Waterloo Wellington Integrated Wound Care Program

Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Recommendations Assessment and Wound Management Venous and Mixed Venous/Arterial Leg Ulcers

Content:

1. Objectives

2. Background

a. Best Practices for Assessment, Prevention and Treatment of Venous Leg Ulcers Registered Nurses Association of Ontario (RNAO) b. Clinical Best Practice Guidelines Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients c. Canadian Association of Wound Care Best Practice Enabler and Quick Reference Guide d. Wound Bed Preparation Paradigm

3. Address Patient-Centered Concerns

a. Assess Psychosocial Needs /Pain and Quality of Life (QOL) b. Socioeconomic Determinates of Health c. Chronic Disease Self-management d. Ulcer recurrence

4. Identify and Treat the Cause

4.1 Assessment

a. Risk Factors and Etiology of Venous Leg Ulcers (VLUs) b. Odds Ratio of Venous Leg Ulcer NOT Healing in 24 weeks c. Common Signs and Symptoms of Chronic Venous Insufficiency and Venous Leg Ulcers

4.2 Obtain a Comprehensive Patient History and Perform a Physical Assessment

a. Obtain a comprehensive patient history b. Complete a comprehensive physical examination c. Lower Leg Assessment d. Assess Wound and Peri-wound e. Wound Measurement f. Comparison of Venous versus Arterial versus Mixed Venous/Arterial Leg Ulcers g. Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI ) h. Determine if the wound is “Healable, Maintenance or Non-Healable” i. Nutritional Assessment

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 1 4.3 Determine the Cause of Venous Insufficiency Based on Etiology

a. Valves (reflux) b. Obstruction c. Calf-muscle-pump failure

4.4 Implement Appropriate Compression Therapy

a. Principles of Compression Therapy b. Benefits of Compression bandaging c. Compression Choices d. ABPI and Compression Bandaging Table e. Compression for LIFE! (compression stockings)

4.5 Medical Therapy: Pharmacological Treatment

a. Pentoxyfilline (Trental) b. Plebotonics

4.6 Surgical Interventions

5. Provide Local Wound Care

a. Intervention Algorithm b. Signs and Symptoms of Wound Infection c. Signs and symptoms of Lower Leg Cellulitis d. Management of Lower Leg Cellulitis e. Venous Dermatitis: Signs, Symptoms, Prevention and Treatment f. Determining Goals for Local Treatment for Venous Leg Ulcers g. Utilize Product Picker from Canadian Association of Wound Care (CAWC) h. South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection & Cleansing Enablers i. Patient Education on Skin Care j. Adjunctive Therapies

6. Provide Organizational Support

a. Multi-disciplinary Referral Criteria b. Patient/Patient Teaching and Learning Resources c. Discharge or Transfer Planning and Communications d. Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Venous and Mixed Venous/Arterial Clinical Pathway

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 2 7. Venous and Mixed Venous/Arterial Leg Ulcer Toolkit

RNAO’s Assessment and Management of Venous Leg Ulcers 2,4 Levels of Evidence

A Evidence obtained from at least one randomized controlled trial or meta-analysis of randomized controlled trials

B Evidence from well-designed clinical studies but no randomized controlled trials

C Evidence from expert committee reports or opinion and/or clinical experience or respected authorities. Indicates absence of directly applicable studies of good quality

RNAO’s Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients 5 Levels of Evidence

la Evidence obtained from meta-analysis or systematic review of randomized controlled trial

lb Evidence obtained from at least one randomized controlled trial

lla Evidence obtained from at least one well-designed controlled study without randomization

llb Evidence obtained from at least one other type of well-designed quasi- experimental study, without randomization

lll Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

lV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 3 1. Objectives

The objectives of the development and implementation of these resources is to help Health Care Providers to:

a. Find practical, evidence-based resources to use when caring for individuals that have or who are at risk of developing, venous leg ulcers

b. Perform a comprehensive patient assessment including assessing for indicators of venous leg ulcers that will not heal in the inpatient and outpatient care settings (Acute Care, Long Term Care and Community Care Settings)

c. Identify the correct etiology of lower leg ulcers d. Recognize/ differentiate between venous stasis dermatitis and lower leg cellulitis; and obtain appropriate interventions e. Arrange for a holistic Lower Leg Assessment including ABPIs in order to recommend/implement the appropriate compression therapy. If patient is a diabetic, toe pressures should be obtained.

f. Perform accurate wound assessment including progress towards healing

g. Recognize signs & symptoms of infection and identify treatment interventions

h. Increase the use and implementation of evidence-based venous leg ulcer treatment plans including pain management using pharmacological and non-pharmacological interventions

i. Identify and implement appropriate topical wound care and compression therapy j. Understand the need for a comprehensive plan for “Compression for life”

k. Improve the coordination and communication between care providers/care institutions regarding the transfer/discharge plan for patients with venous leg ulcers

2. Background From April 2013 until March 2014, venous leg ulcer care in Waterloo Wellington region cost the Community Care Access Centre over half a million dollars. A significant number of nursing visits were required for over 300 patients with venous leg ulcers at an average cost per client of $1631. The average length of stay requiring community wound care for patients with venous leg ulcers in Waterloo Wellington was 104 days.1 Venous leg ulcers are often chronic wounds that are usually the result of compromised circulation. Patients with venous ulcers require vascular assessments to determine treatment and their ability to heal. These patients require long term compression treatment to treat ulcers and to prevent reoccurrence.8 As the population ages and increases, the number of patients with venous ulcers, the strain on community services and the inherent cost of care are expected to increase exponentially. It is imperative for evidence-based best practices be followed in order to improve clinical outcomes and improve access to wound care services, thereby allowing the utilization of health care funds in the most appropriate manner. 8

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 4 Best Practices for Assessment, Prevention, and Treatment of Venous Leg Ulcers In 2001, The Canadian Association of Wound Care (CAWC) developed best practice recommendations for the prevention and treatment of venous leg ulcers for clinical practice. The RNAO produced a nursing best practice guideline for the Assessment and Management of Venous Leg Ulcers in 2004.2 In 2006, Burrows et al did a review of existing literature to identify any new changes of practice. They reviewed both the CAWC and RNAO guidelines. Combining both sets of guidelines allowed them to produce a paper that is evidence-based and inter-professional. 3 All clinicians are expected to use best practices to assess, prevent, and treat venous ulcers to improve patient outcomes. The framework used in this guideline was applied from the Registered Nurses Association of Ontario (RNAO) “Clinical Practice Guidelines of Assessment and Management of Venous Ulcers (2004)2 and its supplement (2007)4. The RNAO Clinical Best Practice Guidelines “Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients” (2010)5 was also used for self-management section. A complete list of references used can be found in the appendices.

Wound Bed Preparation Paradigm The wound bed preparation (WBP)3 paradigm is used to assess, diagnosis, and treat wounds while considering patient concerns. It links evidence-based literature, expert opinion, and clinical experiences of respected wound care specialists. The framework is beneficial because the components are interrelated and can be re-evaluated if the wound deviates from the care plan. Furthermore, the interprofessional team is able to collaborate together through shared discussion to classify a healable, maintenance, and non-healable wound.

i.A.3. Address Patient-Centered Concerns 2,4,5,6 (see Toolkit Item #6 for worksheet) Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 5 (Level B,C: RNAO’s Assessment and Management of Venous Leg Ulcers) (Level la, lb, lll: RNAO’s Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients)

a Assess Psychosocial Needs /Pain and Quality of Life (QOL)

 Communicate with patients, their caregivers and significant others to identify patient- centered goals to determine realistic expectations for healing or non-healing outcomes.  Assess pain and in collaboration with patient and caregivers, create a pain relief plan6  Assess quality of life (QOL) (see Toolkit Item #12a and #12b for assessment forms) and screen for mental health concerns (i.e. depression see Toolkit Item #13 for assessment form)  Encourage and provide ongoing support for smoking cessation if applicable (see Toolkit Item #7a for Smoking, Chronic Wound Healing, and Implications for Evidence-Based Practice – McDaniel and Browning, Toolkit Item #7b for Checklist to readiness to quit smoking, see Toolkit Item #7c for Applying 5 A’s to smoking cessation, see Toolkit Item #7d for WHY test, see Toolkit Item #7e for smoking cessation medication comparison chart and see Toolkit Item #7f for Strategies to avoid relapse).7

b Socioeconomic Determinates of Health (see Toolkit Item #5 for Canadian Nurses Association Social Determinants of Health and Nursing: A Summary of Issues)

 Provide education to patients, caregivers and significant others for care and the management of venous disease.  Educate patients, their caregivers and significant others regarding the need for long term compression garments. Assess need for assistance in utilizing garments.  Assess for the presence or absence of social support system for treatment and preventions of venous leg ulcers.

Health is a resource for everyday life and is influenced by the determinants of health: income, social status, support networks, education, employment and working conditions, health services, healthy child development, physical environment, gender, culture, genetics, and personal health practices 9. Unemployment, lack of sick benefits, job insecurity, low income, and homelessness can deter healing and cause more stress. For example, money is needed to purchase adequate food that is vital for wound healing. Patient may need a referral for a social worker to assist with finances.

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 6 The following questions could assist in assessing your patient’s financial concerns:

 Do you have benefits from any other sources to cover cost of compression stockings, medical drugs, parking fees, food allowance (e.g. work place or private Insurance, Veterans Affairs Canada, Aboriginal Affairs, Workers Safety and Insurance Board (WSIB), Trillium Drug Plan, Ontario Disability Support Program (ODSP))  Are you the sole bread-winner in your family?  How often have you used the food bank or soup kitchen this month?  Do you have sick-time benefits or unemployment insurance?  Would you like a referral to Meals on Wheels or information on food bank/soup kitchen?

Social Supports

There is evidence to suggest that strong supportive networks improve health and healing. 9 Patients who have limited social support are more at risk for depression, greater risk for complications, decreased well-being, poor mental health and physical health. Furthermore, patients who are disabled, migrants from other countries, ethnic minorities and refugees are vulnerable to racism, discrimination and hostility that may harm their health. Patients who have stigmatizing conditions such as mental health, addictions (street drug use, methadone patients and cigarette smokers), and diseases such as HIV/AIDS suffer from higher rates of poverty and limited supports.

