate method for management and hence ensure optimal outcomes for the patients. In the community, it seems somewhat unclear as to whose responsibility it is to manage such a condition. Hence, nurses end up lining the patients to go and consult the general practitioner. This paper champions the thesis that whilst it may be uncertain as to whose role it is to manage venous leg ulcers, any competent community nurse can independently diagnose and manage venous leg ulcers to achieve an optimal outcome for the patient, and also to relieve some of the burden off the healthcare system.
Quite a number of articles are directly relevant to this research topic. Most have been written from the United Kingdom and Canada, while a few have been written from the United States and Germany. The research papers used feature literature that have either been researched or simply based on expert opinion. Five national evidence based guidelines on venous leg ulcer assessment and management were present from various parts of the world.
Regmi and Regmi (2012:56) define leg ulcers as an area of the lower leg skin that experiences a discontinuity of the epidermis and dermis that continues for over four weeks. This definition is quite similar to others that have been offered in literature, although the period given before being diagnosed as venous leg ulcers varied between four to six weeks (Salavastru, Nedelcu & Ţiplica 2012: 306). The underlying etiology is what has been used to distinguish between the different types of leg ulcers available. For this reason, venous ulcers have been found to be the most common type of leg ulcers.
Literature strongly emphasizes on the importance of always establishing the right leg ulcer etiology (Carter, Waycaster, Schaum & Gilligan 2014: 804). This is because the options of managing the condition will differ depending on it. Hence, it is important to identify whether the cause is venous insufficiency, a result of arterial disease, a combination of both instances or something else that is yet to be diagnosed. Other factors that may cause this leg ulcer include skin cancer, or even a manifestation of yet another underlying disease (Rai 2014: 409).
An accepted treatment for the venous leg ulcers is through the compression therapy. This is because when the condition is managed without compression therapy, it has been noted to persist without improving for months or even a couple of years (Petherick, Cullum & Pickett 2013: 3). This procedure, however, is contraindicated for patients who may be suffering from peripheral arterial disease as it could lead to irreversible leg damage, hence potentially the risk of amputation that could have been avoided from the start (Rai 2014: 411). Hence, it is vital for nurses to be in a position to determine correct etiology and also professional decision making with regards to managing this condition.
According to Myles (2007: 39). determining the correct etiology requires a comprehensive assessment. Frameworks for this assessment of leg ulcers are widely discussed throughout the nursing course, and they are also predicated on areas such as expert nursing knowledge, skills and even experience. Despite the presence of this information, there is still a wide variation in the modes used to manage the condition (Adderley & Thompson 2015: 347). An audit conducted recently showed that over half of the population of individuals suffering from leg ulcers had not received a confirmed etiology, and at the onset of the condition, approximately 19% of those who should have been exposed to compression therapy were already receiving treatment (Åkesson, Öien, Forssell & Fagerström 2014: S7). For this reason, the authors claim that insufficient training is highly to blame. This literature, however, does not provide a consensus of what constitutes adequate training. Although strong emphasis has been placed on the importance of training and educating nurses on the venous leg ulcer management, it is not as evident for general practitioners and other professionals in healthcare. Whilst general practitioners also manage leg ulcers, their competency is highly variable as research has also identified practice shortfall, most especially in regards to compression therapy and the application of an evidence based practice.
According to the presently available leg ulcer guidelines, assessment should include; a critical understanding of the unique social factors, concerns and experience of individual patients; a clear understanding of the level and extent of pain experienced; a thorough look into the patient’s clinical history; nutritional assessment and full body physical examination; relevant investigations that must cover peripheral vascular assessment, blood pressure, glucose levels, urinalysis and weight. Regmi and Regmi (2012:59) describe an assessment as a complex process whereby no single element is supposed to be considered more important than others. This is why the results of the assessment must account for all information on the body of the patient so as to enhance the possibility of the best clinical decision being made. Before any treatment is started, the ABPI must first be measured using the Doppler ultrasound. In this literature, emphasis has been placed, once again on the fact that clinicians have also been trained in using the ABPI technique, thus they have experience in managing leg ulcers (Carter, Waycaster, Schaum & Gilligan 2014: 810). Using the correct procedure and technique is vital to the efficiency and applicability of the obtained results.
