INTRODUCTION:

Chronic leg wounds are otherwise termed as chronic lower limp ulcer or chronic lower extremity ulcer. The incidence of this ulceration common among elderly people as well as adults. Chronic legs wounds affect the full thickness of the skin and delays in healing .

There are many factors associated with delayed healing in diabetes mellitus and chronic venous insufficiency. Global prevalence of the chronic leg wounds 1% of the adult population and 3.6% of people older than 65 years. Chronic leg ulcer affects 0.6–3% of those aged over 60 years, increasing to over 5% of those aged over 80 years¹.

In India, the Cost of treatment of Complete Healing for neuropathic ulcer is 56 US$, Infected neuropathic foot is 165US$ and 960US$ for advanced diabetic foot Limb amputation ⁶.Apart from the health burden it also affects the mobility .Pain, odour, itching, often fever, chills and drainage of chronic leg wounds affects the quality of sleep, activities of daily living, self care and quality of life. Continuous struggle produces loss of hope, feeling of helpless, loss of job, diminished work capacity, low self esteem, fear and distress.

Increased duration of ulcer, negligence of the wound care and treatment of primary diseases, poor knowledge and economic burden are the factors which increases the risk of poor healing, recurrence, multiple ulcer, amputation and psychological comorbidities mainly anxiety and depression .

Epidemiological reports gave the picture of seriousness of the chronic leg wounds. It is essential to develop a theory to assess the impact and need of the chronic leg wounds for the health professional to provide the contemporary care. Researcher’s experiences instigated her to do systematic review on the impact of chronic leg and foot ulcer and develop a theory specific to chronic leg wounds.

STATEMENT OF THE PROBLEM:

A systematic review an impact of chronic leg wounds: a step to develop theory.

OBJECTIVES:

1. Identify the impact of chronic leg wounds on health and well being.

2. Develop a theory of chronic leg wounds.

METHODOLOGY:

Research design is the overall blueprint to conduct the study. Systematic review is one of the research designs to collect various literatures for the evidence based health care. Systematic review provides various literature supports for the single concept .Researcher had selected this design in order to develop a theory of chronic leg wound. The following steps were planned by the researcher.

1.Framing questions for a review:

In order to be address questions for a review, statement of the problem defined by the researcher. Problem or research question framed by the researcher was impact of chronic leg wounds .After defining the problem researcher searched relevant literature.

2. Identify the relevant work:

Relevant literature were searched in different databases mainly from the Medline, Pub med central, interventional sciences, British nursing Index, Ebase,Google ,plusone, Helinet( library of RGUHS,Bangalore ) and Springerlink. Scientific articles, research papers, conference proceedings, were searched .The qualitative studies were identified and included to improving the sensitivity of the study. Totally 100 studies were collected from the above mentioned data bases related to the chronic leg wounds.

3 .Criteria used in selecting the studies:

The criteria were set by the researcher to select the studies for a systematic review.

Inclusion criteria:

1. The primary research reported by the author directly

2. Studies related to the impact of chronic leg wounds and its care.

3. Both qualitative and quantitative studies.

4. Studies conducted in the adult and elderly populations.

5. Studies conducted in the venous leg ulcers and diabetic foot ulcer.

6. Studies reported only in English language.

7. Studies conducted in community, home care and long -term health care settings.

8. Studies conducted in all the countries.

9. Only research articles.

10. Studies conducted by health care professionals.

Exclusion criteria:

The studies

1. Outcomes not reported clearly

2. Review article

3. Not relevant

4. Published after 2007

4.Summarizing the evidence:

The retrieved results scrutinized for the relevant studies fulfilling the inclusion and exclusion criteria. The obtained results were presented in the data extracted tables. The themes were categorized based on the findings.