The following questions could assist in assessing your patient’s support system:

 Do you have someone to help you? Friend, family, neighbor, church member?  Does patient seem depressed or suicidal?  Do you have transportation to receive medical follow-up and to obtain groceries?  Do you have someone to help you with your personal care such as showering?  Do you have someone to get your groceries, housekeeping and other necessities?  Are you afraid of your partner or family member?  Would you like a referral to a social worker or case worker?

c Chronic Disease Self-management

 Assess level of patient’s self-management skills

Chronic Disease Self-management Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 7 Self-management promotes and strengthens the confidence (self-efficacy) of the patient to be able to care for their chronic disease.5 The focus of self-management is to allow the patient to self-identify concerns and to address these concerns collaboratively with nurses and health professionals. Fostering and promoting independence is strongly encouraged but the patient and caregiver will need to be assessed by health professional for cognitive and physical ability.

The Self-management Initiative, through the Ontario Ministry of Health and Long-Term Care (MOHLTC), is an integrated, comprehensive strategy aimed at preventing and improving management of chronic conditions in Ontario. The goal of this cost-free program is to provide education and skills training workshops to both health care providers and patients with chronic conditions. For more information, please call 1-866-337-3318 or www.wwselfmanagement.ca.

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 8 The 5 A’s of Behavioural Change

These activities are not necessarily linear with each step following the other sequentially. The goal of the 5 A’s, in the context of self-management support, is to develop a personalized, collaborative action plan that includes specific behavioural goals and a specific plan for overcoming barriers and reaching those goals. The 5 A’s are elements that are interrelated and are designed to be used in combination to achieve the best results especially when working with patients in complex health and life situations.

1. ASSESS Beliefs, Behavior and Knowledge

 Establish rapport with patients and families  Screen for depression on initial assessment, at regular intervals and advocate for follow- up treatment of depression  Establish a written agenda for appointments in collaboration with the patient and family, which may include: a) Reviewing clinical data b) Discussing patient’s experiences with self-management c) Medication administration d) Barriers/stressors e) Creating action plans f) Patient education including assessing learning style  Consistently assess patient’s readiness for change to help determine strategies to assist patient’s readiness for change to help determine strategies to assist patient with specific behaviours  Identify patient specific goals

2. ADVISE Provide specific information about health risks and benefits of change

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 9  Combine effective behavioural, psychosocial strategies and self-management education processes as part of delivering self-management support  Utilize the “ask-tell-ask” (also known as Elicit-Provide-Elicit) communication technique to ensure the patient receives the information required or requested  Use the communication technique “Closing the Loop” (also known as “ teach back”) to assess a patient’s understanding of information  Assist patients in using information from self-monitoring techniques (e.g., glucose monitoring, home blood pressure monitoring) to manage their condition  Encourage patients to use monitoring methods (e.g., diaries, logs, personal health records) to monitor and track their health condition  Identify community resources for self-management (e.g., support groups)

3. AGREE Collaboratively set goals based on patient’s interest and confidence in their ability to change the behaviour

 Collaborate with patients to: a) Establish goals b) Develop action plans that enable achievement of SMART goals (see below) c) Establish target dates for success of goals and reassessment d) Monitor progress towards goals

SMART Goals

Specific A specific goal is detailed, focused and clearly stated. Everyone reading the goal should know exactly what you want to learn.

Measurable A measurable goal is quantifiable, meaning you can see the results.

Attainable An attainable goal can be achieved based on your skill, resources and area of practice.

Relevant A relevant goal applies to your current role and is clearly linked to your key role responsibilities.

Time-limited A time-limited goal has specific timelines and a deadline. This will help motivate you to move toward your goal and to evaluate your progress

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 10 4. ASSIST Identify personal barriers, strategies, problem-solving techniques and social/environmental support

 Use motivational interviewing with patients to allow them to fully participate in identifying their desired behavioural changes  Teach and assist patients to use problem-solving techniques  Be aware of community self-management programs in a variety of settings, and link patients to these programs through the provision of accurate information and relevant resources

5. ARRANGE Specify plan for follow-up (e.g., visits, phone calls, mailed reminders)

 Arrange regular and sustained follow-up for patients based on the patient’s preference and availability (e.g., telephone, email, regular appointments). Nurses and patients discuss and agree on the data/information that will be reviewed at each appointment and share with other interdisciplinary team members involved  Use a variety of innovative, creative and flexible modalities with patients when providing self-management support such as: a) Electronic support systems b) Printed materials c) Telephone contact d) Face-to-face interaction e) New and emerging modalities  Tailor the delivery of self-management support strategies to the patients’ culture, social and economic context across settings  Facilitate a collaborative practice team approach for effective self-management support  Share with caregiver/family members/circle of care

Stages of Change Model

Stage in Transtheoretical Model Patient Stage of Change Not thinking about change May be resigned Feeling of Pre-contemplation no control Denial: does not believe it applies to self Believes consequences are not serious

Contemplation Weighing benefits and costs of behavior, proposed

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 11 change

Preparation Experimenting with small changes

Action Taking a definitive action to change

Maintenance Maintaining new behavior over time

Relapse Experiencing normal part of process of change Usually feels demoralized

There are 3 self-management strategies that health professionals can use to promote self-management in patients with venous leg ulcers 5

1. Motivational Interviewing (assess patient-centered concerns) (see Toolkit Item #6 for worksheet)

The following questions could assist in assessing your patient’s concerns:

 What is your most important problem or concern? (It may not be related to the disease)  Do you have a history of depression? Are you depressed now?  What has worked in the past and what did not work?  Why do you want to change and how hard are you willing to work?  Are you willing to make the changes in your lifestyle to improve your health?  What might prevent you from working hard on this (e.g., barriers that are present)

Choose the one area that you would like to work on:  Improve physical activity  Perform wound care  Practice leg exercises  Purchasing, wearing and caring for my compression stockings  Donning and doffing compression stockings using aids

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 12  Nutrition  Leg elevations  Skin care of my legs  Control weight  Stop smoking  Prevention of new ulcers  Managing co-morbidities  Alternative therapy modalities  Work modifications  Meet new people

How willing are you to set goals and make changes in lifestyle on a scale of 1-10?

What is it that you find most difficult about living with venous disease and how can I help you?

2. Goal Setting

 Provide specific health information and health risks requested from patient and family. Here is a sample of topics to discuss: ABPI, compression bandaging, stockings for life, wound treatment, managing pain, nutrition, smoking cessation, vascular consult, benefits of walking, ankle/leg exercises.  Collaboratively develop a Personal Action Plani (see below)  Set SMART Goals (specific, measureable, achievable, relevant and timely) Try to make goals small enough to achieve success or patient may not try again if she/he fails

Personal Action Plan

1. List specific goals in behavioral terms 2. List barriers and strategies to address them 3. Specify Follow-up Plan 4. Share plan with practice team and client's social support

3. Problem Solving

 Assist with problem solving to help identify barriers and enlist family/social support  Ascertain financial barriers  Arrange for follow-up visits to review goals and discuss challenges  Encourage healthy coping such as yoga, music, counselling, friends, and family support

d Ulcer recurrence Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 13 There is a high rate of recurrent leg ulcerations. Grey, Harding, and Enoch provided evidence that suggests recurrence rates in Ontario are as high as 60 percent to 70 percent within five years of a healed ulcer.10 The problem identified according to the literature is that ulceration recurrence rates are strongly influenced by patient adherence. Sibbald and colleagues claim that adherence with compression therapy is further substantiated by the fact that the recurrence rate of venous ulcers was reduced from 75 per cent to 25 per cent with compression hosiery worn consistently after the ulcer has healed.8 Controlling edema and venous hypertension through adequate compression with support stockings is essential to prevent recurrent ulcerations.

4. Identify and Treat the Cause (Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

4.1 Assessment (see Toolkit Item #8 for worksheet)

Should be undertaken by healthcare professional(s) trained and experienced in leg ulcer management

a. Identify Risk Factors and Etiology of Venous Leg Ulcers (VLUs)

History of:

 Deep vein thrombosis, lower leg fractures, lower leg injuries, varicose veins  Protein C, S or Factor 5 clotting disorders  Venous insufficiency  Episodic chest pain, pulmonary emboli or hemoptysis  Heart disease, stroke, transient ischemic attack  Diabetes mellitus  Peripheral vascular disease (intermittent claudication)  Smoking  Rheumatoid arthritis Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 14  Ischemic rest pain  Prolonged sitting or standing  Bed rest  Obesity (causes outflow obstruction)  Pregnancy  Fixed ankle joint/loss of calf muscle pump  Previous vascular tests or surgeries  Malignancy  Radiotherapy

b. Odds Ratio of Venous Leg Ulcer NOT Healing in 24 weeks

Research demonstrates that several factors will influence whether the ulcer is going to heal, which include the initial size of the ulcer and the length of time that the ulcer has been present. For this reason, it may be prudent to ensure that there is a wound care specialist consult for all patients with venous ulcers that are >5 cm² (length X width in cm) &/or if the wound is older than 6 months as these wounds will not generally heal with only moist wound healing, debridement and appropriate compression therapy.