Research showed that general practitioners who are involved in primary care do not follow a holistic assessment procedure and thus many have surpassed the ABPI measurements (Partsch 2014: 140). Conversely, a big number of nursing courses has provided them with information on how to apply the measuring of ABPI in the management of leg ulcers. Therefore, nurses are better exposed to the application of the ABPI more than general practitioners who are frequently expected to attend to patients suffering from the venous leg ulcers. As a result, doctors do not have sufficient knowledge in dealing with the problem, compared to nurses who are supposed to be equipped with knowledge to deal with the issue. Additionally, most of the assessment tools used are basically aimed at nurses, a factor that greatly supports the argument that management of venous leg ulcers is within the scope of the nursing practice (Partsch 2014: 143).
Integrating Theory and Practice
The management of leg ulcer is client centered, whereby care must be specialized around the patient’s concerns, experiences and history. Aside from this, it is essential to note that management of the venous leg ulcer occurs through the use of a collaborative, multidisciplinary approach which will involve certain health professionals to work side by side (Myles 2007: 40). Therefore, it is important that the general practitioner is involved in the management process despite the fact that they may not be the most skilled and knowledgeable enough to lead the team of professionals. Therefore, irrespective of the professional background, great emphasis must be placed on the practitioner expected to offer treatment, he must possess appropriate skill and knowledge to ensure leg ulcer can be managed effectively. Where such expectations cannot be met, then the professional is expected to refer the patient to a highly trained and skilled personnel in the area of interest.
A big number of evidence have proven the effectiveness of compression therapy as a method of treating venous leg ulcers (Partsch 2014: 145). For cases where compression bandaging have been used, the outcomes were improved healing rates of the ulcer and also increased cost effectiveness (Carter, Waycaster, Schaum & Gilligan 2014: 812). This process of applying bandages and dressing is clearly within the scope of the role of nurses. It is well understood that this application of compression bandaging needs a background in training on bandaging art, compression principles and also good application technique (Åkesson, Öien, Forssell & Fagerström 2014: S10). Theoretical and practical knowledge are both highly needed to undertake the procedure effectively. The nursing profession is usually highly trained on such activities. As a result of this, general practitioners, who have not been highly trained on such an area, claim to have very little confidence in their expertise of performing the compression therapy (Adderley & Thompson 2015: 350). Thus they rarely prescribe it to patients.
Leg Ulcer Management: Who is the Best Professional to offer Management?
Although wound management is an issue in the health system, it is a topic that is being handled almost exclusively by the nursing profession, individuals who are gradually taking up a distinct knowledge body (Myles 2007: 42). Generally, it has been realized that medical practitioners assign patients with leg ulcers to nurses without actually predetermining the underlying etiology (Petherick, Cullum & Pickett 2013: 6). Generally, literature has provided evidence that nurses are indeed considered to be the most knowledgeable, skilled and experienced managers of wounds, a factor that cannot be noted for the general practitioners. It has been argued that a nurse does not have the authority to offer a diagnosis on a patient. However, existing guidelines for leg ulcers do not prohibit nurses from determining the correct etiology and hence instituting management. The presence of such conflicting ideas are what cause confusion as to which group of professionals is responsible for wound management. In case of a wrong assessment result, the nurse will be held accountable for any decisions made so far on the patient.
Difference Between Medical Diagnosis and Nurse Diagnosis
The difference between medical and nurse diagnoses revolves majorly around assessment and management. Nurses have a pivotal role in the management of leg ulcers as they possess the knowledge and expertise, the general practitioner, on the other hand, have a directing role (Salavastru, Nedelcu & Ţiplica 2012: 309). Therefore, the confusion in roles is what has greatly undermined the health and service quality offered to patients. This is because, those who do not have the necessary skill are getting involved in procedures that require only skilled and well trained employees. On their own, general practitioners cannot be able to administer the right treatment to patients suffering from leg ulcers as they are trying to balance a wide range of treatment goals.
Nurses are viewed as the center for effective leg ulcer management. The literature reviewed above have all brought back the attention of whose role it is to manage the condition to the nurses. The boundries, however, are not so clear for both nurses and general practitioners, as to who should be responsible for such procedures, especially when it comes to the issue of diagnosis. From the literature reviewed, it is clear that nurses are majorly involved in the assessment and diagnosis of venous ulcers, and also make decisions on the management. The environment whereby people go to is in the community, which is why this management is majorly thought to be the duty of the nurse. As a result of their training, and the hence acquired knowledge, nurses should be responsible for the patients so as to improve the quality of care they receive.
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