Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo Apr. 2012
ARTIGO DE REVISÃO
La persona con úlcera de pierna, intervención estructurada de los cuidados de enfermería: revisión sistemática de la literatura
César FonsecaI; Tiago FrancoII; Ana RamosIII; Cláudia SilvaIV
IDoctoral student in nursing, Universidade de Lisboa. Researcher, Nursing Research & Development Unit. Ramada, Portugal. email@example.com
IIRN, CHLO Centro Hospitalar Lisboa Ocidental. Ramada, Portugal. firstname.lastname@example.org
IIIRN, CHLN Centro Hospitalar Lisboa Norte. Master student in Education Sciences. Researcher, Nursing Research & Development Unit. Ramada, Portugal. email@example.com
IVRN, CHLN Centro Hospitalar Lisboa Norte, Palliative Care Unit, Domus Vida Parque das Nações. Ramada, Portugal. firstname.lastname@example.org
The objective of this study is to identify the nursing interventions for people with venous, arterial or mixed leg ulcers. This study was performed using the EBSCO search engine: CINAHL and MEDLINE yielded results, based on full-text articles published between 2000 and 2010, using the following descriptors: Leg* Ulcer* AND Nurs* AND Intervention*, filtered using a starting question using PICO. At the same time, a search was performed on the National Guideline Clearinghouse, using the same search guidelines. A person-centered intervention increased positive health outcomes, with a range of direct wound care in agreement with the etiology. The following interventions associated with the healing of leg ulcers of any etiology were highlighted: nurse/client treatment relationship, individualization of care and pain monitoring.
Descriptors: Leg ulcer; Nursing care; Wound healing
Identificar las intervenciones de enfermería en la persona con úlcera de pierna de origen venoso, arterial o mixto. Se realizó investigación en motores de búsqueda EBSCO, CINAHL, MEDLINE, procurándose artículos en texto integral, publicados entre 2000 y 2010, con los siguientes descriptores: Leg* Ulcer* AND Nurs* AND Intervention*, filtrados mediante pregunta de inicio en formato PICO. Simultáneamente, se realizó investigación en la National Guideline Clearinghouse, con la misma orientación. Una intervención focalizada en la persona aumentó los resultados en salud, variando los cuidados directos a la herida en consonancia con su etiología. Como intervenciones asociadas a la cicatrización de la úlcera de pierna de cualquier etiología, se destacaron: relación terapéutica enfermero/paciente, individualización de cuidados, monitoreo del dolor.
Descriptores: Úlcera en la pierna; Atención de enfermería; Cicatrización de heridas
Nursing focuses case on the promotion of the health projects that each individual lives and pursues. In this context, throughout the life cycle, it aims to prevent diseases and promote the readapting processes after the disease, meet the bare human necessities and maximal independence in the activities of daily living(1). Therefore, nursing care helps people to manage community health resources, considering the value of assuming a center role within the team(1-2).
At the same time, nurses face, in their practice, challenges of increasing demands and complexity, as a result of an increased mean life expectation(3) and the consequent prevalence of chronic diseases, which include leg ulcers.
Leg ulcers are defined as an ulceration below the knee on any part of the leg(4), including the foot, and is classified as a chronic wound, i.e., a wound that remains stagnated in any one of the healing phases for a six-week period or longer, and thus requires a structured nursing care intervention(5). Leg ulcers have several known etiologies, with venous ulcers being the most common, accounting for 70% of the cases, followed by arterial ulcers with 10 to 20% of cases, and those of mixed etiology, with 10 to 15% of cases(6). The main causes for leg ulcers are chronic venous hypertension, arterial diseases, or a combination of both(5-6). Less frequent causes include neuropathy; infection, vasculitis, neoplasm, blood and metabolism disorders, lymphedema and those of iatrogenic origin(5).
The pertinence of this condition is founded on the fact that it is estimated that 1.5 to 3 of every 1,000 people have a leg ulcer, and the prevalence increases with age to 20 in every 1,000 people aged 80 years or older(2,7). Literature refers that leg ulcers are interpreted as: a forever healing experience(8), in which 40% of cases have a leg ulcer for a year or more, 20% for five years or more, and 45% have relapses, with 35% of cases with four or more relapse episodes(2).