Factors that may affect healing potential

Local  Presence of necrosis, foreign body and/or infection  Disruption of microvascular supply  Cytotoxic (toxic to cells) agents

Host  Co-morbidities (i.e. inflammatory conditions, nutritional insufficiencies, peripheral vascular or coronary artery disease)  Adherence to plan of care by patient and caregivers  Cultural and personal belief systems

Environment  Access to care  Family support  Healthcare sector  Geographic  Socioeconomic status

Predictors of delayed healing

 ABPI < 0.8 Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 15  Fixed ankle joint  Wound base has more than 50% yellow fibrin  Wound has been present longer than 6 months  Wound is larger than 5cm2 (L x W=>5cm2)  Patient had previous hip or knee surgery  Patient has history of vein ligation or stripping

In addition, the practitioner must assess whether the person with the leg ulcer is willing to wear compression bandages and/or stockings to heal, and then to wear compression ongoing.

c. Common Signs and Symptoms of Chronic Venous Insufficiency and Venous Leg Ulcers

 Venous ulcers are may be circumferential and are often located over medial malleolus or gaiter area of leg  Ulcers are usually shallow and moist  Edema may be pitting or firm  Exudate from wound may be minimal or copious  Skin changes may include hyperpigmentation, atrophie blanche, lipodermatosclerosis, dermatitis (eczema), woody fibrosis and corona phlebectatica (ankle flare)

Signs and Symptoms of Venous Disease Examples

Varicosities (Varicose Veins)

▸ Either small or larger vessels ▸ First indicator of chronic venous insufficiency is often the presence of a dilated long saphenous vein on the medial aspect of the calf

Hemosiderin staining

▸ Brown or brownish red pigmentation and purpura (purplish discoloration of the skin produced by small bleeding vessels near the surface) ▸ Caused by extravasation (leaking) of red blood cells into the dermis ▸ Insoluble form of storage iron collects within the macrophages and melanin deposition occurs [2] ▸ Will not disappear over time (internal cause)

Chronic Lipodermatosclerosis

▸ Lower 1/3 of leg becomes sclerotic (hardened tissue) and woody. ▸ Leg becomes champagne bottle or bowling-pin shaped Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 16 ▸ Venous ulcers surrounded by extensively fibrotic (excess connective tissue ) skin ▸ Ulcers are more difficult to heal

Acute lipodermatosclerosis

▸ Hyperpigmentation and hypopigmentation interspersed with telengectasia or tiny blood vessels on the surface ▸ Painful and tender panniculitis (inflammation of adipose tissue) ▸ Ulcers can occur within the lesion ▸ Becomes intensely fibrotic over time [3]

Stasis (venous) dermatitis

▸ Erythema ▸ Scaling ▸ Pruritis (itchy) [2] ▸ Sometimes weeping ▸ May develop cellulitis - portal of entry small breaks in the skin

Atrophie blanche

▸ Located on the ankle or foot ▸ Ivory white lesions, atrophic plaques ▸ Caused by scarring from previous injuries ▸ Ulcerations in areas of atrophie blanche tend to be exquisitely painful [2]

Woody fibrosis

▸ deposits of fibrin in the deep dermis and fat results in a woody induration of the gaiter area (lower 1/3 of calf) of the leg ▸ peri-wound skin is often hardened and indurated, may be thickened

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 17 Ankle (submalleolar) flare (corona phlebectatica)

▸ Incompetence in perforating vein valve which results in venous hypertension ▸ Causes dilation of the venules ▸ Venule sometimes forms tiny bleb that will rupture with +++bleeding

Ulcer base moist -Exudate may be copious in presence of edema

▸ Shallow ▸ Sloping edges ▸ Shape serpiginous or “geographic” shape ▸ Yellow slough or fibrin ▸ Buds of granulation may grow through the yellow fibrin [2] ▸ Rarely have black eschar

Ulcer located in gaiter region (lower 1/3 of calf)

▸ Ulceration is usually on the medial lower leg superior to malleolus but can be on lateral aspect as well or may encircle the entire ankle or leg ▸ Ulcers occurring above the mid-calf or on the foot likely have other origins, but may be caused by trauma in a leg with existing venous insufficiency [6]

Scarring from previous ulcer(s)

▸ Areas of pale skin and possible fibrosis can indicate previous ulcerations

Brawny edema

▸ A change typical of chronic venous insufficiency, characterized by: thickening, ▸ induration, lipodermatosclerosis and non-pitting edema stopping above the ankle; ▸ the brawny color is due to hemosiderin from lysed red blood cells (RBCs) with [2] chronic ischemia ▸ the skin undergoes atrophy, necrosis, and stasis ulceration, surrounded by a rim of dry, scaling, and pruritic skin

Pitting edema

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 18 ▸ Can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger x 10 – 15 seconds. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema ▸ It is graded based on the depth of the indentation: 1+ = 0 - ¼” 2+ = ¼” – ½” 3+ = ½ - 1” 4+ = takes several minutes to rebound [7]

In non-pitting edema

▸ Pressure that is applied to the skin does not result in a persistent indentation. ▸ Can occur in certain disorders of the lymphatic system such as lymphedema, where edema is particularly prominent on the dorsum of the feet and in the [8] toes.

Fixed Ankle Joint / Impaired calf muscle pump

▸ Fibrous or bony ankylosis at the ankle can occur because of immobility (joint assumes the least painful position and becomes fixed) ▸ In chronic venous insufficiency, fibrotic tissue deposits due to lipodermatosclerosis also decrease ankle mobility—lose ability to dorsiflex (upper illustration) or rotate (lower illustration)the foot at the ankle. ▸ Possible loss of ability to walk normally may occur resulting in ‘shuffling’ and calf [9] muscle not being pumped effectively with the activity of walking ▸ This may decrease the chance of healing by 70%

▸ Feel pain with deep palpation ▸ Describe that their pain is relieved with elevation [10] ▸ Describe ache in the leg(s) when standing or walking for long periods of time

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 19 4.2 Obtain a Comprehensive Patient History and Perform a Physical Assessment (Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Information obtained should be documented in a structured format (see Toolkit item #8 for assessment form) for a patient presenting with either their first or recurrent leg ulcer and should be ongoing thereafter

a. Complete a comprehensive patient history including:

 Medical history including history of venous insufficiency  Family history of venous, arterial or mixed ulcers  History of deep vein thrombosis (DVT) and/or lower leg injury  History of episodes of chest pain, hemoptysis or pulmonary embolus  History of heart disease, stroke or transient ischemic attack (TIA)  Comorbidities (diabetes, peripheral vascular disease, intermittent claudication, rheumatoid arthritis or Ischemic rest pain)  Pain  Smoking history  History of ulcer and past treatments  Current and past medications  Nutritional status  Allergies

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 20  Psychosocial status including quality of life  Functional, cognitive, emotional status and ability for self-care  Lifestyle (activity level, interests, employment, dependents, support system)

b. Complete a comprehensive physical examination including:

 Blood Pressure, height, weight, pulses in foot and ankle  Review bloodwork that should include the following:

 Pre-albumin if available (low scores indicate risk for malnutrition) Protein-Calorie  Serum albumin level (<30g/l will delay healing; <20g/l will be non-healable) Malnutrition  C-reactive Protein (CRP)  CBC (including  Serum Iron RBC, Hct, Hgb,  Total Iron Binding Check for MCV, Platelets  Ferritin anemia etc.)  Transferrin

If anemic, proceed to  B12 checking →  Red blood cell folate level Kidney function  BUN (To check  Creatinine hydration)  Potassium

c. Lower Leg Assessment (Level A: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

(See Toolkit item #9 for lower leg assessment form)

Perform a BILATERAL lower leg assessment including ABPI/TPBI

Assess for the following:

 Edema (may be pitting or firm)  Skin changes (eczema, lipodermatosclerosis, hyperpigmentation, atrophe blanche)  Ankle range of motion (ROM)  Foot deformities (hammer toes, prominent metatarsal heads, charcot joint)  Ankle flare  Skin temperature  Presence of pain  Nail changes  Capillary refill  Peripheral pulses (Dorsalis Pedis and Posterior Tibial)  Presence of varicosities (varicose veins)  Circumference measurements of thighs, ankles and calves

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 21 d. Assess the Wound and Peri-wound

Wound and Peri-wound Assessment is best performed using a validated and reliable wound assessment tool. (See Toolkit item #10a for Bates-Jensen Wound Assessment Tool and #10b Leg Ulcer Measurement Tool (LUMT) )

A comprehensive wound assessment should include observation and documentation of the following:

a.i.1. Location: Venous leg ulcers are usually situated on the gaiter area of the leg a.i.2. Odour a.i.3. Sinus Tracts (including undermining and tunneling): Measurement can be obtained by gently inserting small probe into sinus tract, marking probe with end of finger and measuring length from end of probe to finger end a.i.4. Exudate: Comment on amount and colour of exudate present a.i.5. Pain: a.i.6. Wound bed appearance: colour and type of tissue present (fibrin, granulation or epithelial tissue) and presence of eschar or slough a.i.7. Condition of peri-wound (surrounding skin) and wound edges

e. Wound Measurements (Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

1. Measure and document the surface areas of ulcers at regular intervals to monitor progress 2. Measure depth of Wound 3. Measure size of wound: Area of wound measured by multiplying length (longest measurement) and width (shortest measurement) of wound

f. Comparison of Venous versus Arterial versus Mixed Venous/Arterial Leg Ulcers (Level C: RNAO’s “Assessment and Management of Venous Leg Ulcers”)

People who have cardiovascular insufficiency (CVI) can also develop peripheral arterial disease, which can complicate the ability to treat and heal those individuals who develop lower leg ulcers. These wounds are generally called “mixed venous/arterial” leg ulcers. While the principles of treatment fall under those for Venous Leg Ulcers, extra attention and caution must be taken to the selection of a safe level of compression. Because pain with ischemic disease has a neuropathic component, it is essential that adequate pain management be implemented BEFORE compression therapy is started.

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 22 Venous Disease Arterial Disease Mixed Venous/Arterial and Ischemia

 Wound Base: ruddy red; yellow adherent Base: pale; granulation rarely  Ulcers may have Appearance or loose slough; granulation tissue present; necrosis, eschar, elements of both kinds of may be present gangrene (wet or dry) may be disease: Venous shape present  Yellow/black fibrous Depth: usually shallow base Depth: may be deep  Wound bed may be Margins: irregular dry (if no edema or infection) Margins: edges rolled; “punched Undermining: is rare. If present, out” appearance, smooth Surrounding Skin: further assessment should be Possible cool skin, edema, undertaken to rule out other Undermining: may be present pallor on elevation, etiologies (i.e. arterial) dependant rubor Exudate: minimal Exudate: moderate to heavy Infection: can have signs and Infection: frequent (signs may be symptoms of both venous and Infection: less common but chronic subtle) arterial disease venous ulcers are prone to Cellulitis, necrosis, eschar, biofilms, induration, cellulitis, gangrene may be present Edema: variable inflamed, tender blisters Surrounding Skin: Pale or blue Nails: Thickened toenails Surrounding Skin: Venous feet, pallor on elevation, dermatitis, hemosiderosis dependant rubor lipodermatosclerosis; atrophy Shiny, taut, thin, dry blanche Hair loss over lower extremities Atrophy of subcutaneous tissue Temperature: normal; warm to touch Edema: atypical

Edema: pitting or non-pitting; may Temperature: decreased/cold worsen with prolonged standing or sitting from legs being in a Nails: Dystrophic dependent position

Scarring: from previous ulcers, ankle flare, tinea pedis (athlete’s foot)

Nails: Usually normal unless infection present Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 23  Location Ulceration is usually on the medial Areas exposed to pressure or  Same as venous or lower leg superior to malleolus in repetitive trauma, or rubbing of ulcer may be circumferential gaiter region but can be on lateral footwear aspect as well or may encircle the Lateral malleolus entire ankle or leg Mid tibial Ulcers occurring above the mid-calf Phalangeal heads or on the foot likely have other Toe tips or web spaces origins, but may be caused by trauma in a leg with existing venous insufficiency

Pain Described as throbbing, sharp, Pain is increased with elevation Pain with elevation itchy, sore, tender, heaviness of limb. Pain may also be Intermittent claudication Worsens with prolonged incurred with walking. This is (early) dependency. Some relief on usually due to the presence of Night time rest pain (late elevation of limb. intermittent claudication which disease) will be relieved with 10 minutes of rest

g. Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI ) (Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Perform ABPI/TBPI to rule out the arterial disease. If patient is a diabetic, toe pressures should be obtained

An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy. ABPI measurement offers valuable information as a screening tool for lower extremity peripheral arterial disease.11

Where peripheral arterial disease is suspected, compression therapy treatments designed for venous leg ulcers may be contraindicated. ABPI may also offer prognostic data that are useful to predict limb survival, wound healing and patient survival. The use of ABPI measurement for diagnosis is generally outside of the scope of nursing practice. Furthermore, only those practitioners with the appropriate knowledge, skill and judgment to perform this measurement should do so.