RESULTS:

Reviews were retrieved from the various databases (100 studies were collected) .Totally 27 studies were selected to conduct a systematic review on chronic leg wounds based on the criteria. Twenty three were quantitative studies and four were qualitative studies. Extraction tables formed from the extracted data which includes Setting, design, outcome and location. Studies conducted in India, Europe, America, Africa, Asia and Australia were included. The results were discussed in the following headings

Care of the person:

Table 1implicated studies related to the care of chronic leg wounds. Results show that regular checkup, compliance to the regimen, continuous prognostic information, wound guidelines, regular screening program and combined medical and surgical treatments have a good prognosis on wound healing, compression therapy, and early notification of skin changes or ulcer have high prognostic value. Long term hospitalization affects the quality of life. Review studies of the care process recommended that the psychological aspect of the health need to focus in order to promote the healing of chronic wounds. Odour and excessive exudates leading to leakage had an adverse effect on patients' psychological state, leading to feelings of disgust, self-loathing low self-esteem, social isolation and depression.

Factors Influencing:

Table 2 represented studies related to factor influencing the chronic leg wounds .Outcome of the studies reported that healing of the chronic wounds were associated with smoking ,poor glycemic control as evidenced by an elevated glycosylated hemoglobin large size, increased depth of wound, alcoholism ,obesity ,presence of skin callus ,infection ,ankle brachial pressure index, impaired limb perfusion ,impaired protective sensation ,obesity ,poor knowledge ,negligence of wound care after amputation ,lack of exercises ,low and average income and noncompliance to treatment regimen. Review studies on this aspect suggested controlling of the socioeconomic factor, biological parameters and negligence of self care will promote the health and wellbeing of the chronic leg wounds and prevents associated risks of chronic leg wounds.

Associated risks:

Table 3 implicated the associated risk of chronic leg wounds .Follow up and prospective studies listed out that abscess, wet gangrene, infected ulcers, osteomyelitis, necrotizing fasciitis and cellulitis are increasing the risk for amputation. Major cause for amputations is infections. Major amputations are less than the minor amputation. Venous and diabetic ulcer recurrences were equally high. Amputation is high among diabetic ulcer than venous ulcer also in combination diabetic and venous ulcer. Perceived health and psychological well-being were significantly affected by chronic leg wounds which increase the risk of psychiatric co morbidities mainly depression.

Table 2 show that the studies related to factor influencing chronic leg wounds

Sl.no

Type of study

Author and year

Design and place

Socioeconomic proﬁle of diabetic patients with and without foot problems.

Associated risk factors and management of chronic diabetic foot ulcers exceeding 6 months’ duration

Epidemiology of diabetic foot infections (DFIs) and its

Predictive factors for lower extremity amputations.

A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients.

The Prevalence of Diabetic Peripheral Neuropathy and Related Factors.

Aziz Nather et al 2010

Hassan Gubara et al.

2012

Zameer Aziz et al.

2011

J. Joseph Anderson et al 2012

O Tabatabaei-Malazy et al .2011

Cohort study in Singapore.

Prospective study in Sudan.

Prospective study in Singapore

Retrospective study in USA

Cross sectional study in

Iran

Table 3 shows that the prevalence and psychological risks of chronic leg wounds

Sl.no

Study

Author and year

Design and place

The association between history of diabetic foot ulcer, perceived health and psychological distress.

Prevalence of obstructive sleep apnea in patients with chronic wounds.

Depression is associated with an increased risk of incident diabetic foot ulcers.

Depression and incident lower limb amputations in veterans

with diabetes.

Marjolein M Iversen and 2009

Patt BT in 2010

Lisa H. Williams et al and 2010

Population based survey (prospective survey) and Norway

Crosssectional survey and Ohio, USA

Population-based prospective cohort study

USA

Retrospective cohort study USA from 2001

Table 4 shows that the studies related to the quality of life of chronic leg wounds

Sl.no

Type of study

Author and year

Design and place

Compare the HRQoL in diabetic patients with and without foot ulcers and to determine demographic and clinical factors influencing HRQoL

Impact of foot problems on health-related quality of life (HRQoL) in patients with diabetes in Malaysia

Health-related quality of life (HRQL) between those with healing ulcers and those with ulceration,

Impact of Lower Extremity Venous Ulcers due to Chronic Venous Insufficiency on Quality of Life

Health Related Quality of Life in Patients with Type 2 Diabetes Mellitus in Iran: A National Survey

Itch: Association with Chronic Venous Disease, Pain and Quality

of Life

Yekta Z, Pourali R, Ghasemi-Rad M and 2011

Mazlina M, Shamsul AS, Jeffery FA.

