People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables

Abstracts

Objetivou-se analisar características sociodemográficas e clínicas de pessoas com úlceras vasculogênicas e investigar a associação entre estas variáveis. Realizou-se um estudo clínico observacional transversal, em salas de curativo de serviços municipais de saúde, de fevereiro a agosto de 2009. Realizou-se entrevista, exame clínico, aplicação da escala Pressure Ulcer Scale Healing (PUSH) e registro fotográfico das lesões. Participaram 42 indivíduos, com média de 60 anos (± 12), 73,8% do sexo masculino, com lesões únicas (66,7%), decorrentes de alteração da circulação venosa (90,5%), duração de até um ano (55,5%). Houve associação entre o escore da PUSH (p=0,019) e profundidade da lesão (p=0,027) com exercício de atividade ocupacional na atualidade, assim como entre o histórico de tabagismo e o gênero (p=0,049). As características sociodemográficas evidenciadas são semelhantes às de outros, com exceção do gênero masculino, o que indica a necessidade de maiores investigações na população goianiense.

Úlcera varicosa; Úlcera da perna; Cicatrização; Cuidados de enfermagem

ARTIGO ORIGINAL

People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables

Personas con úlceras vasculares en atención ambulatoria de enfermería: estudio de las variables clínicas y sociodemográficas

Suelen Gomes Malaquias^I; Maria Márcia Bachion^II; Silvia Maria Soares Carvalho Sant'Ana^III; Ceres Cristina Bueno Dallarmi^IV; Ruy de Souza Lino Junior^V; Priscilla Santos Ferreira^VI

^IRN. Master Student of the Graduate Program in Nursing, College of Nursing, Universidade Federal de Goiás. RN, Goiânia Municipal Health Department. Goiânia, GO, Brazil. [e-mail]

^IIPh.D. in Nursing. Full Professor, College of Nursing, Universidade Federal de Goiás. Goiânia, GO, Brazil. [e-mail]

^IIIRN. Master Student of the Graduate Program in Nursing, College of Nursing, Universidade Federal de Goiás. Goiânia, GO, Brazil. [e-mail]

^IVUndergraduate student, College of Medicine, Universidade Federal de Goiás. Goiânia, GO, Brazil. [e-mail]

^VRN. Ph.D. in Pathology. Adjunct Professor, Institute of Tropical Pathologies and Public Health, Universidade Federal de Goiás. Goiânia, GO, Brazil. [e-mail]

^VIUndergraduate student, College of Nursing, Universidade Federal de Goiás. Goiânia, GO, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

The aim of this study was to analyze the sociodemographic and clinical characteristics of people with vascular ulcers and to investigate the association between these variables. This cross-sectional, observational clinical study was conducted in outpatient clinics from February to August 2009. Interview, clinical exam, Pressure Ulcer Scale Healing and photographic registry of the wounds were performed. Forty-two individuals participated who were, on average, 60 (± 12) years old, 73.8% males, with single wounds (66.7%) resulting from alterations in venous circulation (90.5%). Their wounds had lasted for up to one year (55.5%). There was an association between the PUSH score (p=0.019) and depth of wound (p=0.027) with currently performing occupational activity, as well as between history of tobacco use and gender (p=0.049). The sociodemographic characteristics that were observed were similar to the others, except for being male, which indicates the need for more studies in the population in Goiânia, Brazil.

Descriptors: Varicose ulcer; Leg ulcer; Wound healing; Nursing care

RESUMEN

Se objetivó analizar características sociodemográficas y clínicas de personas con úlceras vasculares e investigar la asociación entre estas variables. Se realizó estudio clínico observacional transversal, en salas de curaciones de servicios municipales de salud, entre febrero y agosto de 2009. Se realizó entrevista, examen clínico, aplicación de escala Pressure Ulcer Scale Healing (PUSH) y registro fotográfico de lesiones. Participaron 42 individuos con promedio de 60 años (± 12), 73,8% de sexo masculino, con lesiones únicas (66,7%), derivadas de alteración de la circulación venosa (90,5%), duración de hasta un año (55,5%). Existió asociación entre el "puntaje de PUSH" (p=0,019) y profundidad de la lesión (p=0,027) con ejercicio de actividad ocupacional en la actualidad, así como entre historia de tabaquismo y género (p=0,049). Las características sociodemográficas evidenciadas son semejantes a las de otros, con excepción del género masculino, lo que indica la necesidad de mayores investigaciones en la población goianense.