Further Investigation Required (Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 24 An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. People with abnormally low or abnormally high ABPI should be further investigated for peripheral arterial disease. For example, an ABPI >1.3 is considered indicative of non- compressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age. In these cases, compression therapy may not be recommended.4

If ulceration does not heal or show improvement after 3 months of compression and patient has an Ankle Brachial Pressure Index (ABPI) of > 0.8 to 1.3, a referral to a vascular surgeon to review potential surgical interventions is recommended.12

Ankle Brachial Pressure Index (ABPI) / Toe Brachial Pressure Index (TBPI ) Interpretations 3,12 ABPI

> 0.9-1.2 ....Normal (1.2 or > could indicate calcification, seen in diabetes, patients that smoke, hypertension, rheumatoid arthritis, systemic vasculitis or advanced age )

0.80-0.9 ...... Mild ischemia (inflow disease may be present)

0.50-0.79 ....Moderate ischemia (Would benefit from vascular surgeon consult to expedite wound healing)

0.35-0.49 ....Moderately severe ischemia (Urgent vascular surgery consult recommended)

0.20-0.34 ....Severe ischemia (Urgent vascular surgery consult recommended)

<0.20 ...... Likely critical ischemia, but absolute pressure and clinical picture must be considered (Urgent vascular surgery consult recommended) TBPI:

> 0.7 …………Normal > 0.7

0.64 - 0.7…..Borderline Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 25

< 0.64………. Abnormal indicating arterial disease (Urgent vascular surgery consult recommended)

Right Left Lower Leg Vascular Assessment

RNAO recommends a 3 month complete reassessment if no evidence of healing and a 6 month reassessment for resolving and healing (but not yet healed) wounds 2,4 ABPI: TBPI: ABPI: TBPI: If ulceration does not heal or show improvement after 3 months of compression and patient has an Ankle Brachial Pressure Index (ABPI) of > 0.8 to 1.3, a referral to a vascular surgeon to review potential surgical interventions is recommended

h. Determine if the wound is “Healable, Maintenance or Non-Healable”

Healable: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized Maintenance: have healing potential, but various patient factors are compromising wound healing at this time Non-healable/Palliative wound: has no ability to heal due to untreatable causes such as terminal disease or end-of-life13

i. Nutritional Assessment (Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

The following assessments and blood work should be considered when investigating nutritional status of a person with a wound:

Body Weight (kg): Height (cm): Recent Weight Loss: Y / N BMI: Weight Loss (kg): ______ Pre-albumin if available (low scores indicate risk for malnutrition) Protein-Calorie  Serum albumin level (<30g/l will delay healing; <20g/l will be non-healable) Malnutrition  C-reactive Protein (CRP)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 26  CBC (including  Serum Iron RBC, Hct, Hgb,  Total Iron Binding Check for MCV, Platelets  Ferritin anemia etc.)  Transferrin

If anemic, proceed to  B12 checking →  Red blood cell folate level Kidney function  BUN (To check  Creatinine hydration)  Potassium

In addition to inquiring about recent weight loss, signs of dehydration, and assessing the Braden Scale Nutritional sub-scale, which helps to capture protein intake, there are several signs of micronutrient deficiencies that are easy to detect when you know what to look for.

Signs of micronutrient deficiencies:

 Reddish tongue with a smooth surface (Vitamin B deficiency)  Magenta flank-steak appearing tongue with cracks at corners of the mouth (called angular

stomatitis) (Vitamin B2 deficiency )  Dementia, diarrhea, dermatitis (pellagra)—crepe paper skin with wrinkles in the skin and flat surfaces between the wrinkles –also associated with bullous pemphigoid and gramuloma

annulare (Vitamin B3 deficiency)  Prominent “snowflake” exfoliation of the epidermis of the lower legs (Essential Fatty Acid deficiency)  Skin and capillary fragility with purpura, skin tears, increase risk of pressure ulcers, severe collagen deficiency so that the skin is like plastic wrap, and extensor tendons and venous plexus is easily seen through the transparent epidermis (Chronic Scurvy/Vitamin C deficiency)  Reddish, scaly, itchy skin lesions (Vitamin A, E, and K deficiency)  Seborrheic-like rash that is red, flaky seen along the lateral eyebrows, nasal labial folds and chin (Zinc deficiency)  Prolonged tenting of the skin in the presence of adequate fluid intake

If the presence of any of these signs of micronutrient deficiencies is noted, a referral should be made to a Registered Dietitian who can work with the primary care provider for screening of dietary deficiencies and treatment.

The Nestle Mini-Nutritional Assessment (MNA) ( Toolkit item #11) is a screening and assessment tool that identifies individuals age 65 and above who are malnourished or at risk of malnutrition, allowing for earlier intervention to provide adequate nutritional support. It has not been validated for use with younger individuals. The screening tool consists of 6 questions.

 Complete the screen by filling in the boxes with the appropriate numbers.  Total the numbers for the screening score.

The screening score (max 14 points):

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 27 12- 14 points = normal nutritional status 8-11 points = at risk of malnutrition 0 -7 points = malnourished

4.3 Determine the Cause of Venous Insufficiency Based on Etiology 2,4

When a patient is lying down the pressure is close to zero inside the deep veins compared to standing, where the pressure could increase to 80-90 mmHg. When walking, the calf-muscle-pump contracts allowing the blood to flow proximally towards the heart. Blood flow from the superficial veins to the deeper veins occurs when the pressure decreases. In fully functional vessel valves, retrograde blood flow is prevented as the leg muscles relax.

Venous hypertension occurs when the venous system becomes damaged or when the valves become leaky causing the pressure not to decrease normally. When the action of the calf-pump- muscle is disrupted the venous pressure is also affected.

a. Valve dysfunction or reflux Often occurs in the deep perforator and/or superficial veins

b. Obstruction (complete or partial) May be caused by deep vein thrombosis

c. Calf-muscle-pump failure Usually occurs from decreased activity level which may be secondary to paralysis, localized deformity or injury. Decreased range of motion of the lower leg and ankle joint are often the cause

Physical Activity (Level A: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Physical activity has also been identified as a vital factor to prevent and heal venous leg ulcers. Lower leg exercises including tip-toe exercises in the standing position, flexing and stretching of feet in the sitting position are important exercises to enhance venous return. Walking will activate the calf muscle pump that is essential to support venous circulation. A diminished calf muscle pump function or absence of calf muscle pump will result in edema in the lower legs and other chronic venous insufficient symptoms. The immobility of the ankle joint will influence ambulatory venous hypertension and is a factor in causing venous ulceration. A referral to physiotherapy is recommended for patients that have reduced or no ankle joint mobility to loosen soft-tissue contractures through the use of physical therapy. Studies have shown that patients with venous leg ulcers have low level of physical activity. Heinen et al concluded that 35% of venous leg ulcer patients did not walk 10 minutes once a week.14

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 28 4.4 Implement Appropriate Compression Therapy (Level A, B and C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

A. Principles of Compression Therapy

In general, stockings are for prevention and compression bandages or compression wraps are for therapy, although there are a number of stockings that have been developed specifically to accommodate ulcer dressings and care, and are effectiveii. These ulcer stockings may have a special trellis-like knit that increases pressure similar to that seen with compression bandages, or a two layer system including a low (10 mmHg stocking liner) and a zippered second stocking that increases pressure to the 30-40 mm Hg range. In situations where self- care is possible, compression stockings or devices may be seen to be more cost-effective than compression bandaging systems.

 Therapeutic Graduated Compression Stockings, worn on a daily basis, are the best known prophylaxis to prevent venous ulcer recurrence.  Appropriate compression bandaging at highest level safe for, and tolerated by, the individual should be initiated within the first week.

B. Benefits of Compression bandaging

 Stimulates fibrinolysis  Removes sodium from subcutaneous tissue and reduction of edema  Facilitates fluid movement due to the pressure gradient  Creates an environment suitable for wound healing  Creates a pressure gradient extending from ankle to the knee (highest pressure at the lowest aspect and progressively diminish as it extends up the leg)  Overcomes gravitational effects  Combined effect of graduated compression plus activation of the calf muscle pump moves fluid towards the heart

Definitions:

. Tension- amount of force used to apply the bandage . Extensibility- ability to stretch in length with applied force . Power- the force required to increase the length of the elastic bandage, which determines the level of pressure exerted by the bandage . Elasticity- ability of the bandage to return to its original length after reducing tension . Stiffness- increase in pressure per square cm. increase in circumference

Pascal’s and LaPlace’s Law both form the physical basis of HOW compression works to reduce chronic venous insufficiency, but the calculations are not used by clinicians to determine how much compression is appropriate or needed for a given situation. They are included here only for interest sake, not for a practical application.15

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 29 C. Compression Choices

NO compression bandaging (including tubular bandaging such as tubigrip or surgigrip) is initiated until Lower Leg assessment and APBI/TBPI is completed, patient is assessed to be appropriate for bandaging and communications with physician or primary care provider has occurred.

Compression Bandaging includes single layer and multi-layer choices elastic and inelastic, with various applications to provide a range of 20 to 40 mm Hg compression, based on the patient’s vascular status and tolerance.