In association with leg ulcers, there is an increasing demand of both technical and material health resources, in which approximately 1-2% of the total health budget of Western countries(9), which includes Portugal, consists of clients with leg ulcers(4). In addition, it is estimated that 50% of community nurses' working time is invested in taking care of this type of client(4,9). Besides the impact on health economics, there is also a deep change in the activities of daily living of individuals with this problem(6-8), namely the presence of pain, limited mobility, sleep pattern disturbances, self-image changes and the incapacity to perform at work, which reduces their monthly income, increases their expenses with treatment and encourages social isolation(10).
In this sense, the objective of the present study is to identify the nursing interventions to people with venous, arterial or mixed leg ulcers.
As a starting point for the systematic literature review, the following guiding question was formulated, using PICO(11): Regarding the individual with venous, arterial or mixed leg ulcer (Population), what nursing interventions (Intervention) can affect healing (Outcomes)? The EBSCO search engine was used, with access to two databases: CINAHL (Plus with Full Text) and MEDLINE (Plus with Full Text), selecting full-text articles (March 4, 2010), published between March 1st, 2000 and March 1st, 2010, with the following descriptors: Leg* Ulcer* AND Nurs* AND Intervention*. A total of 114 articles were found: 48 articles on CINAHL, and 56 articles on MEDLINE, with a final total of 7 articles. Guyatt and Rennie (2002) recommend that systematic literature reviews should take into consideration the last five years. However, we considered a ten-year time window in order to provide a broader coverage in view of the current knowledge about the analyzed subject(11).
At the same time, the National Guideline ClearinghouseTM (NGC) electronic database was surveyed, and the guideline for clinical practice were consulted as a Detailed Search, (March 17, 2010), selecting the following research options: Keyword: Leg Ulcer, Intended Users: Nurse, Clinical Specialty: Nursing. A total 13 guideline for clinical practice were located, five of which were selected.
In order to know the different types of knowledge production stated in the filtered articles, seven levels of evidence were used(11): Level I: Evidence from Systematic Reviews of Meta-Analysis of relevant Randomized Controlled Trials (RCT's), or evidence from clinical practice Guidelines, based on the systematic reviews of RCT's; Level II: Evidence obtained from at least RCT; Level III: Evidence obtained through a controlled study, without randomization; Level IV: Evidence obtained through case-control or cohort studies; Level V: Evidence obtained through systematic reviews and qualitative and descriptive studies; Level VI: Evidence obtained through a single descriptive or qualitative study; Level VII: Evidence obtained from the opinion of authors and/or expert panel reports. The research and material selection process for the analysis is presented in Figure 1.
To make the present study methodology perceptible and transparent, we present a list of the 12 articles selected (Chart 1) for the body of analysis, which comprised the substrate for developing the discussion and drawing the respective conclusions. All articles were ranked according to the level of evidence.
A successful treatment for people with leg ulcer is associated with motivation(2-4,7). On the other hand, the non-compliance to treatment of many clients with venous and mixed ulcers is related to the presence of pain, discouragement, social isolation, insufficient social support, and not having a healthy lifestyle, which is repeatedly emphasized by health care professionals, namely nurses(4,6). At the same time, it is recommended that nurses learn and use information about the sociocultural environment/context in which clients live, the existing social support and its quality, the client's profession and life habits(12-13). Furthermore, it is recommended that nurses use an approach centered on pain management(10), especially when the therapeutic plan involves compression of the wound bed(12-13). Including people considered to be the client's significant others is a factor that has a positive association with an active participation in the care plan(4), as well as being in touch with people in a similar situation, i.e., people with leg ulcer either in the active or remissive phase(2,14-15).
In Australia, a new health care service concept for people with leg ulcer was introduced, which lies on the creation of places (Leg Clubs)(10) where nurses that specialize in leg ulcer promote the social interaction between people with the same kind of ulcer, and evaluate the support that each individual needs, educate these clients towards self-care and case management, perform the respective treatment and provide continuous follow up(4-9). The outcome from implementing this project was pain reduction, a significant progress in healing, and improved quality of life, namely at work, mood, mobility, sleep pattern, and other aspects(10). The positive effect of this model also reflects on the social level(9), considering that a broader social contact and with people who have or had the same problem reduces social isolation and provides efficient coping mechanisms to deal with the crisis situation the disease(4,16).
