Theme: Wound Care

The use of biopsychosocial perspective of health and illness is a framework developed by

Engel (1977), which expands the biomedical view by integrating the biological,

psychological and social factors into one model. The interaction between the three factors can

determine the cause, indication and outcome of wellness and illness. Each of the three

systems can affect and be affected by the persons health (Sarafino, 2006).

A wound is any injury that breaks the continuity of skin, it can be caused by traumatic

reasons (physical/mechanical), intentional injury (surgery), ischaemia and pressure. Hence, it

is important for a nurse to understand the physiological processes involved in wound healing

to provide an appropriate care (Sarafino, 2006).

This essay will present the theme of wound care, focusing on the topic of venous leg ulcers

and demonstrating a key link between the biological and psychological issues that can arise

with it.

A normal venous system comprises of three components: the deep veins, superficial veins

and perforating veins. The deep veins are found within the fascial muscle compartments and

these include tibial veins, which carry venous blood to popliteal vein, to the femoral and

common femoral veins, to the iliac veins and finally into the vena cava. These deep veins

transport the major venous return from the lower limb. Large, superficial veins of the legs lie

above the fascial muscle of the lower extremity and play a significant role in the venous

system by collecting capillary blood and transporting it to the deep veins through multiple

tributaries of reticular and accessory veins. The superficial veins consist of two main venous

structures, the great saphenous vein and the small saphenous vein. Perforating veins are small

veins that bridge the superficial veins to the deep veins, allowing blood flow between them

(Gordon et al., 2016). The superficial veins function at low-pressure system, while the deep

veins are high-pressure systems (Etufugh and Phillips, 2007).

All of the three-venous system have one-way valves, thus, preventing blood from flowing

backwards due to gravity. Venous pressure forces the valves to open under normal conditions

and allow for forward flow; this same change of pressure on the other side of the valves close

it, preventing reflux of blood (Gordon et al., 2016). During mobilisation, the calf muscle

contracts and squeezes the blood upwards through the deep veins to propel it back to the

heart. This is called as the calf muscle pump (Dealey, 2012). As calf muscle relaxes, the

venous valves close to avoid backward flow of blood and the deep veins empty, which allow

for sudden drop in pressure (Gordon et al., 2016). The venous valves open to allow blood

flow from the superficial veins through the perforating veins and to the deep system veins

(Etufugh and Phillips, 2007).

However, when valves are incompetent, the blood flow of the veins in the lower extremities

become inadequate, resulting venous insufficiency and causing the blood to pool up in the

legs due to gravity. Eventually, leading to an abnormally high blood pressure in the veins of

the legs, called venous hypertension. This is further increased due to one or combination of

the following factors: reduced mobility, a sedentary lifestyle or being overweight, deep vein

thrombosis (DVT), varicose veins, dysfunctional valves due to thrombotic damage or trauma,

and calf muscle pump insufficiency. This venous hypertension is then transmitted all through

the venous system of the lower extremity (Etufugh and Phillip, 2007).

How a sustained venous hypertension can be a cause of venous leg ulceration is still

unknown, but several theories have been suggested. According to the fibrin cuff theory of

Browse and Burnard (1982), venous hypertension cause elevated capillary pressure by

distending its wall and capillary pores are stretched, increasing the permeability of the

capillaries and allowing for leakage of macromolecules, called fibrinogens, into the dermis

and subcutaneous tissue. Fibrinogen then polymerize into fibrin to make pericapillary fibrin

cuffs outside the blood vessel. These pericapillary cuffs act as a barrier that block oxygen and
other nutrients from reaching the skin, leading to ischaemia, cell death and tissue ulceration

(Etufugh and Phillip, 2007). Patient with venous disease can have decreased fibrinolytic

capacity to clear fibrin. This theory was supported by discovering pericapillary cuffs within

the ulcer beds and at the edge of ulcers with the use of immunofluorescence. However,

investigations done by other authors showed that the pericapillary cuffs are likely to cause a

major barrier to the diffusion of oxygen and nutrients. Additionally, they also found that the

cuffs are mostly spread in an even manner and that ulcer healing is not related to the decrease

in size of the cuffs (Etufugh and Phillip, 2007).

Fibrinogen and its degradation products have been also found to be part of the cause of

venous ulcerations via other mechanisms, such as reducing the regulation of procollagen

type-1 synthesis by dermal fibroblasts. The deposition of fibrinogen and fibrin inside the

blood vessels are believed to inhibit the function of dermal fibroblast to make collagen, thus,

impairing the adequate repair of tissue ulceration (Etufugh and Phillip, 2007).