. Inelastic bandages: Provide support and resistance: high pressures with exercise, minimal pressure at rest e.g. Viscopaste and kling wrap, Circaid ® Boot, Short stretch Comprilan®, Coban 2™, Coban 2 Lite™ . Elastic bandages: Provide compression with high pressures at rest but less with muscle contraction e.g. Profore™, Surepress™, Coban™ Self Adherent Wrap (Coban 4” with 20 mmHg should only be used as part of a Duke’s Boot over zinc paste

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 30 . Velcro-strap system (inelastic): lasts about 6 months, easy to doff and don . Specialized stockings designed for venous ulcer care e.g. Jobst Ulcer Care . Tubular support: which when combined in layers of at least 2 can provide variable amount of compression e.g. Tubigrip, Tubifast, Surgigrip (non-latex) Tubular net-type that mimics the work of taping for lymphedema reduction e.g. Edema Wear

Important Considerations: Prevent pressure damage in patients with:

 Impaired peripheral perfusion  Thin or altered limb shape  Foot deformities  Dependent edema  Achilles and tibialis anterior tendon areas  Rheumatoid arthritis  Reduced sensation  Long-term steroid use  Loss of calf muscle pump by choosing an inelastic (rigid) bandaging system  Applying extra padding or foam over bony prominence

D. ABPI and Compression Bandaging Table 4: 2,16

(see Toolkit Item #16 for reference chart below)

Type of Examples of Products Compression Characteristics Compression

High Compression (40mmHg pressure and higher)

Normal ABPI = 1.0 to 1.2 Mild Ischemia = 0.8 to 0.9

ABPI >1.2 or you cannot obliterate the pulse with BP cuff Calcification (Non-compressible arteries)

Request Toe Brachial Pressure Index (TBPI) or Segmental Pressures to determine safety of compression therapy

High elastic Surepress* (Convatec) Sustained compression; can be worn continuously for up to 1 compression week; can be washed and re-used, but may slip. Surepress and flexible cohesive (Long stretch) bandage

Profore* (Smith & Nephew) 4 Can use flexible cohesive for slippage. layer bandage comprising of Multilayer high orthopedic padding; crepe; compression Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 31 Elset; Coban.

Coban 2

Inelastic Short-stretch bandage, e.g., Designed to apply 40 mmHg pressure at the ankle, Compression graduating to 17 mmHg at the knee; sustainable for 1 week. Comprilan (Beiersdorf)

Unna’s Boot Reusable with slight stretch giving low resting pressure but high pressure during activity.

Medium Compression (20-40 mmHg pressure)

ABPI = 0.6 to 0.8

Multilayer bandages Profore light Bandages can be made by combining Kling and a Tensor (spiral or figure 8) and a flexible cohesive bandage on top. Coban 2 Lite Components can be re-used.

Cohesive bandages Coban (3M), Roflex Self-adherent to prevent slippage; useful over non-adhesive bandages such as elastocrepe and paste bandages;

compression well sustained. Provides approximately 23 mmHg or higher at the ankle graduating to approximately

one-half this pressure at the knee.

Low Compression (15-20 mmHg pressure)

ABPI = 0.5 to 0.6

Light support only Kling/orthopedic wool For holding dressings in place, as a layer within the multilayer bandage (inelastic)

Light Compression Tensor/Elastocrepe Low pressure obtained; used alone it gives only light support; a single wash reduces pressure by about 20 single layer elastic Tubi-grip percent.

Light Compression Coban 2 Lite

multilayer ABPI <0.5 - severe arterial disease→ urgent vascular surgery consult

ABPI <0.3 – Critical Ischemia → urgent medical attention

NO compression to be used

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 32 E. Compression for LIFE! (compression stockings)16

 Graduated compression stockings are the best-known method of preventing swelling of the legs and feet, after a period of being wrapped with bandages

 These stockings provide a measured amount of compression to the lower legs

 They come in open and closed-toe, knee or thigh-length versions

 Stockings should go on first thing in the morning before the legs start to swell

 They can be removed at bedtime, but CAN be worn over night if the individual cannot get them on and off by independently

 If they wear them overnight, they should fit smoothly without causing deep creases or folds in the skin

 It is important that certified stocking specialist measure the legs to fit them (see Toolkit item #17 for list of fitters in Waterloo Wellington Region)

 One of the most difficult things about compression stockings is that even though they may still feel tight, they actually stretch and lose their ability to control the edema or the venous problem in your legs  They need to be replaced every 4- 6 months  If the individual alternates stockings with two pairs, two pairs will last 8 -12 months  Scientific testing shows that the stockings lose pressure after just one month of wear, and by 6 months they are not providing you with the amount of compression needed, so that skin breakdown and complications will start to happen  There are many devices designed to assist people with “donning” (applying) and “Doffing” (removing ) medical grade compression stockings  There are times when a person who should be in compression stockings either cannot tolerate them or refuses to wear them. In those situations, it is believed that some compression is better than no compression in terms of prevention of recurrence. This is where the tubular stocking (i.e. Tubigrip) may be helpful

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 33 ABPI 0.5 to 1.39 Long-term Compression systems Compression stockings To be worn after healing or for Strength is dependent on ABPI Tubifast/Tubigrip for patients unable to ‘don ulcer prevention and LLA results and doff’ compression stockings Juxta and Juxta lite (stocking with Velcro straps) [stiffness or resistance]

4.5 Medical Therapy: Pharmacological Treatment 2,4

F.a. Pentoxyfilline (Trental)17

 It is a haemorheological agent, thought to increase red and white cell filterability by altering the shape and flexibility and therefore the flow of cells, and decrease whole blood viscosity, platelet aggregation and fibrinogen levels 18  Influences microcirculatory blood flow and oxygenation of ischaemic tissues  The full product monograph should be consulted re: precautions when using with anticoagulants such as Plavix, as Trental may increase the risk of bleeding  In a Cochrane review of 11 randomised trials comparing Pentoxifylline with placebo or other therapy in the presence or absence of compression, in people with venous leg ulcers, Pentoxifylline was seen to be an effective adjunct to compression bandaging for treating venous ulcers and may be effective in the absence of compression 19  The majority of adverse effects were gastrointestinal disturbances  If woody fibrosis and induration are present in the peri-wound area or in the leg, Pentoxyfilline (Trental) 400mg TID helps to soften fibrosis and allows the wound to heal.  Start with a BID dosage and increase to TID as tolerated, with appropriate precautions with individuals with known history of indigestion or GERDs.  Be aware that it may take two months before benefit can be seen

F.b. Plebotonics  Phlebotonics are a class of drugs that are often used to treat cardiovascular insuffiency  These are natural flavonoids extracted from plants and similar synthetic products (e.g. french maritime pine bark extract, grape seed extract and aminaftone)  In a Cochrane review in 2005, there was not enough evidence to globally support the efficacy of phlebotonics for chronic venous insufficiency 19  There is a suggestion of some efficacy of phlebotonics on oedema but this is of uncertain clinical relevance 18

4.6 Surgical Interventions

Varicose veins involving the long and/or short saphenous vein(s)12

Surgical services (ligation/stripping) for the treatment of varicose veins involving the long saphenous and/or short saphenous vein(s) are only insured when all of the following conditions are met: Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 34  There is incompetence (i.e. reflux) at the saphenofemoral junction or saphenopopliteal junction that is documented by Doppler or duplex ultrasound scanning;  The patient has failed a trial of conservative management of at least three months duration; and  The patient has at least one of the conditions described in either a. or b. below:

a. One or more of the following signs of chronic venous insufficiency:

1. Eczema; 2. Pigmentation; 3. Lipodermatosclerosis; 4. Ulceration

b. Varicosities that result in one or more of the following:

1. Ulceration secondary to venous stasis; 2. One or more significant hemorrhages from a ruptured superficial varicosity; 3. Two or more episodes of minor hemorrhage from a ruptured superficial varicosity; 4. Recurrent superficial thrombophlebitis; 5. Stasis dermatitis; 6. Varicose eczema; 7. Lipodermosclerosis; 8. Unremitting edema or intractable pain interfering with activities of daily living and requiring chronic analgesic medication.

Note:  Conservative management includes analgesics and prescription gradient support compression stockings.  Significant hemorrhage refers to a hemorrhage related to varicose veins that requires iron therapy or transfusion.

5. Provide Local Wound Care

2..iv.a. Intervention Algorithm Figure 3

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 35 2..iv.b. Signs and Symptoms of Wound Infection 8, 20 (Level A, B and C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4) Venous ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria. The validated mnemonics “NERDS” and “STONEES” classify the signs and symptoms of localized infection (NERDS) and spreading infection (STONEES). Increased localized pain is a significant predictor of deep compartment infection. Presence of Superficial Bacteria  N- Non-healing wound  E- Exudate increased  R- Red friable (fragile tissue that bleeds easily)  D- Debris (presence of necrotic tissue (eschar/slough) in wound  S- Smell Presence of Spreading Bacteria (< 3 low bacteria count, >3 high bacteria count)  S- Size increasing  T- Temperature increased (> 3 degrees F difference)  O- Os (probes to bone or bone is increased)  N- New areas of breakdown  E- Exudate present Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 36  E- Erythema and/or Edema  S- Smell In addition to recognizing the signs and symptoms of infection in venous leg ulcers, it may be helpful to obtain a culture and sensitivity (C&S) using a validated method of sampling to quantify bacteria in wounds. Tissue biopsies are considered the gold standard but unfortunately are not practical in many settings. Fortunately, a linear relationship between quantitative tissue biopsy and swab for C&S taken using the Levine method of sampling (see below) has been validated and is recommended for assessing any open wound. Swabs for C&S are important in determining the type of bacteria and the appropriate antibiotics, but are not necessary to confirm the presence or absence of infection. The C&S results may not reflect the presence or absence of biofilm. Levine Method for obtaining C&S laboratory swab 20 1. Cleanse wound thoroughly 2. Place swab on granulation tissue 3. Apply enough pressure to extract fluid 4. Turn swab 360 degrees on fluid (avoid slough or debris) 5. Place swab in transport medium

2..iv.c. Signs and symptoms of Lower Leg Cellulitis 16

 Cellulitis is a spreading bacterial infection of the dermis and subcutaneous tissues, where the edge of the erythema may be well-defined or more diffuse and typically spreads rapidly

 Systemic upset with fever and malaise occurs in most cases, and may be present before the localising signs such as the local symptoms seen with STONEES23

 Lower leg cellulitis can be extremely serious with long-term morbidity, including lower leg edema. It requires prompt recognition by health care providers and appropriate interventions

