Question

Mr 8 comes into your community health clinic with a large weeping ulcer on the malleolus of the right foot that he claims is not painful. He has 2+ edema in both feet. VS within normal limits. Lab results are remarkable for a WBC OF 12,300/mm3. He states that is occupation is a collector in a toll booth, he stands most of the time and he reports often working 10 and 12 hour shifts. He denies taking meds other than occasional Tylenol for headache.

1 what is the likely cause of the ulcer on Mr B’s foot?

2. What are the usual signs and symptoms for this disorder?

3. State three nursing diagnosis appropriate for this client?

4. What are the primary nursing interventions?

Answer 1

Name of the patient: Mr.8,

physical examination : large weeping ulcer on the malleolus of the right foot ,

- not painful,

- 2+ edema, both feet,

- wbc - 12300 cells per cumm,

Diagnosis is the pt having weeping ulcer rt foot and bilateral pedial edema with mild Leukocytosis.

Q)1) what is the likely cause of the Ulcer on Mr Bs foot?

This is likely cause of Ulcers of lower leg, secondary to venous Hypertension have an estimated prevalence of around 1% are more common in women than in men, and account for some 85% of all leg ulcers seen in USA and UK.  

Or

This type of ulcers may due to cause of Venous Hypertension, the gravitational syndrome and venous leg ulcer.

cause: satisfactory venous drainage of the leg requires three sets of veins.

1. Deep veins surrounded by muscles,

2. Superficial veins,

3. Veins connecting these together.

A. When the leg muscles contract , blood in the deep veins is squeezed back,against gravity to the heart ( the calf muscle pump), reflux is prevented by valves,

B. When the muscles relax,with the help of gravity,blood from superficial veins passes into the deep veins via the communicating vessels,

C. If the valves in the deep and communicating veins are incompetent,that calf muscle pump now pushes blood into the superficial veins,where the pressure remains high (venous Hypertension) instead of dropping during exercise.

D. This persisting venous Hypertension enlarges the capillary bed white cells accumulate here and are then activated ( by hypoxic endothelial cells), releasing oxygen free radicals and other toxic products which cause local tissue destruction and ulceration.

E. The increased venous pressure also forces fibrinogen and alpha 2 macroglobulin out through the capillary walls, these macromolecules trap growth and repair factors so that minor traumatic wounds cannot be repaired and an ulcer develops,

F. Patient with these changes develop lipo dermato sclerosis and have a high serum fibrinogen and redused blood fibrinolytic activity.

​​​​​( How these above points supports to Mr.Bs case: this client working as collector at toll booth and he stands more than 10 hrs, that is why his muscles are not contract,the calf muscle pump pushes the blood into superficial veins where the pressure remains high, swelling, accumulation of wbc cells and formation of ulcers)

Q)2) what are the usual signs and symptoms of this disorder?

Venous Hypertension is heralded by a feeling of heaviness in the legs and by pitting oedema. Other signs include :

1. Red or bluish discoloration,

2. Loss of air,

3. Brown pigmentation ( mainly hemosederin ) and scattered petechiae,

4. Atrophie Blanche,

5. Induration caused by fibrosis and edema of the dermis and subcutis some times called lipodermatosclerosis.

Ulceration is most common near the medial malleolus, venous ulcers large but shallow with prominent granulation tissue in their bases.

Symptoms are : 1. Bilateral super infections, is inevitable a long standing ulcer, but needs systemic antibiotics only when there is pyrexia,

2. Purulent discharge,

3. Rapid extension or an increase pain, cellulitis, Lymphangitis or septicemia,

4. Eczema is common around venous ulcers,

5. Allergic contact dermatitis,

Should be suspected if the rash worsens itches or fails to improve with local treatment, the culprits are mainly Lanolin, parabens, and neomycin.

Differential Diagnosis: Atherosclerotic, vaaculitic, thrombotic , infectious,panniculitis, malignant ulcers and pyoderma gangrenosum.

Q)3) Three Nursing diagnosis for this case?

The nursing diagnosis for this case are mainly

1. Assess venous insufficiency of subjective data

- ankels,lower legs,

- aching,tightness,

- varies with fluid intake, use of support hose and decreased muscle activity,

- greater in evening than morning,

- increases during course of a day with prolonged standing or sitting,

- immobility,

- extremely dependance,

- extremely elevation,

- compression stockings or ace wraps

- no change unless arterial system or nerves are effected. These Ara all by asking pain location, quality, chronology, setting , aggravating factors and parasthesia like symptoms.

- compare with subjective data of arterial insufficiency,

2. Comparison with the help of objective data with arterial insufficiency with venous sufficiency , these mainly by sign like temperature, color, capillary filling,pulses, movement,ulceration

in venous insufficiency : mainly signs like - warm skin,

- flushed,cyanotic,

- typical brown discoloration around ankles,

- motor ability,

- occurs around ankle,

- ulcers shallow with irregular edges,

- surrounding tissue edematous with engorged veins.

3. Assessing defining characteristics

The nursing goals for diagnosis is checkbased on to check sensory functions: cutaneous, tissue integrity,tissue perfusion,peripheral.

Q)4) what are the primary nursing care interventions?

1. Peripheral sensation management,

2. Circulatory care,

3. Venous insufficiency,

4. Arterial insufficiency,

5. Positioning

6. Excersice promotion

A. Assess causative and contributing factors,

B. Promote factors that improve arterial insufficiency and venous insufficiency,

C.initiate health teaching if indicate,

d. Prepare a daily walking program,

e. Give special attention to toe and feet,

f. Explain the certain risk factors to the development of atherosclerosis,

g. Maintain normal Hypertension and hyperlipidemia,

h. Wound care if necessary debridement.

Summary of the entire topic: patient having weeping ulcer at medial mallenous due to the cause of lower leg Hypertension,signs and symptoms brelated to color and pain and temperature.Nursing diagnosis mainly basis on insufficiency if arteries and veins and care should be on wound care and peripheral management.