Descriptores: Úlcera varicosa; Úlcera de la pierna; Cicatrizacíon de heridas; Atención de enfermería

INTRODUCTION

Among the types of leg ulcers, those of vascular origin (venous, arterial or mixed) are the most prevalent, which are characterized by a chronic, painful, recurrent process that has a negative effect on the quality of life, mobility, emotional state and functional capacity of those affected, requiring multidisciplinary care, including local and systemic interventions^(1-11).

The nursing interventions for this population should consider several aspects, which include sociodemographic characteristics such as gender, age, education, marital status, income and occupation, which will guide the language to be used in the approach, the concern about whether or not there is a need for social support, and the capacity of involving action to prevent complications.

In addition, there are the characteristics regarding morbidity, such as the type of altered circulation, the size and location of the wound, the existence of prior wounds, the healing condition of the wound, and the existence of comorbidities that could affect circulation and healing^(2-3,10-11).

Studies performed with people affected by leg ulcers, undergoing treatment at health units, indicate convergence among some socioeconomic and demographic characteristics between the population with venous ulcers, e.g., most are female (55 to 85%), have a low income and education (about 65%), and were not performing any occupational activity at the time of study^(1,12-16). However, other characteristics diverge, depending on the region of the study. Studies performed in Brazil indicate that the predominant affected age group is of 51-70 years^(1,15,17), whereas studies performed in Europe indicate a predominant age group of 70 years or older^(13,18).

Although there is consensus, until now, regarding the predominance of the female gender ^(1,12,15-17), a study performed in the city of Goiânia identified a higher frequency for males (80.4%) regarding primary health care for leg ulcers, and vascular ulcers were identified as the most frequent⁽¹⁷⁾.

Regarding the morbidity characteristics^{(1,3,7,13-20)}, venous ulcers prevail (60 to 90% of cases) among the vascular ulcers. Generally, individuals are affected by one single wound (ranging from 55 to 65%), usually on the distal half of the leg (up to 90% of cases), alone or not ^{(1-3,12,17-19)}. The recurrence rate can vary, with reports ranging from 38%⁽¹⁹⁾ to 80%^(1,3,7,20). In some cases, extensive wounds prevail^(1,14-15), while small wounds predominate in others⁽¹³⁾. The predominant duration, reported in the literature, ranges from months to years^(1,13).

Therefore, it is necessary to identify these characteristics in the different settings, in order to understand the particularities of each context and make an appropriate plan of the care to be delivered. Usually, people with vascular ulcers receive professional care at basic health units (BHU), at home, in outpatient clinics at reference services, and whenever there are complications or comorbidities, such as diabetes mellitus, they are seen at hospital units. Despite outpatient clinics being the main place where these individuals receive care, there are only a few Brazilian studies performed within the context of municipal health networks, addressing the population affected by this problem. A better understanding of this health condition is a starting point for multidisciplinary health teams to provide appropriate primary care for this specific clientele, as well as for the public health policy.

OBJECTIVES

The general objective of this study was to analyze the socioeconomic, demographic and clinical characteristics of individuals with vascular ulcers, comparing the population seen at municipal health unit dressing rooms. The specific objectives were: to identify the presence of venous, arterial or mixed ulcers among the study participants, describe the extension of the destruction to their skin layers (area and macroscopic characteristics of the wounds), characterize and investigate the association between the characteristics involved in the development of vascular ulcers and the morbidity involved in the development of vascular ulcers among the population assisted at municipal health unit dressing rooms.