2011

Ribu L, Birkeland K, Hanestad BR, Moum T, Rustoen T 2008

Sotirios A et al. 2008

Mehdi Javanbakht1

2012

Thomas N. Templin. 2011 ;

Descriptive study.

Iran

Descriptive study Malaysya

Longitutinal study for one year .Norway

Systematic Review

Cross sectional study in Iran

Exploratory, cross sectional design.USA

Table 5 shows that the qualitative studies related to the chronic leg wounds.

Sl.no

Study

Author and year

Design and place

Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study

Physical activity in patients with venous leg ulcer – between engagement and avoidance.

The care process of diabetic foot ulcer patients: a qualitative study in Iran

Explore beliefs about diabetic foot complications and everyday foot self-care practices among people with type 2 diabetes

Irene M van de Glin et al. 2012

Kirsti Skavberg et al 2011.

Mansooresh Aliasgharpour et al. and 2012

Gale et al and 2008

Multiple case study method. Netherland

Phenomenology

Sweden

Grounded theory

Iran

Phenomenology United Kingdom

Health and wellbeing:

Table 4 and 5 presented the impact of chronic leg wounds on health and well being. Health related quality of life was negatively affected by the chronic leg wounds. Physical problems were pain, immobility, odour, drainage; bleeding and sleep disturbances are the struggle are experienced by a person daily. Loss of hope, worthless, feeling helpless, embarrassed, fear and worries are the emotional reactions experienced by a person related to their chronic leg wounds.

Review studies reported that the negative impact of the chronic leg wounds equally affect physical and psychological health. It should be focused to promote the health of the individual with chronic leg wounds. Care needs of the individual with chronic leg wounds should be

focused on self-management, instructions and support, fear of injury’ and a wish to stay normal’.

DISCUSSION:

Chronic leg wounds have an impact mainly in physical and psychological domain. It became one of the leading causes for disabilities, morbidity and increasing health care cost burden to the individual and country. The above findings were supported by the study conducted about systematic review on impact of leg ulceration on patient’s quality of life in Germany 2007

The above study reviewed the various predictors of impact on the all the health domains and quality of life, knowledge of patients and psychological outcomes of the chronic leg wounds and care of health professionals³⁶.Based on the concepts obtained from the analysis of systematic review researcher developed the care, control and caution theory of chronic leg wounds.

Care, control and caution theory of chronic leg wounds:

Theory of chronic leg wounds developed from a systematic review an impact of chronic leg wounds on health and well being. Chronic leg wound the wound which is developed below the knee mainly affecting the leg and foot for more than 3 to 4 weeks due to diabetes mellitus, venous ulcer and peripheral arterial disease

Care:

Psychological disturbances

Existing health problems

Disease continuum:

Recurrence, Multiple ulcers, Amputation, Anxiety, Depression, Disability and Death

Associated risks:

Caution:

Control:

Socio economic factors.

Compliance and Negligence

Biological parameters

Emotional disturbances

Aggravating factors:

Figure 1. Conceptual framework of Care, control and Caution theory of chronic leg wounds. (Author: Kirupa. P) Concept of theory chronic leg wounds intrudes the psychological health and aggravating factors also influences the disease and its risks. Care of chronic leg wounds at all the level of disease continuum, control of aggravating factors and caution of associated risks are three concepts comprises in the assessment and management of chronic leg wounds

Care and Diseases continuum:

Care chronic leg wound should integrate mental health services also in the management. Pain, immobility, long term hospitalization, wound drainage, bandages, diminished work capacity are the various health problem faced by a person suffering from chronic leg wounds. A continuous experience of this problem instigates psychological and emotional disturbances include loneliness, low self esteem, fear, guilt, depression and emotional imbalance. Nurse should focus existing health problem to severe intensity of the health problem in a physical domain to psychological domain.