As an active member of a multidisciplinary team, nurses should not work alone. Rather than that, they should, collectively, create objective and strategies that promote work directed to the real needs of a given individual(16-17). To do this, nurses must keep updated, and attend education and training in the area and maintain good conversation with their pairs, because taking care of this type of disease is more effective if the care is provided by a multidisciplinary team(12).
Clients often observe the approach and attitude of health care professionals, considering that the mobilization of interpersonal relationship competencies help to establish trust(17-19), which together with the nurses' good technical-scientific performance generates a positive process for wound healing(10). Therefore, nurses should work to promote well-being by establishing an empathetic relationship and a holistic approach to clients(20), and this relationship should continue even after the ulcer has healed(21), because some clients reported they do not want their ulcer to heal, so they could keep in touch with their nurse(4). By establishing the interpersonal relationship, informed consent increased the trust in the health care(14,17), because clients were able to make free and accountable choices regarding their autonomy, thus favoring the empowerment of people in their health/disease process(10). Communication is a nursing instrument with evident relevance(15), and developing education programs that include and combine the cognitive, behavioral and affective aspects promoted an effective advantage to clients(2,7).
Regarding the recommended guidelines to take care of an individual with venous, arterial or mixed leg ulcer, it is important for nurses to: know the individual's clinical history (personal history, chronic pathologies, and current state) and the ulcer's history (origin, time, undergone treatments)(6,12,14,20). Through a careful evaluation of the characteristics of the wound (size, depth, exudate, wound bed, type of tissues, perilesional skin, pain)(14,18), nurses are able to decide on the treatment always together with the client (Chart 2), so that common goals can be established(15,18,21-22).
Therefore, the treatment should focus on the prevention of pain(10), wound bed preparation(6-9), would cleaning(14-15,16), management of the products to be applied on the wound bed and perilesional skin(7), joint decision about the type of material to be used in the compression therapy and the development of a physical exercise program(8-14-18), continuous client education(23), and referrals to experts in case there is any allergic reaction(13), the need for complementary therapies and/or prior inefficient treatments in which the ulcer/client state worsens.
CONCLUSIONS AND IMPLICATIONS ON NURSING PRACTICE
The foundation of nursing care for clients with leg ulcer, regardless of the etiology, is to establish a therapeutic relationship that would permit to collect detailed information about the client and the environment, the problems they perceive as theirs and if the how far they affect their activities of daily living. This is necessary to, later, create an individualized health care plan that would answer the individual's real needs, i.e., the whole evaluation and treatment process implies an approach to the person, as a complex and complete being, and not only the ulcer.
For a structured nursing intervention that is effectively focused on the person it is, at first, essential to mobilize competencies to establish effective communication and interpersonal relationship, which create a warm environment that suits the individualization of care. This personalization permits to obtain deep knowledge about the patients' habitual life patterns, social, financial and family situation, their perceptions and expectations about their current state and their perceptions and expectations about their current state, and their preferences are associated with an increase in positive outcomes. It is observed that it is essential to promote adaption mechanisms in order to deal with the crisis situation, induced by the disease, with particular highlight on self-efficacy and motivation, which permitted them to deal with the new situation more as a challenge than as a threat. The existence of social support was the factor most often reported as been key to the adaption process, which is provided by a number of significant people, such as by being in touch with people experiencing a similar situation (self-support groups) or with the nurse. Education for self-management in health is considered of utmost importance to diminish co-morbidity, as it reduces the existing risk factors and creates physiological conditions that are positive for better healing. Factors such as monitoring and managing pain, offering continuous care, and using a multiprofessional approach increased the clients' satisfaction towards the health plan, improved the compliance rate to the therapeutic regimen, and promoted the patients' perceptions about quality of life. Continuous and up-to-date education of nurses who take care of individuals with leg ulcer emerged as another positive aspect associated with the effectiveness of the implemented interventions. Implementing an appropriate and timely treatment is a component that cannot be dissociated from the aforementioned nursing actions, which are accountable for the reported health improvements.
Thus, we present specific guidelines and recommendations for the nurses' practice, with the purpose of making this article an instrument of support in the context of providing care to individuals with leg ulcer. However, we advise it to be adapted to each individual's professional reality, so that the evaluation and treatment can be the most appropriate possible, and always focusing on the client, the person.