METHOD

This is a descriptive, observational, cross-sectional, and quantitative study performed at the dressing rooms of municipal health units, which are open 24 hours a day, from February to August 2009. The inclusion criteria were: have a chronic vascular ulcer (duration of six weeks or more), on the functioning lower limbs, undergoing treatment at the dressing rooms of the health units involved in the study. The population consisted of 67 individuals, 25 of which were excluded because they presented one or more of the exclusion criteria: a) incapacity to express their agreement to participate in the study; b) death; c) refusal; or d) stopped attending the BHU to change the dressings.

In order to approach the individuals, data were obtained about the routine of the dressing rooms and the existence of users who met the aforementioned inclusion criteria, as well as the attendance and times of the day that they usually visited the units. Hence, it was found that of the 13 municipal health units that work 24 hours a day, 11 provided care to individuals with chronic ulcers, ten of which had a demand of users with vascular ulcers. The individuals were approached while in the waiting room. After confirming they met the inclusion criteria, they were handed the Free and Informed Consent Form.

The participants were asked about their availability to meet, and, when necessary, a new appointment was scheduled to the date closest to their next appointment at the unit. An average of three meetings were held with the users, ranging between two and six, in order to complete the data collection protocol.

This protocol contained information regarding the interview procedures, clinical examination, digital planigraph of the ulcers, the application of the Pressure Ulcer Scale for Healing (PUSH), and the macroscopic description of the wound using a photographic registry. The interview comprised items to identify the socioeconomic, demographic (age, gender, social class, marital status, years of study, occupational activity they performed for the most of their lives, and personal and per capita income) and morbidity (duration of the wounds, number of wounds per participant, relapse of the wound, affected zone or region of the limb, body mas index – BMI, macroscopic characteristics of the wound, current and former tobacco user) aspects, as well as questions regarding the intervenient factors of the vascular alterations of the lower limbs and ulceration.

The clinical examination of the lower limbs verified the pigment and/or trophic alterations, the presence of claudication, edema, peripheral tissue perfusion, temperature of the affected limb compared to the opposing limb, ankle-brachial index (ABI) and anthropometry. If available at the unit, the subjects' patient record was reviewed. Furthermore, the location of the wound was registered, and classified as zone 1 if on the foot to the malleolus, zone 2 if on the distal half of the leg, and zone 3 if on the proximal half⁽¹⁾.

The wounds were measured using planimetrics, with an acetate sheet, and the outline was analyzed using Image J® (NIH) software, version 1.38X. The depth of the wounds was verified using a sterilized device, placed in the deepest point of the wound bed, considering its surface line, and by positioning the sterilized scale that helps to mark the height of the tip of the device.

To classify the type of circulatory alteration, the following set of clinical indicators was used:

• Venous circulation alteration – presence of telangiectasia and/or varicose veins, edema of the ankle and/or above; hyperpigmentation, ochre dermatitis, eczema, lipodermatosclerosis; ankle-brachial index

  >0.9; complementary exams: duplex mapping indicating venous thrombosis and/or insufficiency due to obstruction and/or reflux of the venous systems.

• Arterial circulation alteration- intermittent claudication; pain when elevating the affected limb; paleness of the affected limb when elevated or at rest, reduced pulse of the leg arteries; hypotrichosis; thick and/or irregular nails; cold extremity compared to the non-affected limb or area not compromised with the wound; ankle-brachial index< 0.75; complementary exams: arteriography or equivalent indicating arterial obstruction.

• Associated arterial and venous alteration– presence of clinical indicators of both venous and arterial alterations, ankle-brachial index > 0.5

  < 0.8; complementary exams indicating venous and/or arterial alterations.

The Pressure Ulcer Scale Healing – PUSH, a tool originally developed to be used to evaluate the healing process of a specific type of wound, was broadened for also measuring chronic wounds of the lower limbs, and it covers the analysis of the following parameters: wound area in cm², amount of exudate on the wound, appearance of the wound bed. Each of these parameters has sub-scores that add up to a value between 0 and 17, in which higher total scores indicate worse wound conditions⁽²¹⁾.

Data analysis was performed using the Statistical Package of Social Sciences for Windows®, version 16.0. Descriptive statistics, central tendency and dispersion measures were used. In order to analyze the association between clinical (number of wounds per participant, wound duration, PUSH score, depth of wound, affected zone, relapse, BMI, tobacco use) and sociodemographic variables (gender, age, social class, years of education, occupation, occupational activity, personal and per capita income), the data were dichotomized using the chi-square or Fisher's exact test. Differences were considered statistically significant if smaller than or equal to 5% (p<0.05).

