I read with interest Dr Kevin Ilsley's article 'Practice devises an effective strategy for venous leg ulceration' (Guidelines in Practice, April 2001, Vol 4(4):43), and in particular the protocol for leg ulcer management and interpretation of ankle-brachial pressure index (ABPI) results.
I have previously encountered a patient with an ABPI of >1.3, and was unsure of the significance of the reading. It was interesting to note that the protocol suggested that referral to a vascular surgeon for assessment may be appropriate.
Further guidance on the management options for patients would be appreciated, to enable a comprehensive adaptation of the protocol.
Sister Gail Sibley, practice nurse, Stockton on Tees
Dr Kevin Ilsley replies:
It is our policy to refer patients to a vascular surgeon for a second opinion if their ABPI is >1.3. sometimes, calcification of the medial layer of the artery can make the artery resistant to compression and cause a falsely high reading. People with diabetes are particularly prone to this.
We refer any patients about whom there is doubt or concern for a second opinion, although we are often reassured by the vascular team that in their view it is safe to proceed with four-layer bandaging.
However, as stated in the article, the number of patients with ulcers that we refer is relatively small, and many fewer than was the case before the nursing team developed their current expertise.
Dr Kevin Ilsley, GP, Bromyard, Herefordshire
I am writing to ask if you are aware of any studies on the effectiveness of district nurse involvement in bereavement visiting after a community patient has died. As team leader in a rural practice, I am interested in developing our service to relatives.
I am particularly interested in a multidisciplinary approach to bereavement services and would be grateful for any references or information, or contact names or addresses.
Louise Morgan, district nurse team leader, Dartmouth
Dr John Wiles replies:
There is some published material in the literature. The reference that is closest to your enquiry suggests that the community nurse is well placed to provide bereavement care,1 given that most grief is not pathological in nature, and with some support and use of the available resources will resolve in time.1
Stewart et al2 also suggest that community health nurse practitioners could benefit from the lessons learned about timing, duration, and selection of sensitive outcomes.
Dr John Wiles, consultant in palliative care, Bromley Hospitals NHS Trust
- Koodiaroff S. Bereavement care: a role for the community nurse. Collegian 1999; 6(2): 9-11. ACT Community Health Care Programme, Canberra, ACT.
- Stewart M, Craig D, MacPherson K, Alexander S. Promoting positive affect and diminishing loneliness of widowed seniors through a support intervention. Public Health Nurs 2001; 18(1): 54-63.
- Charlton R, Dolman E. Breavement: a protocol for primary care. Br J Gen Pract 1995; 45: 427-30.
- Fenner P, Manchershaw A. A group aproach to overcome loss. A model for a bereavement service in general practice. Prof Nurse 1993; July: 680-4.
- Kaunonoen M, Tarkka M-T. Grief and social support after the death of a spouse. J Adv Nurs 1999; 30(6): 1304-11.
- Payne S, Field D. Primary care based counsellors' experiences of bereavement counselling (abstract). Palliat Med 1999; 13(6): 505-6.
- Wolf R. The future of bereavement care in British general practice. Eur J Cancer Care 1997; 6(2): 133-6.
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