 Note that lower leg cellulitis usually affects only one leg, not both. If both legs are affected, it is likely venous dermatitis or allergic contact dermatitis, but this does not mean that it could never be cellulitis in both legs 24

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 37 Signs and Symptoms of Cellulitis of Lower Risk Factors Legs

Symptoms: • Takes only a pin-point opening in the skin • May have fever for bacteria to enter….. grazes, abrasions, • May have flu-like symptoms before cellulitis cuts, puncture wounds develops • Maceration between toes in web space • Area very painful or tender • Tinea Pedis (Athlete’s foot) • May not tolerate current compression esp. • Diabetes elastic types • Liver disease with chronic hepatitis or cirrhosis • Lower leg edema of any etiology especially lymphedema • Obesity with swollen limbs • Burns • Peripheral arterial disease • Recent surgery (especially vein harvesting Signs: for bypass grafting) and related infections  Appears as a diffuse, bright red, hot leg or may • Osteomyelitis have streaking. This will spread if untreated. • Venous stasis dermatitis; eczema or Mark with indelible marker to determine psoriasis spread or resolution of infection. IF person has • Shingles or chickenpox darker skin, this may be difficult to determine. • Severe acne  May have a clear demarcation line of pale skin • Any blunt trauma to the leg against the darker red. • Leg ulceration  Clear serous or yellow exudate will “pour” out • White ethnicity of the small openings, saturating the dressings • Insect, spider or animal bites quickly • Immuno-suppression Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 38  May have small blisters or large bullae • Foreign objects in the skin (e.g. orthotic unrelated to venous disease pins)  Rapid increase of edema up the lower leg… • Open wounds or ulcerations often starts at the foot but can start in the calf  Raised, swollen, tight shiny or glossy skin with a stretche d appearance  Skin is hot to touch

Suggested Investigations: • High WBC, increased ESR and C-reactive protein. • Blood culture usually negative; swabs C&S usually negative unless necrotic tissue is swabbed (which is inappropriate)

2..iv.d. Management of Lower Leg Cellulitis

 Swabs for c&s not usually helpful if cellulitis is dry; if wet then should be done using LEVINE semi-quantitatitve method Levine Method for obtaining C&S laboratory swab 22 1. Cleanse wound thoroughly 2. Place swab on granulation tissue 3. Apply enough pressure to extract fluid 4. Turn swab 360 degrees on fluid (avoid slough or debris) 5. Place swab in transport medium  Mark line of demarcation on leg distally and proximally with soft-tip indelible marker (not pen) which helps caregivers and patient to visualize if the infection spreads beyond the point of first assessment

 High compression, especially elastic systems, may be too painful to tolerate until the infection starts to respond to the antibiotic therapy. Do not stop compression entirely, because the edema will increase as a result of the cellulitis. May use appropriate lower mmHg compression such as two layers of tubular support bandage (e.g. Tubigrip)

 Leg elevation is important

 Treat any co-existing conditions such as venous ulcer, venous dermatitis or tinea pedis in addition to the systemic antibiotics

 In some individuals, discomfort can be soothed using a compress of Burosol solution or Burrow’s solution x 15-20 minutes available from some compounding pharmacies Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 39  Polyhexamethylene Biguanide (PHMB –e.g. AMD) antimicrobial kerlix loose- woven (11.4 cm x 3.7 m) may be used. Wrap the affected leg from the base of the toe to below the knee, overlapping each turn by 50%. If exudate amount is large, cover with absorptive secondary dressing and kling wrap, covered by appropriate lower mmHg compression such as two layers of tubular support bandage (e.g. Tubigrip)

 Another option if there is dermatitis along with the cellulitis and the individual is not allergic to sulpha or silver, is to obtain a prescription for Silver Sulfadiazine applied 3- 5 mm thick to a combine (abdominal pad) roll with a non-metal device, place over the weeping areas, cover with high exudate absorptive dressing and kling. This must be done BID if the amount of exudate is high; once exudate diminishes it can be reduced to q 2-3 days

 Combination systemic antibiotic therapy is needed for cellulitis (see table 6)

 Once cellulitis is responding to systemic antibiotics and discomfort is resolving, resume previous level of higher compression.

Situation Suggested antibiotics If allergic to penicillin Comments

Non-purulent MILD: Oral treatment Clindamycin Treat for about 10 to 14 Skin/Soft Tissue Penicillin VK Or Vancomycin days or until signs of Infection Amoxicillin inflammation have resolved (i.e. erysipelas, cellulitis, Cephalexin necrotizing infections) Cloxacillin Clindamycin

MODERATE: IV treatment Penicillin G Cefazolin or ceftriaxone Clindamycin

SEVERE: Surgical vs. empiric treatment Surgical Vancomycin + Piperacilin/tazobactam Purulent MILD: Clindamycin Skin/Soft Tissue Incision and drainage Or Infection Vancomycin (i.e.iImpetigo, ecthyma, MODERATE: Or furuncle, carbuncle, Incision & drainage Linezolid abscess) and culture & sensitivity , plus empiric or defined treatment Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 40 Trimethoprim/Sulfamethoxa zole Doxycycline Cephalexin Cloxacillin

SEVERE: Incision & drainage and culture & sensitivity, plus empiric or defined treatment Vancomycin Linezolid Trimethoprim/Sulfamethoxa zole Cefazolin Clindamycin

Table 6: Per Dr. Stephan Landis Guelph 2015

2..iv.e. Venous Dermatitis: Signs, Symptoms, Prevention and Treatment

Venous Stasis Dermatitis: Signs, Symptoms, Prevention and Treatment Table 7 16

Description Treatment

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 41  Avoid the use of known sensitizers in individuals with venous disease (perfume, latex, dyes, lanolin or wool alcohols, balsam of peru, cetylsterol alcohol, parabens, colophony propylene glycol, neomycin, rubber, some adhesives, framycetin or gentamycin) (Sibbald et al. 2007).  Limit baths and showers to 15 minutes in warm not hot water.  Avoid harsh soaps  Avoid vigorous use of a washcloth or towel. Blot or pat areas dry so there is still some moisture left on the skin. Venous Stasis dermatitis (also  Use moisturizers immediately after bathing such as Glaxal Base (ask pharmacist known as “Venous if not on shelf), Cliniderm, Eucerin or Moisturel lotions (not cream) or plain dermatitis”, “Gravitational Vaseline petrolatum ointment to keep the skin healthy and free of dry scales. dermatitis” or “Venous, stasis  Any products containing petrolatum or alcohol should be stopped if severely eczema” describes the red, dry scaly skin develops. itchy rash on the lower legs  For severely dry, scaly skin (Xerosis) use products containing Urea such as which can be dry and scaly or Uremol 20% or Attractain (contains 10% urea and 4% AHA), Eucerin 10% Urea can weep and form crusts Lotion, Lac-Hydrin 12%. commonly seen in people Urea works by enhancing the water-binding capacity of the stratum corneum. with chronic venous Long-term treatment with urea has been demonstrated to decrease insufficiency. transepidermal water loss. Urea also is a potent skin humidifier and descaling The skin may appear brown agent, particularly in 10% concentration. or purple in colour and the Lactic acid (in the form of an alpha hydroxy acid) can accelerate softening of lower legs become the skin, dissolving or peeling the outer layer of the skin to help maintain its increasingly edematous. capability to hold moisture. Lactic acid in concentrations of 2.5% to 12% is the It may be associated with most common alpha hydroxy acid used for moderate to severe xerosis.iii acute contact dermatitis,  Use creams and lotions as directed, and stop if any signs of dermatitis occur. which appears as itching,  Only use topical corticosterioid preparations for two weeks at a time (if being burning red areas on the applied more frequently than 2 x/ week) because they cause skin to break lower leg corresponding to an down or develop a rebound dermatitis area where a topical product  If dermatitis occurs and patient is using compression stockings, there is a risk has been used. that the lotions or creams will cause accelerated deterioration of the stocking material. In this case, it is best to only apply the topical products at bedtime when the stockings are removed.  If the dermatitis is severe, there may be a need to switch to compression bandaging with a medicated wrap containing zinc or other products.  Systemic antibiotic therapy is not needed for acute contact dermatitis, unless cellulitis has developed  Referral to dermatologist for allergy patch testing is indicated if dermatitis does not respond to treatment

Dressing Choices for Venous Stasis Dermatitis (Eczema)16

 Itching and burning can be soothed using a compress of Burosol solution or Burrow’s solution x 15-20 minutes (product is no longer available over the counter (OTC) but can be obtained in powdered sachets from some compounding pharmacies

 Apply prescribed steroidal cream to all affected areas- with added Menthol ¼ % to ½ % will aid in soothing and anti-itch effect, and cream can be kept in refrigerator

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 42  Apply Unna’s boot using a medicated zinc paste bandage* (e.g. Viscopaste) wrapped in a spiral wrap using fan-fold pleats to prevent constriction

2..iv.f. Determining Goals for Local Treatment for Venous Leg Ulcers 13 (Level A, B and C: RNAO’s Assessment and Management of Venous Leg Ulcers)

Healable Wounds: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized

Goal: Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control, protect peri-wound skin

Maintenance Wounds: have healing potential, but various patient factors are compromising wound healing at this time

Goal: Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control and protect periwound skin. Avoid higher cost advanced wound treatments until factors compromising wound healing are resolved. Focus on quality of life issues, exudate and odour management

Non-healable/Palliative wounds: has no ability to heal due to untreatable causes such as terminal disease or end-of-life

Goal: Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues.

Calculating Current Percentage of Healing Since Admission

2..iv.g. Utilize Product Picker from Canadian Association of Wound Care (CAWC)

Product Picker for Classification of Dressing Products Each organization may use the PDF Fillable CAWC Product Picker to list the products available within their organization (see Toolkit Item #14)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 43 2..iv.h. South West Regional Wound Care Program’s Wound Cleansing Table: 8 (see Toolkit Item #15 for reference chart)

Wound Assessment

Clean Clean Granulating Clean Granulating Necrotic Healable Necrotic Non- Epithelializing Wound, Wound NOT Wound Healable Wound Wound Decreasing in Decreasing in Size (Debridement is (Debridement is Surface Area 20- 20-30% in 3-4 Appropriate) NOT 30% in 3-4 Weeks* Appropriate)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 44 Irrigate with < 7 PSI Irrigate with < 7 PSI Irrigate with 7-15 PSI Irrigate with 7-15 PSI Do not irrigate or pressure, or pour pressure, or pour pressure. pressure. cleanse the solution over the solution over the wound itself (the wound bed. wound bed. intent is to allow the necrotic tissue Use at least 100cc’s Use at least 100cc’s Use at least 150cc’s of Use at least 150cc’s solution, at room or of solution, at room to dry out and of solution, at room of solution, at room stabilize). or body temperature. or body temperature. body temperature. or body temperature.

