TOP TIPS

Top tips for managing venous leg ulcers

Venous leg ulceration is a significant and complex problem for clinicians to manage. This article provides some best practice management tips to ensure the patient, the A leg ulcer is defined wound, the environment, the resources and the clinician’s as a loss of skin below skills are all taken into account when looking after patients the knee, which takes with venous leg ulcers. more than six weeks to heal leg ulcer is defined as a 8 Skills and knowledge of the loss of skin below the knee, clinicians involved which takes more than 8 Resources and treatment-related Asix weeks to heal (NHS Centre for factors Reviews and Dissemination, 1997) 8 Environmental factors. (Figure 1). 2 ASSESSMENT OF Venous leg ulcers are caused by RISK FACTORS sustained high pressure within For any patient that presents with the venous system of the leg. a new or recurring leg ulcer, the More than half are caused by Royal College of Nursing (RCN) progressive venous reflux, which guidelines (RCN, 2006) suggest that begins as varicose , and the a full clinical history, together with a remainder develop after a deep physical examination be conducted. (Kistner, 2010). It is important to use a structured The key to effective management assessment tool based on the risk is accurate assessment of risk factors identified. Family history of factors to enable the appropriate venous disease or history of varicose diagnosis to be made and the use of veins or can compression therapy to reduce the increase the risk of developing venous venous . In order to ulcers. Any history of phlebitis, trauma achieve this, there are a number of or surgery, which may have damaged important factors to consider. the veins, also increases the risk as can prolonged standing, obesity and 1 HOLISTIC MANAGEMENT multiple pregnancies. Robust risk When managing venous leg ulcers, assessment can lead to a more accurate a holistic approach should be taken. diagnosis, which, in turn, supports This ensures that all relevant factors effective management. are taken into account. Vowden et al HEATHER NEWTON (2008) identified five key factors that SKIN ASSESSMENT Consultant Nurse Tissue Viability, Royal 3 Cornwall Hospitals NHS Trust should be considered in relation to the Skin changes are often found on Truro, UK. progression of healing: the lower leg as a result of a rise in 8 Wound-related factors venous pressure over a prolonged 8 Patient-related factors period of time (Figure 2). These skin

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Venous leg ulcers are caused by sustained high pressure within the venous system of the leg Figure 1. Deep venous leg ulcer.

changes aid diagnosis and lead to one (Stephen-Haynes, 2011). Anyone appropriate management. Brown/ undertaking this procedure should pink pigmentation can be caused be suitably trained in the technique by leakage of red blood cells and as management regimens are often deposits of haemosiderin. The skin based on ABPI results, although can become very dry and itchy and, not in isolation from risk and skin as the pressure rises, more leakage of assessments waste products from the veins occurs, resulting in an eczematous reaction 5 ULCER MANAGEMENT known as gravitational eczema. The There is no evidence to support tissue around the gaitor area can the superiority of any dressing type become thickened as fibrous tissue is over another when applied under deposited in the dermis and fatty layers compression bandaging (SIGN, of the skin. The leg shape subsequently 2010), therefore, it is recommended changes appearance and over time that, where possible, a simple non- can take on the look of an inverted adherent dressing should be used. champagne bottle. Remember that it is the treatment of the underlying cause through the 4 VASCULAR ASSESSMENT use of compression therapy that A thorough patient and skin will ultimately heal the leg ulcer. If assessment can lead the practitioner to the ulcer is clinically infected then a diagnosis, however, it is appropriate antimicrobial dressings important that a Doppler assessment may be of benefit in the short term and or Duplex scan is performed prior if the wound is highly exuding, more to the application of compression absorbent dressings or an increase bandaging or hosiery to exclude the in the frequency of dressing change presence of arterial disease. This would prevent the skin from becoming involves measuring the blood flow in macerated. Attention should be given the of the lower leg compared to the causes of the symptoms in the with that in the upper arm and is first instance. recorded as the ankle brachial pressure index (ABPI). In the absence of arterial 6 ELASTIC COMPRESSION disease, the systolic THERAPY should be equal to or exceed that in The mainstay of venous leg ulcer the arm, giving an ABPI of at least treatment is compression therapy,

