BH WOUND CARE | Case Study 109

Patricia P., a 55-year-old female, presented with a challenging case of a venous leg ulcer.

• Age: 55
• Gender: Female
• Medical History: Patricia has a history of hypertension and chronic tobacco use.
• Venous Leg Ulcer: Patricia was diagnosed with a venous leg ulcer, a condition associated with venous insufficiency that leads to the formation of chronic wounds on the lower leg.

1. Wound Identification: A comprehensive assessment of Patricia’s wound, detailed 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, Patricia 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 the application of skin moisturizer to maintain skin integrity.
4. Nutrition: Dietary modifications tailored to her medical history, including addressing hypertension, tobacco use 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 4 months.

• First Dressing Change: Early signs of healing were observed at the first dressing change.
• 3 Weeks: Substantial improvement in wound appearance and size occurred by 7 weeks.
• Fully Healed at 4 Months: The wound was completely healed, marking a successful outcome.

This case study highlights the successful resolution of a chronic venous leg ulcer in a 55-year-old female with a history of hypertension and chronic tobacco use. Through a comprehensive treatment approach encompassing wound assessment, vascular studies, lifestyle modifications, and advanced wound therapies, the ulcer achieved complete healing in 4 months. Early signs of improvement were evident, underscoring the effectiveness of the chosen interventions and emphasizing the importance of a multidisciplinary approach to managing chronic venous leg ulcers.