The study was approved by the Research Ethics Committee at Universidade Federal de Goiás (protocol number 032/2008).

RESULTS

The sample consisted of 42 participants, with, in average, 60 years of age (± 12), 73.8% males, 66.6% with a per capita income equal to or less than a minimum salary, 85.7% with a low education level, i.e., individuals that reported having completed primary education (64.3%) and those with no education (21.4%) (Table 1).

The total number of ulcers found on the participants was 63. Twenty-eight (66.7%) participants had one single wound, 35 (55.5%) of which lasted more than one year (Table 2).

Thirty-eight (90.5%) presented an ABI equal to or greater than 0.9 and signs of compromised venous flow. All participants showed characteristics of venous alterations such as varicose veins and/or telangiectasia (100%), edema in 40 (95.2%), ochre dermatitis in 25 (59.5%) and lipodermatosclerosis in 17 (40.5%).

On participant (2.4%) presented an ABI of 0.73 on the affected limb and ABI of 0.4 on the opposite limb, intermittent claudication, paleness when the limbs were elevated for less than 40 seconds, reduced pulse, hypotrichosis in the perilesional area, thick and irregular nails, necrosis of approximately 60% of the wound bed, small amount of exudate, hence this case was classified as an arterial ulcer.

Three people (7.1%) presented ABI between 0.5 and < 0.8 as well as signs of venous alterations (edema, ochre dermatitis, lipodermatosclerosis, hyperkeratosis and/or erythema), suggesting it is a case of mixed ulcer.

Regarding the location of the ulcers, it was verified that zone 2 was the most affected area, as the only affected area in 31 (49.2%) wounds, and associated with zone 1 in 19 (30.1%) cases. It was found that among the 63 analyzed wounds, there was a predominance of granulation tissue (46.0%) in amounts superior to 75% of the wound beds, and slough entwined to the granulation tissue in 88.9% of the wounds. Most (84.1%) wound did not present eschar (Table 2).

Approximately half the participants were overweight or obese, 71.4% had a tobacco use history, but at the time the evaluation was performed, there had been a drastic reduction in this behavior, as it was present in only 19.0%.

A statistically significant association was found between the variables "PUSH score" (p=0.019) and depth of the wound (p=0.027) regarding currently performing occupational activity, (Table 3).

A significant association was found between the PUSH score (p=0.019), maximum depth of the wound (p=0.027), and the presence of a current occupational activity, in that participants with higher PUSH scores and deeper wounds were not involved in a occupational activity at that time (Table 3).

The history of tobacco use was most frequent among males (p=0.049) as shown in Table 4, showing no association with any other socioeconomic, demographic, or clinical variable (Table 4).

Discussion

In the present study, it was observed that most participants were male, similar to a prior study performed at the same primary health care setting in Goiânia, which found a prevalence for males close to 70% regarding individuals with leg ulcer, mostly vascular ulcers⁽¹⁷⁾. On the other hand, studies performed in other settings have found a predominance of females^(1,13), reaching 80%⁽¹⁴⁾.

This finding requires further investigation, because some suppositions may occur in the studied setting, such as the possibility that most women are treated at home, or, yet, that men are susceptible to risk factors that are more prevalent at the studied location, and, thus need an approach that takes these specificities into consideration.

One studied⁽²⁰⁾ called attention to the fact that, supposing that vascular ulcers are an occurrence particular of females, with more than 60 years of age, could be an equivocated assumption, considering that venous insufficiency occurs in approximately 30% of the adult population, and that varicose veins are thicker in men than in women. This study found that, among the people with venous ulcer before the age of 50 years, males predominated (59.0%), while in the population affected by this problem at an age above 50 years, the female gender predominated (77%) (p=0.001).

The participants' age was similar to the findings of a study performed in northeast Brazil⁽¹⁷⁾, but younger compared to other studies^{(1,9,13-14,16)}, though with no substantial change to the predominant age group of the affected population, i.e. above the age of 50 years.