32 Wounds Essentials 2012, Vol 1 which aims to reverse venous are achieved using this system and, hypertension. This can be achieved therefore, are suitable for patients with through the application of compression mixed aetiology ulceration and chronic bandages or hosiery. Elastic or oedema, under supervision. Many staff long-stretch bandages, of which find short-stretch bandages easier to the four-layer system is an example, apply than the four-layer system and provide a pressure profile of between they are generally less bulky for patients. 35–40mmHg at the ankle. This pressure can be sustained for a week The bandage should be applied by rolling as the bandages have an ability to it around the leg and ‘tugging’ as it passes accommodate changes in limb shape around the back of the leg to ensure full and movement (World Union of stretch. It is important to remember Wound Healing Societies [WUWHS], that when used on oedematous legs, the Family history 2008). It is important to measure the fluid can reduce rapidly and, therefore, of venous disease ankle circumference prior to bandage the bandages should initially be renewed selection and most bandages are more frequently to control the oedema or history of varicose developed to apply the correct amount veins or deep vein of pressure for an ankle circumference 8 COMPRESSION HOSIERY thrombosis can between 18–25cm (Beldon, 2009). The range of compression hosiery has increase the risk significantly increased over the past 10 of developing Training is required before applying years, with stockings, socks and tights multi-layered compression bandages, now available in both standard and venous ulcers both in the theory of compression made-to-measure sizes. Compression therapy and its practical application. hosiery can be used for primary The shape and size of the limb are prevention of venous complications important factors in achieving the following deep vein thrombosis or in appropriate compression levels to patients with , to prevent heal venous ulcers. Bandages that are recurrence of leg ulcers following inappropriately applied can lead to healing (and more recently to heal pressure necrosis, skin breakdown venous ulcers). and increased pain if too tight, and slow ulcer healing if the pressure is too When used for healing ulcers, it is light. Competence can be improved important to ensure that the correct and maintained through practising pressure is applied using a combination the technique repeatedly on willing of single, multiple layer or specifically subjects. Some patients find that designed two-layer hosiery kits to ensure applying four-layers of bandages is not the pressure is sufficient to achieve practical because they cannot wear healing. Hosiery is available with UK their normal shoes, therefore, staff and European/RAL classification with should be mindful of this when making the European/RAL stockings providing a bandage selection. a higher pressure profile that those from the UK. Evidence suggests that healing 7 INELASTIC COMPRESSION rates improve and recurrence rates THERAPY reduce when RAL hosiery has been These type of bandages are known introduced as part of a comprehensive as short-stretch and, as such, have leg ulcer service (Dowsett, 2011). little extensibility, forming a tube Clinicians need to assess the ability of around the leg rather than a graduated patients/carers to apply their hosiery to compression from the ankle to the ensure effective management. knee. Pressure is exerted against the bandage when the leg or foot is 9 VENOUS SURGERY exercised through movement of the As previously described, underlying calf muscle and the pressures can range superficial venous reflux is often the between 30–60mmHg. Low resting primary cause of leg ulceration. If pressures and high working pressures venous ulcers recur, patients should be

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CONCLUSION Venous leg ulceration is a significant and complex problem for clinicians to manage, as well as having a potentially dramatic effect on patients’ quality of life.

Managing all of the holistic factors detailed in section one will ensure the patient , the wound, the environment, the resources and the clinician’s skills are all taken into account when managing patients with venous leg ulcers. WE

References Any history of Figure 2. phlebitis, trauma or Ankle flare and venous skin Beldon P (2009) Bandaging: which changes. bandage to use and when. Wound surgery, which may Essentials 4: 52–61 have damaged the assessed for the degree of venous reflux Dowsett C (2011) Treatment and veins, also increases and should be considered for superficial prevention of recurrence of ve- the risk as can venous surgery to prevent recurrence nous leg ulcers using RAL hosiery. prolonged standing, (SIGN, 2010). The SIGN guidelines Wounds UK 7(1): 115–19 obesity and multiple show that surgery does not improve Kistner R (2010) Emerging treat- pregnancies ulcer healing rates but does significantly ment options for venous ulceration reduce 12-month recurrence rates after in today’s wound care practice. healing. The ability of patients to wear Ostomy Wound Manage 56: 3–4 compression hosiery greatly affects Lindsey E (2001) Compliance with recurrence rates, therefore, surgery may science: benefits of developing be an alternative for this patient group. community leg clubs. Br J Nurs 10(22): S66–74 10 QUALITY OF LIFE Many patients with venous leg NHS Centre for Reviews and Dis- ulceration go through a cycle of ulcer semination. (1997) Compression healing and recurrence, which can therapy for venous leg ulcers. Ef- influence their quality of life. When fective Health Care 3(4): 1–12 managing a patient with venous leg RCN (2006) Clinical Practice ulcers it is important to explore quality Guidelines. RCN, London of life issues that may be influencing this cycle and introduce measures to Stephen-Haynes J (2011) How to… improve and sustain changes where Top ten tips for Doppler ABPI. possible. Consideration should be Wounds International 2(4) given to pain, both at the dressing SIGN (2010) Management of change and throughout the day. Chronic Venous Leg Ulcers. A National Clinical Guideline. SIGN, The effects of leaking and odour Edinburgh from a leg ulcer should also not be Vowden P, Apelqvist J, Moffatt C underestimated and increasing dressing (2008) EWMA Position Document. changes and treating infection can make Hard-to-heal wounds: a holistic ap- a difference to quality of life. Social proach. MEP, London isolation can also have a major impact on a person’s life and an important part WUWHS (2008) Principles of Best of managing leg ulceration should focus Practice: Compression in venous leg on the psychosocial aspects of living ulcers. A consensus document. MEP with a venous leg ulcer (Lindsey, 2001). Ltd, London

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