Control of Aggravating factors:

Care of chronic leg wound combined with control aggravating factors. Uncontrolled biological parameters, non compliance to the treatment, negligence to the self care and socioeconomic and cultural factors are the aggravating factors need to be controlled. Biological parameters such as poor glycemic control, ankle brachial pressure index are some of the factors aggravate the intensity of the problem and associated risks. Associated health risks could be prevented by controlling the risk factors in the management of chronic leg wound.

Caution of associated risks:

Health and well being is promoted by preventing the associated risks. Associated health risks range from mild upset to major depression and recurrent ulcer to amputation. Caution about the associated health risks helps to promote the healing of wound and prevent the comorbidities and disabilities associated with illness. Health education, awareness of chronic leg wound and regular screening of psychiatric comorbidities are included in the care of chronic leg wounds to prevent serious consequences of illness.

Advantages:

1 This theory is easy to apply for Nursing practice, Nursing education administration and Nursing research.

2 Easy and simple to follow.

3 Based on evidence based article.

4 It can be scientifically tested

Limitation:

1 Specific to chronic leg wounds.

2 Require strong validation.

3 Reviews regarding the social support and cost analysis of chronic wound were not included.

Recommendations:

The study recommended the healthcare professionals focus towards

· The measures to rectify the impact of chronic leg wounds on patients' health and healing.

· Providing clear and continuous information in the management of chronic leg wounds.

· Psychological aspect of chronic leg wounds

Government can:

· Conduct funded foot care screening programs.

· Provide foot wears for diabetic patients those who are BPL.

· Initiate special insurance program for the chronic leg wound patients.

CONCLUSION:

Chronic leg wounds have its impact on the patient health and well being. Chronic leg wounds (venous and diabetic ulcer) are one of the complications of the disease. Awareness and knowledge about primary diseases and its complications are very poor. Socioeconomic cultural factor as well as biological factors, psychological factors, noncompliance and negligence are the aggravating factors which increasing the associated risks of the chronic leg wounds. Care and education are adequately required by the population in order to prevent associated risks. Recurrence, amputation and depression are main risks of the chronic leg wounds. Care, Control and Caution theory of chronic leg wound is specific to the chronic leg wounds it could be used by the health professional while taking care of a patient with chronic leg wounds. This theory is equally insisting mental health needs along with physical health at the point of emotional need to psychological need.

REFERENCES:

1 Shubhangi Vinayak Agale. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Volume 2013 (2013), Article ID 413604, 9 pages http://dx.doi.org/10.1155/2013/413604

2 Sasanka CS. Venous ulcers of the lower limb: Where do we stand?. Indian Journal of Plastic Surgery [serial online] 2012 [cited 2013 Jul 9];45:266-74. Available from: http://www.ijps. org/text.asp?2012/45/2/266/101294

3 Matthias Augustin, Wolfgang Vanscheidt. Chronic venous leg ulcers: the future of cell-based therapies. www.lancet.com Published August 3, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61255-0

4 V. K. Shukla, M. A. Ansari, and S. K. Gupta, “Wound healing research: a perspective from India,” International Journal of Lower Extremity Wounds, vol. 4, no. 1, pp. 7–8, 2005.

5 Sunil Gupta. Management of diabetic foot .Medicine update 2012.Vol 22:287-293

6 S. P. Pendse, “Understanding diabetic foot,” International Journal of Diabetes in Developing Countries, 2010 ,vol. 28, no. 5, pp. 519–526.

7 Khalid S Khan et al. Five steps to conducting a systematic review. Journal of Royal Society of Medicine 2003;96:118–121.

8 Yekta Z, Pourali R, Ghasemi-Rad M. Comparison of demographic and clinical characteristics influencing health-related quality of life in patients with diabetic foot ulcers and those without foot ulcers. Diabetes ,Metabolic Syndrome Obesity: targets and therapy. 2011;4:393-9.