Clinical features of venous ulcers include: swelling of the lower limb, ulceration in the gaiter

area of the leg, typically over the medial malleolus; brown-coloured hyperpigmentation of

skin due to deposits of haemosiderin; and ulcer beds are usually covered with red granulation

tissue or a fibrinous layer, surrounded by irregular shaped edges. In long term venous

insufficiency, lipodermatosclerosis occurs, characterised by induration of skin and

inflammation of subcutaneous tissue which alter the shape of leg like an inverted champagne

bottle, where the proximal leg swells and the distal part constricts due to subcutaneous fat

loss and fibrosis (Grey et al., 2006).

It is important to rule out any arterial disease, indicated by abnormal blood pressure, history

of cardiovascular disease and absence of pedal pulses when performing clinical assessment.

With this knowledge, the nurse should be able to obtain signs from medical history to suggest

for venous leg ulcer (VLU), such as history of DVT, varicose veins, family history of VLU,
surgery or trauma of the affected leg that can damage the valves, chest pain or pulmonary

embolism, obesity, sedentary behaviour or occupation with prolonged sitting/standing, and

severe pain in the lower limbs (Vasudevan, 2014).

There is no doubt that VLU has significant impacts on psychological and social aspects in

patients life. Based on a study carried out by Maddox (2012), individuals who suffer from

VLU experience multiple physical problems, such as, pain, leakage of exudate and malodour,

that can reduce patients social interaction with others and affect psychological wellbeing by

experiencing depression. NICE (2015) recommends that the nurse staff should promote self-

care routines, such as, regular mobility and elevation of the leg and use of preventive

compression hosiery to improve wound healing. However, patients who suffer from

depression may be unwilling to follow these routines over long period as they will lose

interest on wound management, leading to feeling of hopelessness and inability to set goals

due to reduced confidence (Isaac and Watson, 2015).

Depression is prevalent in patients with VLU. According to findings supported by Jones et al

(2006), they reported that 27% of the participants with VLU suffered from depression.

Patients with VLU are at risk of experiencing depression triggered by physical symptoms of

venous ulcers. The three main symptoms associated with depression were pain, uncontrolled

exudate and foul odour (Maddox, 2012). In order to control these devastating symptoms,

patients will limit their contact with others, therefore, creating a self-imposed isolation, which

has a massive impact on their social life and daily activities as a result of VLU (Green et al.,

2013).

A negative psychosocial factor such as depression have been found to further delay wound

healing and have also been associated with recurrence of VLU (Upton et al., 2017).

According to Finlayson et al (2011), there is a clear link between depression and an inability
to comply with wound treatment and self-care guidelines, which result patients to become

more dependent to nurses as they have not practiced self-care (Isaac and Watson, 2015).

Research has recognized the psychological effects of VLU and influence of locus of control

(LOC) theory by Rotter (1966) regarding patients experience. LOC theory concerns the

extent to which an individual feels they can control events that affects him/her. It specifically

measures the degree to which an individual believes that his/her behaviour is driven by

his/her personal decisions and efforts (internal LOC) or primarily guided by fate, luck or

other external situations that are beyond his/her control (external LOC) (Karstoft et al.,

2015). Reported by Maddox (2012), patients who has internal LOC assumed an active

approach towards ulcer management and in control of events, whereas individuals with

external LOC believed that other factors were in control, which can lead to feelings of

powerlessness, grief and feelings of loss, along with depression. These feelings may be

worsened by the appearance of ulceration, daily wound dressing changes and debridement of

the wound, which further reduce patients quality of life (Salom et al., 2013). Hence, having

an effective communication between the nurse and patient is a crucial part of developing a

therapeutic relationship that can promote self-efficacy and sense of control (Maddox, 2012).

The psychological and social effects of VLU are greatly influenced by the nurse-patient

relationship, therefore, it is essential for the nurse to prioritise other aspects that influence the

quality of life of patients with VLU as they will be the patients first point of contact and will

be the one to monitor their progression. The nurse should take these opportunities to have a

good insight of patients thoughts, feelings and concerns, rather than focusing solely on the

physical problems of VLU (Maddox, 2012).

In conclusion, the quality of life of patients with VLUs is compromised by physical,

psychological and social factors (Green et al., 2013) and evidence suggest that nurses
primarily concentrate on the clinical aspect of wound care management, therefore, the

psychological and social needs are often overlooked (Maddox, 2012). An acknowledgement

of patients experience of VLU will enable the nurse to provide a holistic care and establish a

good understanding of the complex of VLU in patients quality of life with the use of

biopsychosocial model to guide their nursing practice (Salom et al., 2013).