The low income and education level found in the studied sample is an aspect constantly observed in studied that include individuals with venous ulcers^{(1,9,13-14,16)}, which could indicate a lifestyle that may cause wounds, or, yet, the inappropriate care by health care professionals that take care of this population.

This situation could compromise treatment compliance, which is costly for both the user and the health care institution⁽³⁾.

On the other hand, in the public health system there is a suppressed demand in specific areas such as angiology, which means that this evaluation and the systemic approach occur at a time when these wounds are truly set in.

The predominance of single wounds, observed among the present study participants is also observed in general studies^(1,14,17). This could characterize a phenomenon due to the long course periods of the wounds, which permitted the confluence of multiple wounds, or a lesser severity of the vascular alteration.

Regarding the duration of the wounds, variations were observed in this study as well as in the literature^(15,17), which reinforces the interaction between factors such as: the severity of the vascular alteration, accessibility to specialized angiology care, receiving care from a qualified team, the lifestyle, and compliance to treatment and to the service.

The wound recurrence rates found in this study are similar to a prior investigation⁽¹⁹⁾, but differ from most study findings^(1,7,14). This fact calls for further investigation in different settings, because there is a possibility that reference units, as some of those included in the referred studies, have a clientele with wounds of higher complexity than those usually observed in municipal health units.

As to the type of compromised vascular circulation, the occurrence of wounds caused due to alterations in venous circulation continue to stand out from the others, which is in agreement with many studies^(1,13-20). This points, once again, to the need for a systemic and multidisciplinary approach that includes the accessibility to angiology care.

It was observed that the participants were involved in occupational activities at the time of the evaluation of the present study, and the depth of wound and PUSH scores were smaller than those of participants who were not involved in an occupational activity at the time of data collection. This may be due to the fact that, for these individuals, the wound can affect their capacity to work. Studies show that ulcers, particularly venous ulcers, compromise one's functional capacity, and interfere in their mobility, in addition to causing pain^(4,13). This can compromise people's capacity to work, thus triggering a series of consequences that affect their socioeconomic aspects.

Nurses have an important role in developing a way to organize the working process in order to meet the users' needs, integrating health care activities with the necessary qualification and competence, and to managerial and relational processes⁽²²⁾.

This study points at some important implications to nursing practice:

• considering to participate in the development of multidisciplinary interventions, both systemic and local, to prevent the problem and its complications and restore tissue integrity, by implementing therapies appropriate to the type of circulation that has been compromised;

• organizing the service in order to implement a system that permits to: approach specific groups, as the one of the present study, which consisted mainly of men of ages between 50 and 70 years, with a history of working in the construction industry and rural activities, for most of their lives, with a low income and low education level, and who were not involved in occupational activities when they were affected by the wounds.

CONCLUSION

The present study results corroborate, in part, the socioeconomic and demographic profile of the population affected by vascular ulcers, users of outpatient clinics of public health institutions. The marking characteristics are low income and education level. The present study findings differ from the literature, regarding the predominant gender and age group of people with vascular ulcers, which suggests a need for further studies and in different settings.

The results reinforce that the predominant type of vascular ulcers are those of venous etiology, and the most frequent occurrence is a single, extensive exudative wound, located in zone 2 exclusively or in association with other zones. The characteristics of the wound bed tissue indicate that the healing process is compromised.

The associations verified in the present study demonstrate the exposition of individuals to functional limitations caused by the poor conditions of the wounds, which has multidimensional repercussions.