9 Mazlina M, Shamsul AS, Jeffery FA. Health-related quality of life in patients with diabetic foot problems in Malaysia. Medical Journal of Malaysia. 2011 Aug;66(3):234-8.

10 Ribu L, Birkeland K, Hanestad BR, Moum T, Rustoen T.A longitudinal study of patients with diabetes and foot ulcers and their health-related quality of life: wound healing and quality-of-life changes. Journal of Diabetes and its Complications. 2008 Nov-Dec;22(6):400-7.

11 Sotirios A et al. The Impact of Lower Extremity Venous Ulcers due to Chronic Venous Insufficiency on Quality of Life. The Open Cardiovascular Medicine Journal, 2008, 2, 105-109

12 Mehdi Javanbakht et al. Health Related Quality of Life in Patients with Type 2 Diabetes Mellitus in Iran: A National Survey. plos one 7(8):e44526.doi10.1371/journal.pone.0044526.

13 Julia Clarie Paul, Barbara Pieper ,Thomas N. Templin. Association with Chronic Venous Disease, Pain and Quality of Life. Journal of wound ostomy continence nursing.2011; 38(1):46-54.

14 Zameer Aziz, Wong Keng Lin, Aziz Nather, and Chan Yiong Huak, . Predictive factors for lower extremity amputations in diabetic foot infections.Diabetic foot and ankle 2011,2:7463-DOI:10;3402/dfa v2io.7463.

15 Hassan et.al .Associated risk factors and management of chronic diabetic foot ulcers exceeding 6 months’ duration. Diabetic foot and ankle 2012,3:18980-http://dx.doi.org/10.3402/dfa. v3i0.18980.

16 Zameer Aziz, Wong Keng Lin, Aziz Nather, and Chan Yiong Huak, . Predictive factors for lower extremity amputations in diabetic foot infections. Diabetic foot and ankle 2011,2:7463-DOI:10;3402/dfa v2io.7463

17 J. Joseph Anderson et al. Comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patient Diabetic foot and ankle 2012,3:191718-http//dx.doi.org/10.3402/dfav3i0.19178

18 Zahra Yekta, Reza Pourali, Rahim Nezhadrahim, Leila Ravanyar, Mohammad Ghasemi-rad. Clinical and behavioral factors associated with management outcome in hospitalized patients with diabetic foot ulcer. Diabetes, metabolic syndrome and obesity: Targets and therapy .12 october 2011.P:371-375.http://dx.doi.org/10.2147/DMso.525309

19 Edouard Ghanassia et al .Long-Term Outcome and Disability of Diabetic Patients Hospitalized for Diabetic Foot Ulcers :A 6.5-year follow-up study Diabetes Care 31:1288–1292, 2008

20 Viswanathan V, Kumpatla S .Pattern and causes of amputation in diabetic patients--a multicentric study from India. Journal of the Association of Physicians of India. 2011 Mar;59:148-51.

21 Zahra Yekta ,Reza Pourali ,Rahim Nezhadrahim, Leila Ravanyar and Mohammad Ghasemi –Rad Clinical and behavioural factors associated with management outcome in hospitalized patient with diabetic foot ulcer. Diabetes, Metabolic syndrome and Obesity : Targets and therapy 2011;4: 371-75.

22 Marjolein M Iversen et.al The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study Published: 25 August 2009.BMC Endocrine Disorders 2009, 9:18 doi:10.1186/1472-6823-9-18.

23 Patt BT; Jarjoura D; Lambert L; Roy S; Gordillo G; Schlanger R; Sen CK; Khayat RN. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med 2010;6(6):541-544

24 Lisa H. Williams, et al. Depression and incident diabetic foot ulcers: a prospective Cohort study .Am J Med. 2010 August ; 123(8): 748–754.e3. doi:10.1016/j.amjmed.2010.01.023.