Cleanse the Cleanse the Cleanse the Cleanse the periwound skin of periwound skin of periwound skin of periwound skin of debris, exudates. debris, exudates. debris, exudates. debris, exudates.

If there is exudate No antimicrobial No antimicrobial *Granulating wounds present on the solutions. solutions. not decreasing in size periwound skin, may have a localized gently cleanse it infection. and pat dry.

Topical application of proviodine-iodine solution or Chlorhexadine to the wound surface is appropriate, i.e. paint with Proviodine.

Malignant Wounds Wound with Debris Wound with Debris * Localized And/Or Maintenance or Contamination/ or Contamination/ Spreading Infection Wounds Superficial & Partial Superficial & Partial Thickness Burn Thickness Burn

Irrigate with 7-15 PSI Irrigate with 7-15 PSI Irrigate into Irrigate with 7-15 PSI Cleansing will be pressure, if tolerated. pressure. tunneled/undermine pressure. dependent on Reduce pressure as d area using a 5Fr characteristics of needed to minimize Use at least 150cc’s catheter or “soft- Use at least 150cc’s wound bed and pain and damage to of solution, at room cath” with a 30cc of antimicrobial goal of treatment. or body temperature. solution, at room or

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 45 friable tumor tissue. Cleanse the syringe. body temperature. If goal is to periwound skin of prevent wound Use at least 150cc’s debris, exudates. Use at least 150cc’s of Cleanse the from of solution, at room solution, at room or periwound skin of deteriorating, or body temperature. May cleanse small body temperature. debris, exudates. cleanse as per a burns with lukewarm Irrigate until returns Cleanse the Two week challenge: Necrotic Non- tap water and mild are clear. Healable Wound. periwound skin of soap. May use a 10 – 14 debris, exudates. Gently palpate over day cleansing regime undermined or with an antimicrobial Foul odor indicates tunneled areas to solution to address presence of express any irrigation bacterial burden. anaerobes - use an solution that is antimicrobial retained. solution, and/or topical Do not force irrigation Metronidazole. when resistance is detected.

Cleanse the periwound skin of debris, exudates.

NOTE: Normal saline and sterile water do NOT contain preservatives and must be discarded 48 hours after opening

Wound Appearance

Description Eschar Primarily Slough or Fibrin Granulating **** Epithelializing **** Mixed Granulating/Slough Wound Tissue

Exudate Level None → Moderate Small → Large Small→ Large Small → Moderate Depth Unknown Full  Partial Full → Partial Full Thickness → Thickness Thickness Superficial Treatment Objective Debride (unless the Cleanse, protect, Cleanse, protect, Cleanse, protect, eschar is stable and moist wound moist wound moist wound healing,

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 46 on a heel. If stable healing, fill dead healing, fill dead fill dead space eschar is on a heel space, debride space, debride use the maintenance enabler)* Cleansing (min. 100 7-15 PSI irrigation NS 7-15 PSI irrigation NS 7-15 PSI irrigation POUR NS or sterile mL of room/body or sterile water or or sterile water or NS or sterile water water solution temperature commercial wound commercial wound or commercial solution) ** cleanser cleanser wound cleanser Suggested Dressing Have ET/WCS cross- Hypertonic dressing Hypertonic dressing Hydrogel [0] (max 3 Hydrogel [0] (max 3 Products and Rate hatch hard eschar [1+] (daily) [1+] (daily) days) Changes*** first! Or Or Or Hypertonic dressing Hydrogel [0] (max 3 Hydrogel [0] (max 3 Calcium Alginate [2+] Synthetic [0] (max 7- [1+] (daily) days) days) (max 7 days) Or Or Or Or Hydrogel [0] (max 3 Hypertonic dressing Hypertonic dressing Hydrophilic Fiber [2+] days) [1+] buttered with a [1+] buttered with a (max 7 days) Or Hydrogel [0] (daily) Hydrogel [0] (daily) Cover Choices: Hypertonic dressing Or Or Hydrocolloid [1-2+] Synthetic [0] (max 7 [1+] buttered with a Cadexomer Iodine Cadexomer Iodine +/- Film [1+] (max 7 Hydrogel [0] (daily) [1+] buttered on [1+] buttered on days – do not use on Cover Choices: Calcium Alginate [2+] Calcium Alginate plantar foot wounds) Hydrocolloid [1-2+] or Hydrophilic Fiber [2+] or Hydrophilic Or +/- Film [1+] (max 7 [2+] (max 3 days) Fiber [2+] (max 3 Clear Acrylic [2+] days) Cover Choices: days) (max 21 days) Synthetic [0] (max 7 Or Hydrocolloid [1-2+] Cover Choices: Or Foam [1-3+] +/- Film [1+] (max 7 Hydrocolloid [1-2+] Foam [1-3+] (max 7 +/- Film [1+] (max 7 days) +/- Film [1+] (max 7 days) Hydrocolloid [1-2+] days) Or days) Or +/- Film [1+] (max 7 Or Foam [1-3+] (max 7 Or Composite [2-3+] days – do not use on Composite [2-3+] days) Foam [1-3+] (max 7 (max 7 days) +/- Film [1+] (max 7 Or days) days) Composite [2-3+] Or Or (max 7 days) Composite [2-3+] Gauze sealed by Or (max 7 days) Film [1+] (for daily Gauze +/- Film seal Or changes ONLY) [1+] (for daily Gauze +/- Film seal Foam [1-3+] (max 7 changes ONLY) [1+] (for daily changes ONLY)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 47 * Only debride healable wounds. ** If antimicrobial effect is required, consider topical antiseptic cleansers, i.e. chlorhexadine 2% or 4% (for pseudomonas – must soak x 5 min. minimum), povidone-iodine, or ¼ strength acetic acid (for pseudomonas only – must soak x 5 min. minimum). *** If antimicrobial effect is required, consider topical antimicrobial dressings, i.e. silver compounds, iodine compounds, chlorhexadine derivatives, honey, or gentian violet and methylene blue. **** For stalled granulating or epithelializing wounds consider cadexomer iodine or pocidone iodine to initiate acute inflammation or calcium alginate or protease inhibitor dressings to address chronic inflammation. ALSO, may consider pain controlling dressings for painful exudating wounds, biologic dressings for stalled granulating +/- epithelializing wounds in the absence of infection or large drainage, charcoal dressings for odor control (once the cause of the odor has been investigated and treated if able, and adjunctive therapies as indicated. Disclaimer: The information herein is for general informational purposes only and is not intended, nor should it be considered, as a substitute for professional medical advice. Always seek the advice of the attending physician or other qualified healthcare provider regarding a medical condition or treatment. Dressing selection cannot take place in isolation – a holistic patient assessment is MANDATORY.

Wound Appearance

Eschar Primarily Slough, Mixed Granulation Description Granulation/Slough, or Fibrin Wounds

None → Small → Large Small  Large Exudate Level Moderate Unknown Partial → Full Thickness Partial  Full Depth Thickness Stabilize/dry Absorb/dry, fill dead space, prevent Absorb/dry, fill Absorb/dry, fill dead space, prevent Treatment Objective necrotic tissue, extension/infection, manage odor**/pain, dead space, prevent protect prevent odor**/bleeding/pain***, protect extension/infec extension/infecti tion, manage on, manage odor**/pain, odor**/pain, protect protect Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 48 Cleanse POUR Proviodine or Chlorhexadine 2% POUR Proviodine POUR Proviodine or Chlorhexadine 2% Cleansing (min. 100 mL of exudate from solution (min. 100cc). or Chlorhexadine solution (min. 100cc). Soak with room/body temperature periwound Pat or air dry. 2% solution (min. solution if pouring is too painful. solution) ** skin. 100cc). Paint wound Pat or air dry. with Proviodine or Chlorhexadine 2%. Pat or air dry. Suggested Dressing DO NOT DO NOT DEBRIDE* Proviodine or Products and Rate Changes DEBRIDE* Proviodine or Chlorhexadine 2% soaked Chlorhexadine Proviodine or Chlorhexadine 2% soaked Proviodine or non-woven gauze [1+] +/- Non-Adherent 2% soaked non- (Dressing change frequency Chlorhexadine Synthetic (daily) woven gauze [1+] depends on the wear time of 2% soaked Or +/- Non- the primary dressing and the non-woven PHMB gauzed based dressings [0-1+] +/- Adherent PHMB gauzed based dressings [0-1+] ability of the dressing gauze [1+] +/- Non-Adherent Synthetic (max 3-7 days) Synthetic (daily) components to keep the Non-Adherent Antimicrobial Non-Adherent Dressing [0] Or wound dry) Synthetic (max 7 days) PHMB gauzed (daily) Or based dressings antimicrobial component [0] (max 7-14 Or Nanocrystalline Silver Dressings [1+] (max [0-1+] +/- Non- PHMB gauzed 7 days) Adherent based Cover Choices: Synthetic (max 3- Calcium Alginate +/- antimicrobial dressings [0- Non-woven gauze [1+] 7 days) 1+] +/- Non- Or Or +/- Non-Adherent Synthetic [0] (max 7 Adherent Ultra-Absorbent [2-4+] Antimicrobial Synthetic (max Non-Adherent 3-7 days) Dressing [0] (max Hydrophilic Fiber +/- antimicrobial Or 7 days) Antimicrobial Or +/- Non-Adherent Synthetic [0] (max 7 Non-Adherent Nanocrystalline Dressing [0] Silver Dressings (max 7 days) [1+] (max 7 days) Cover Choices: Cover Choices: Non-woven Non-woven gauze [1+] gauze [1+] Or Or Ultra- Ultra-Absorbent Absorbent [2- [2-4+] 4+] OR After painting the eschar, leave it open to air if it is non-draining!

* Only debride healable wounds. Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 49 ** Consider charcoal dressings or topical Metronidazole for odor control once the underlying cause has been determined and managed if possible. *** Consider pain control foam dressing for painful, exudating wounds. Dressing must be in direct contact with wound bed. **** Consider ¼ strength acetic acid or Chlorhexadine 4% soaks (x 5 minutes) for pseudomonas treatment. Disclaimer: The information herein is for general informational purposes only and is not intended, nor should it be considered, as a substitute for professional medical advice. Always seek the advice of the attending physician or other qualified healthcare provider regarding a medical condition or treatment. Dressing selection cannot take place in isolation – a holistic patient assessment is MANDATORY.