1. Ordem dos Enfermeiros. Padrões de qualidade dos cuidados de enfermagem. Lisboa; 2001. [ Links ]
2. Van Hecke A, Grypdonck M, Defloor T. A review of why patients with leg ulcers do not adhere to treatment. J Clin Nurs. 2009;18(3):337-49. [ Links ]
3. Portugal. Instituto Nacional de Estatística. Projecções de população residente em Portugal: 2008- 2060. Lisboa; 2008. [ Links ]
4. Brown A. Does social support impact on venous ulcer healing or recurrence? Br J Community Nurs. 2008;13(3):S6, S8, S10. [ Links ]
5. Werchek S. Diagnosis and treatment of venous leg ulcers. Nurse Pract. 2010;35(12):46-53. [ Links ]
6. Vowden P. Leg ulcers: assessment and management. Indep Nurse. 2010;(1)30-3. [ Links ]
7. Hecke A, Grypdonck M, Defloor T. Interventions to enhance patient compliance with leg ulcer treatment: a review of the literature. J Clin Nurs. 2008;171(1):29-39. [ Links ]
8. Ebbeskog B, Emami A. Older patients' experience of dressing changes on venous leg ulcers: more than just a docile patient. J Clin Nurs. 2005;14(10):1223-31. [ Links ]
10. Edwards H, Courtney M, Finlayson K, Lindsay E, Lewis C, Chang A, et al. Chronic venous leg ulcers: effect of a community nursing intervention on pain and healing. Nurs Stand. 2005;19(52):47-54. [ Links ]
11. Melnyk B, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2005. [ Links ]
12. Van Hecke A, Grypdonck M, Defloor T. The clinical nursing competences and their complexity in Belgian general hospitals. J Adv Nurs. 2006;56(6):669-78. [ Links ]
13. Forssgren A, Fransson I, Nelzén O. Leg ulcer point prevalence can be decreased by broad-scale intervention: a follow-up cross-sectional study of a defined geographical population. Acta Derm Venereol. 2008;88(3):252-6. [ Links ]
14. Domeij D, Flodén M. Population aging and international capital flows. Intern Econ Rev. 2006;47(3):1013-32. [ Links ]
15. Heinen M, Evers A, Van Uden C, CJM, PCM, Van Achterberg T. Sedentary patients with venous or mixed leg ulcers: determinants of physical activity. J Adv Nurs. 2007;60(1):50-7. [ Links ]
16. Registered Nurses Association of Ontario. Nursing Best Practice Guideline. Assessment and management of venous leg ulcers: complete summary [Internet]. Toronto, Ontario; 2008 [cited 2011 Jan 4]. Available from: http://www.rnao.org/Storage/46/4017_RNAO_Venous_Leg.FINAL.pdf [ Links ]
17. US Department of Health & Human Services. National Guideline Clearinghouse. Guideline for management of wounds in patients with lower-extremity arterial disease: complete summary [Internet]. Rockville; 2008 [cited 2011 Jan 4]. Available from: http://www.guideline.gov/content.aspx?id=12613 [ Links ]
18. US Department of Health & Human Services. National Guideline Clearinghouse. Guideline for management of wounds in patients with lower-extremity venous disease: complete summary [Internet]. Rockville; 2005. [cited 2011 Jan 4]. Available from: http://www.guideline.gov/content.aspx?id=12613 [ Links ]
19. US Department of Health & Human Services. National Guideline Clearinghouse. Guideline leg ulcer guidelines: a pocket guide for practice: complete summary [Internet]. Rockville; 2007 [cited 2011 Jan 4]. Available from: http://www.guideline.gov/content.aspx?id=9830 [ Links ]
20. US Department of Health & Human Services. National Guideline Clearinghouse. Guideline Summary algorithm for venous ulcer care with annotations of available evidence: complete summary [Internet]. Rockville; 2005. [cited 2011 Jan 4]. Available from: http://www.guideline.gov [ Links ]
21. Zink M, Rousseau P, Holloway G. Lower extremity ulcers: acute and chronic wounds: nursing management. St. Louis: Mosby; 1992. p. 164-212. [ Links ]
22. Hjerppe A, Saarinen J, Venermo M, Huhtala H, Vaalasti A. Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility. J Wound Care. 2010;19(11):474-84. [ Links ]
23. Azoubel R, Torres GV, Silva LWS, Gomes FV, Reis LA. Effects of the decongestive physiotherapy in the healing of venous ulcers. Rev Esc Enferm USP [Internet]. 2010 [cited 2011 Jan 4];44(4):1085-92. [ Links ]