25 Lisa H. Williams, et.al Depression and incident lower limb amputations in veterans with diabetes .J Diabetes Complications. 2011; 25(3): 175–182. doi:10.1016/j.jdiacomp.2010.07.002

26 Novem Margaret B Harrison et al .Nurse clinic versus home delivery of evidence-based community leg ulcer care: A randomized health services trial . BMC Health Services Research 2008, 8:243 doi:10.1186/1472-6963-8-243

27 Helen Edwards, Kathleen Finlayson, Mary Courtney, Nick Graves, Michelle Gibb and Christina Parker ,Edwards et al. Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care .BMC Health Services Research 2013, 13:86.http://www.biomedcentral.com/1472-6963/13/86

28 AbuBakr H. Widatalla^. Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment. Diabetic Foot and Ankle 2012, 3: 18809 - http://dx.doi.org/10.3402/dfa.v3i0.18809

29 Petherick ES, Cullum NA, Pickett KE. Investigation of the Effect of Deprivation on the Burden and Management of Venous Leg Ulcers: A Cohort Study Using the THIN Database. PLoS ONE,2013 8(3): e58948. doi:10.1371/journal.pone.0058948

30 A. McInnes, W. Jeffcoate, L. Vileikyte, F. Game, K. Lucas, N. Higson, L. Stuart, A. Church, J. Scanlan– and J. Anders. Consensus Statement Foot care education in patients with diabetes at low risk of complications: a consensus statement. Diabetic Medicine. 28, 162–167 (2011)

31 Shanu K. Kurd, Ole J. Hoffstad, Warren B. Bilker, and David J. Margolis, .Evaluation of the use of prognostic information for the care of individuals with venous leg ulcers or diabetic neuropathic foot ulcers. Wound Repair and Regeneration. 2009; 17(3): 318–325. doi:10.1111/j.1524-475X.2009.00487.x

32 O. O. Desalu1, F. K. Salawu, A. K. Jimoh, A. O. Adekoya, O. A. Busari and A. B.olokoba.Diabetic foot care: self reported knowledge and Practice among patients attending three tertiary Hospital in Nigeria. Ghana medical journal . June 2011 volume 45, number 2 .page 60-65.

33 Kafaie P, Noorbala MT, Soheilikhah S, Rashidi M. Evaluation of Patients' Education on Foot Self-Care Status in Diabetic Patients. Iranian Red Crescent Medical Journal . 2012;14(12):829-32. DOI: 10.5812/ircmj.1138.

34 Carolina D Weller, Sue Evans, Christoph er M Reid, Rory Wolfe, John Mc Ne. Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study. Implementation Science 2012,7:104.http://www. implementation science.com/content/7/1/104

35 Kirsti Skavberg Roaldsen , Gabriele Biguet and Britt Elfving .Physical activity in patients with venous leg ulcer – between engagement and avoidance. A patient perspective. Clinical Rehabilitation 2011; 25: 275–286

36 Mansooreh Aliasgharpour and Nahid Dehghan Nayeri. The care process of diabetic foot ulcer patients: a qualitative study in Iran. Journal of Diabetes and Metabolic Disorders 2012, 11:27 http://www.jdmdonline.com/content/11/1/27

37 L Gale, K Vedhara, A Searle, et al. Explore beliefs about diabetic foot complications and everyday foot self-care practices among people with type 2 diabetes .Br J Gen Pract 2008; DOI: 10.3399/bjgp08X319657

38 Jones JE, Robinson J, Barr W, Carlisle C. Impact of exudate and odour from chronic venous leg ulceration. Nursing Standard. 2008 Jul 16-22;22(45):53-4, 56, 58 .

39 Oliver R Herber, Wilfried Schnepp and Monika A Rieger..A systematic review on the impact of leg ulceration on patients' quality of life Health and Quality of Life Outcomes 2007, 5:44 doi:10.1186/1477-7525-5-44

40 Melanie McEwen Evenlyn. M. Wils. Theoretical Basis for Nursing.2^nd Edition. Lippincott Williams and Wilkins 2007.page no 50-72

Received on 31.05.2014 Modified on 30.06.2014

Int. J. Nur. Edu. and Research 2(3): July- Sept. 2014; Page 258-263