Table courtesy of South West Regional Wound Care Program 2015

2..iv.i. Patient Education on Skin Care 21

Skin care is a vital element to promote wound healing and prevent recurrence of venous leg ulcers.

The following information is provided to clients as recommended practices:

. Shower before wrapping of compression bandages.

. Avoid harsh soaps or highly perfumed soaps.

. Soothe any local skin irritation with a moisturizing cream.

. Avoid creams with perfumes, aloe and lanolin, as these products increase the risk of dermatitis.

. Monitor skin for potential reactions, and if present, contact your care provider.

. Discuss long-term use of steroids with your care provider.

. Avoid the use of adhesive products due to increased sensitivity of people with venous disease

2..iv.j. Adjunctive Therapies 2,4

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 50 Consider Multi-disciplinary referrals for adjunctive therapy.

Adjunctive therapy refers to additional treatment used together with the primary treatment to achieve the outcome of the primary treatment.

There are many types of adjunctive therapies for wound management. The ones contained in this resource include only those that have been verified by rigorous research standards and are included in the RNAO/CAWC best practice guidelines.

Electrical Stimulation Therapy (EST) (Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 4)  refers to the application of a low level electrical current to the base of a wound or peri-wound using conductive electrodes to induce cellular activity to facilitate wound healing.

Therapeutic Ultrasound (TU) (Level A: RNAO’s Assessment and Management of Venous Leg Ulcers 4)  refers to the therapeutic application of ultrasound waves to the base of a wound or peri-wound to induce cellular activity to facilitate wound healing.

6. Provide Organizational Support 2,4

a. Multi-disciplinary Team Intervention Referral Criteria Checklist

 Primary Care Physician Identify multi-disciplinary team referrals  Advanced Wound Specialist that need to be arranged  Nurse Practitioner  Infectious Disease Specialist  Vascular Surgeon  Dermatologist  Plastic surgeon  Internist/Endocrinologist  Mental Health Specialist  Psychologists  Social work  Registered Dietitian  Pharmacist  Occupational Therapist  Physiotherapy  Chiropodist  Certified Pedorothist  Certified Orthotists  Certified Prosthetist  Podiatrist  Lymphatic Massage  Compression Stocking Fitter

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 51 iFUN Criteria guidelines for referral to an advanced wound specialist

i Intervention If an intervention is required (i.e. ABPI, toe pressures, debridement)

F Frequency If the frequency of dressing changes is not less than 3 x a week within 4 weeks of treatment U Unknown If the cause of the wound or the cause of the failure to heal is unknown

N Number If the size of the wound has not decreased by 20-30% in 3-4 weeks of treatment Referral Suggestion Chart

CRITERIA SUGGESTIONS FOR REFERRAL

Presence of fixed ankle joint or impaired calf muscle Refer to physiotherapy for ankle/calf-muscle pump in the presence of edema pump training and controlled exercise.

(Level A: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

If ulcer >5cm² &/or > 6 months duration on admission, or Refer to physiotherapy or other qualified health not healed (100%) at 3 months. professional for therapeutic ultrasound (TU) or electrical stimulation therapy (EST).

(Level A and B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Presence of a mixed venous arterial leg ulcer with Refer to family physician, vascular physician or moderate to severe neuropathic pain. pharmacist as needed

(Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4 )

If patient cannot “doff and don” compression stockings Refer to OT for adaptive devices, Professional independently, and no family members are able to do so. Compression Fitters or for PSW to assist with this ADL.

(Level A: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Medical management may include appropriate systemic Refer to family physician or Infectious Diseases antibiotic therapy for patients with bacteremia, sepsis, Specialist for antibiotic treatment. Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 52 advancing cellulitis or osteomyelitis. (Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Prevent or manage pain associated with debridement. Refer to family physician or pharmacist as needed

(Level C: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

For debridement when the need is urgent (such as with Refer to Wound Care Physician/Surgeon. advancing cellulitis or sepsis, increased pain, exudates and odour) or beyond the scope of practice/competency of (Level C: RNAO’s Assessment and Management the primary care providers. of Venous Leg Ulcers 2,4)

Mini Nutritional Assessment (MNA) < 24 Refer to Registered Dietitian Unable to afford or have access to nutritional food Refer to Social Work

(Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Contact dermatitis due to suspected sensitivity to Refer to dermatologist for patch testing allergens (Level B: RNAO’s Assessment and Management of Venous Leg Ulcers 2,4)

Table: 10 Adapted from South West Regional Wound Care Program 2014 and Waterloo Wellington Integrated Wound Care Program Evidence- Based Wound Care Venous and Mixed Venous/Arterial Leg Ulcers 2015

b. Patient, Caregiver and Healthcare Provider Teaching and Learning Resources

 RNAO Learning Package: Assessment and Management of Venous Leg Ulcers 2006 (see Toolkit Item #18)  Compression for Life patient brochure (see Toolkit Item #19)  Patient Diary (see Toolkit Item #20)

c. Discharge or Transfer Planning and Communications

Regardless of the method of providing the information (e.g. Care Connect, photocopy or Discharge Summary), it is agreed that the following information is critical in providing seamless care when individuals who have venous leg ulcers are being discharged or transferred to a different care setting:

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 53  Current blood work results  Vascular study results  Current and past treatment regimes  Any surgical interventions?

d. Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Venous and Mixed Venous/Arterial Clinical Pathway

PLACEHOLDER FOR FORMATTED PATHWAY

References a.i.1. Waterloo Wellington Community Care Access Centre. Current-State Assessment. February 2014 a.i.2. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004 a.i.3. Burrows C, Miller R, et al. Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada. 2006;4(1)

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 54 a.i.4. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007 a.i.5. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. September 2010 a.i.6. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Pain 3rd Edition. December 2013 a.i.7. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Integrating Smoking Cessation into Daily Nursing Practice. Revised March 2007 a.i.8. Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th Ed. Malvern, PA. HMP Communications; 2007 a.i.9. Health Canada. Population Health Approach. 2000. Retrieved on October 29, 2014 from http//www.hc- sc.gc.ca/hppb/phdd/approach/index.html a.i.10. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006; 332(7537):347-50. a.i.11. Hirsch AT, Criqui MH, et al. Peripheral Arterial Disease Detection Awareness and Treatment in Primary Care. JAMA, 2001. September 19:286 (11):1317-24 a.i.12. Jahromi Afshin, Vascular Surgeon, Guelph General Hospital 2015 a.i.13. Despatis,M.,Shapera,L.,Parslow,N.Woo,K.(2008) Complex Wounds Wound Care Canada 8(2):24‐25 a.i.14. Heinen M, van der Vleuten C, de Rooij M, Uden Caro, Evers A, Van Achterberg T. Physical activity and adherence to compression therapy in patients with venous leg ulcers. Archives Dermatology. 2007; 143(10):1283-1288. a.i.15. Thomas, S. The use of the Laplace equation in the calculation of sub-bandage pressure. World Wide Wounds. 2003. http://www.worldwidewounds.com/2003/june/Thomas/Laplace-Bandages.html a.i.16. Wellington Waterloo CarePartners, Kitchener Ontario a.i.17. Sanofi Aventis, www.sanofi.ca/products/en/trental.pdf a.i.18. Lee, Y. Robinson, M. et al. Diabetes Complications. The Effect of Pentoxifylline on Current Perception Thresholds in Patients with Diabetic Neuropathy. 1997. Sep-Oct; 11(5):274-8 a.i.19. Jull AB, Arroll B et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.:CD001733. Doi:10.1002/14651858.CD001733.pub2 a.i.20. Sibbald R.G, Woo K, Ayello E. Increased bacterial burden and infection: The story of NERDS and STONES Adv Skin Wound Care 2006; 19 (8): 447-461 a.i.21. Registered Nurses Association of Ontario. Learning Package: Assessment and Management of Venous Leg Ulcers. June 2006 a.i.22. Levine NS, Lindberg RB, Mason AD, Pruitt BA Jr. The quantitative swab culture and smear: a quick, simple method for determining the number of viable aerobic bacteria in open wounds. J Trauma. 1976;16(2):89-94 a.i.23. Fulton R. et al. Guidelines on the management of cellulitis in adults. CREST. 2005. www.acutemed.co.uk/.../Cellulitis%20guidelines,%20CREST,%2005.pdf a.i.24. Eagle M. Understanding cellulitis of the lower limb. Wound Essentials. 2007. 2:34-44

Venous and Mixed Venous/Arterial Leg Ulcer Toolkit

Content Item # Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 55 1. Venous and Mixed Venous/Arterial Leg Ulcer Pathway

2. CAWC Best Practice Enabler

3. CAWC Quick Reference Guide

4. Brief Pain Inventory Short Form

5. Canadian Nurses Association Social Determinants of Health and Nursing: A Summary of Issues

6. Assessing Patient-Centered Concerns Worksheet

7. Smoking Cessation

a. Smoking Cessation Smoking, Chronic Wound Healing and Implications for Evidence-Based Practice (Article by: McDaniel and Browning 2014)

b. Readiness to Quit Smoking Checklist

c. Applying 5A’s to Smoking Cessation

d. WHY test

e. Smoking Cessation Medication Comparison chart

f. Strategies to Avoid Relapse

8. Patient Medical History and Physical Assessment Form

9. Lower Leg Assessment Form

10. Wound Assessment Forms

a. Bates-Jensen Wound Assessment

b. Lower Leg Assessment Tool (LUMT)

11. Mini Nutritional Assessment Form (MNA)

12. Quality of Life Assessments

a. Cardiff Wound Impact Questionnaire

b. World Health Organization QOL

13. Depression Screening Tools

a. Geriatric Depression Screen

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 56 14. Dressing ‘Product Picker’

15. South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection & Cleansing Enablers

16. ABPI and Compression Bandaging Table

17. Compression Stockings Resource List

18. Registered Nurses Association of Ontario Learning Package: Assessment and Management of Venous Leg Ulcers

19. Compression patient brochure

20. Patient Diary

21. Venous and Mixed Venous/Arterial Treatment Algorithm

Compiled by: Waterloo Wellington Integrated Wound Care Program 2015

Waterloo Wellington Integrated Wound Care Program Final May 4, 2016 57 i ii iii