BH WOUND CARE | Case Study 108

Sandra K., a 58-year-old woman with a history of hypertension and a chronic smoking habit of 1 pack per day, presented with a challenging case of a venous leg ulcer. The ulcer was located on the anterior right lower leg and had persisted for two years despite prior treatment attempts involving compression therapy and topical alginate applications.

• Age: 58
• Medical History: Hypertension, Chronic Smoking (1 pack per day)
• Chronic Venous Leg Ulcer: Non-healing ulcer on the anterior right lower leg, unresolved for 2 years

The primary objective of this case study was to document the successful resolution of Sandra’s chronic venous leg ulcer, addressing underlying vascular issues, promoting wound healing, and implementing preventive measures.

1. Wound Identification: Comprehensive patient assessment, wound history, Ankle-Brachial Index (ABI) measurement, and examination for venous pigmentation.
2. Venous Studies: Given the absence of abnormal pulses and an unremarkable ABI, Sandra underwent venous vascular studies, Doppler ultrasound, and reflex studies to rule out deep vein thrombosis (DVT), venous reflux, and infection.
3. Skin Care: Resolution of cellulitis and application of skin moisturizer to maintain skin integrity.
4. Nutrition: Dietary modifications, smoking cessation, and lifestyle changes to enhance overall health and support wound healing.
5. Management of Ulcer: Regular wound assessments, utilization of moist dressings, wound debridement, and management of bacterial bioburden.
6. Reduction of Edema: Assessment and management of edema through measures such as avoiding prolonged sitting or standing, leg elevation, compression bandage application, and lymphedema management in patients with phlebolymphedema.
7. Ultra-Mist Therapy: Administered 1-2 times per week to promote wound healing and tissue regeneration.
8. Amniotic Tissue Application: Utilization of amniotic tissue for its regenerative properties by covering with adaptic non-adherent contact layer and securing with moisture retentive dressing. 
9. Prevention Plan: Implementation of measures including the use of compression stockings, leg elevation, offloading, and ongoing lifestyle modifications.
10. Wound Healing: The ulcer achieved complete healing in just 4 weeks.

• First Dressing Change: Early signs of healing were observed at the first dressing change.
• Substantial Healing by [X] Postoperative Week: Significant wound improvement occurred by [X] weeks postoperatively.
• Wound Fully Healed at [Y] Weeks: The wound was completely healed at [Y] weeks, marking a remarkable outcome.

This case study underscores the successful resolution of a chronic venous leg ulcer in a patient with a history of hypertension and chronic smoking. Through a comprehensive treatment approach that included wound assessment, vascular studies, lifestyle modifications, and advanced wound therapies, the ulcer achieved complete healing in just 4 weeks. Early signs of improvement were evident, highlighting the efficacy of the treatment regimen and emphasizing the importance of a multidisciplinary approach to managing chronic venous leg ulcers.