REFERENCES

• 1. Frade MAC, Cursi IB, Andrade FF, Soares SC, Ribeiro WS, Santos SV, et al. Úlcera de perna: um estudo de casos em Juiz de Fora MG (Brasil) e região. An Bras Derm. 2005;80(1):41-6.
• 2. Royal College of Nursing. Clinical Practice Guidelines. The nursing management of patients with venous leg ulcers: recommendations [Internet]. London; 2006 [cited 2010 Mar 2]. Available from: http://www.rcn.org.uk/data/assets/pdf_file/0003/107940/003020.pdf
• 3. Etufugh CN, Phillips TJ. Venous ulcers. Clin Dermatol. 2007;25(1):121-30.
• 4. Koupidis SA, Parakevas KI, Stathopoulos V, Mikhailidis DP. Impact of lower extremity venous ulcers due chronic venous insufficiency on quality of life. Open Cardiovasc Med J. 2008;2:1055-9.
• 5. Kelechi, T, Bonham, P A. Lower Extremity Venous Disorders: Implications for Nursing Practice. J Cardiovasc Nurs. 2008;23(2):132-43.
• 6. Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E. A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs. 2009;18(11):1541-9.
• 7. Finlayson K; Edwards H; Courtney M. Factors associated with recurrence of venous leg ulcers: a survey and retrospective chart review. Int J Nurs Stud. 2009;46(8):1071-8.
• 8. Jull A, Parag V, Walker N, Maddison R, Kerse N, Johns T. The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers. J Wound Care. 2009;18(12):497-503.
• 9. Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg. 2010;51(3):655-61.
• 10. Carmo SS, Castro CD, Rios VS, Sarquis MGA. Atualidades na assistência de enfermagem a portadores de úlcera venosa. Rev Eletr Enferm [Internet]. 2007 [citado 2010 abr. 21];9(2): 506-17. Disponível em: http://www.fen.ufg.br/revista/v9/n2/v9n2a17.htm
• 11. Conferencia Nacional de Consenso sobre Úlceras de la Extremidad Inferior. Documento de consenso C.O.N.U.E.I. Barcelona: Kamed; 2009.
• 12. MacGuckin M, Waterman R, Brooks J, Cherry G, Porten L, Hurley S, et al. Validation of venous leg ulcer guidelines in the United States and United Kingdom. Am J Surg. 2002;183(2):132-7.
• 13. Heinen MM, Persoon A, Kerkhof P, Otero M, Achterberg T. Ulcer-related problems and health care needes in patients with venous leg ulceration: a descriptive, cross-sectional study. Int J Nurs Stud. 2006;44(8):1296-303.
• 14. Bergonse FN, Rivitti EA. Avaliação da circulação arterial pela medida do índice tornozelo/braço em doentes de úlcera venosa crônica. An Bras Derm. 2006;81(2):131-5.
• 15. Deodato OON. Avaliação da qualidade da assistência aos portadores de úlceras venosas atendidos no ambulatório de um hospital universitário em Natal/RN [dissertação]. Natal: Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte; 2007.
• 16. Torres GV, Costa IKF, Dantas DV, Dias TYAF, Nunes JP, Deodato OON, et al. Idosos com úlceras venosas atendidos nos níveis primário e terciário: caracterização sociodemográfica, de saúde e assistência. Rev Enferm UFPE. 2009;3(4):222-30.
• 17. Martins MA. Avaliação de feridas crônicas de pacientes ambulatoriais de Unidades Básicas de Saúde, em Goiânia/GO [dissertação]. Goiânia: Faculdade de Enfermagem, Universidade Federal de Goiás; 2008.
• 18. Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg ulceration in a London population. QJM. 2004;97(7):431-7.
• 19. Olson JM, Raugi GJ, Nguyen VQ, Yu O, Reiber GE. Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affair Medical Center. Wound Repair Regen. 2009;17(5):666-70.
• 20. MacKenzie RK, Brown DA, Allan PL, Bradbury AW, Ruckley CV. A comparison of patients who developed venous leg ulceration before and after their 50th Birthday. Eur J Vasc Endovasc Surg. 2002;26(1):176-8.
• 21. Santos VLCG, Sellmer D, Massulo MME. Confiabilidade interobservadores do Pressure Ulcer Scale for Healing (PUSH), em pacientes com úlceras crônicas de perna. Rev Latino Am Enferm. 2007;15(3):391-6.

Correspondência:

Suelen Gomes Malaquias

Rua 8, n. 39 - Setor Norte Ferroviário.

CEP 74063-150 - Goiânia, GO, Brasil

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  09 June 2010
• Accepted
  30 May 2011