Leg Ulcer Case Study Wound Healing Community Outreach Service Mrs Ivy Hurtzalot, a 71-year-old lady, presents to her general practitioner with an ulcer on her right medial malleolus. Ivy reveals that the wound resulted from a traumatic injury 3 months ago while she was gardening. She denies a history of ulceration and can t think of any obvious reasons for delayed wound healing although she thinks her father had a leg ulcer and her mother had varicose veins. Her medical history reveals that she has mild hypertension for which she is monitored by her GP but does not require medication. She underwent a hysterectomy 3 years ago for uterine cancer followed by chemotherapy. She gets check-ups regularly and there is no evidence of recurrence. Ivy reports that she feels generally well although she tires easily and finds having an ulcer an inconvenience because it stops her from being able to garden as much as she would like to. When questioned about the care of her ulcer she reports that she has been caring for the wound herself using antiseptic lotions and cream and applies a dry dressing with a bandage around her ankle to protect the area. She only sought medical advice when her daughter questioned her about why she was always wearing a bandage around her ankle. She told her daughter that she didn t want to worry her and that she was surprised it was taking so long for her wound to heal. On examination Ivy has pitting oedema concentrated in the calf region and some oedema around her ankle. She has ankle flare and ropey varicose veins extending all the way to the groin on both legs. She reports that her mother suffered from varicose veins and that she developed them in her early twenties after having children but has never been bothered by them although sometimes they ache and her legs feel heavy. Ivy reports that she noticed brown staining in both legs that developed about two years ago. She also reports that her legs had started to become more swollen, particularly if she had been standing for long periods, during hot weather and that it is worse by the end of the day. She states that she considered that these changes were to do with getting old and were best ignored. Ivy reports that her legs are often itchy and she suffers from a red rash around the gaiter region. She says it doesn t seem to matter what she applies, the itching persists. Ivy has Page 1 of 5
evidence of atrophie blanche and ankle flare around both malleoli. Her mobility is good and she walks her dog every morning for about half an hour and generally remains very active. Ivy reports that she is lonely since her husband died a few years ago but that she does have friends that she visits regularly. Her two daughters have moved away from the area but keep in touch regularly. When questioned about pain in the ulcer she reports that this is worse during the evening and that walking causes wound pain from the dressing. Dressing changes are very painful and she finds that the dressings tend to stick even though the wound is leaking. On a numeric rating scale where 0 is no pain and 10 the worst possible pain, she rates her pain at present at 4. Ivy states r that pain intensity fluctuates during the day, depending on what she is doing. She gains relief from ibuprofen which she takes periodically. She finds that the pain subsides during the night and when her legs are elevated but it is particularly severe when she first gets up. She describes the pain as bursting in nature. On examination the wound bed is found to measure 25mm in length X 15 mm wide and is 2mm deep. The wound is covered with predominantly sloughy tissue. The wound is producing moderate amounts of malodouress blue-green stained serous exudate. The odour is another reason Ivy reports changing dressings so often. The periwound skin is moist and slightly hyperkeratotic. Another problem that Ivy reports is difficulty finding footwear that does not rub the area of ulceration. Examination of her ankle range of movement shows that she has reduced range of movement. She does not like to bend her ankle to much as she finds that flexion and extension exercises exacerbate her pain. Ivy expresses frustration that her wound will not heal. During the assessment she has described using denial as a major cooping strategy in a number of circumstances which is why she has taken so long to seek help. She states that it s easier not to think about it and just get on with things. Investigations show that she has mild anaemia. Further discussion reveals that her diet is poor since the loss of her husband. She relies on ready-made frozen meals and does not Page 2 of 5
enjoy vegetables or fruit. Her thyroid function is within normal limits, as are her other routine blood tests. Lower limb vascular assessment reveals that both feet are warm on palpation and capillary refill time is less than two seconds. She is able to detect a 10gram monofilament on the plantar aspect of both feet and her patella and Achilles tendon responses are normal. She has strong dorsalis pedis and posterior tibial foot pulses and an ankle brachial pressure index of 1.2 in both legs with triphasic waveforms suggesting normal peripheral perfusion. Page 3 of 5
Page 4 of 5 Wound Healing Community Outreach Service
Leg ulcers are commonly encountered in the general practice setting. The purpose of this case study is to highlight the need for comprehensive assessment of the person and their wound, for the outcome of assessment will inform best practice care. The questions below are designed to trigger your thinking. You might like to write a few dot points or a sentence in response to the questions below. To ascertain you level of knowledge, you will be asked to answer these questions before and after the workshop. What factors are likely to have led to the development of this wound? How would you assess this wound? Based on the information provided what is your outcome of assessment and diagnosis? What treatment would you implement? In what circumstances would you consider a specialist referral? How would you attempt to prevent recurrence of the wound in the future? Page 5 of 5