LEG ULCER MANAGEMENT GUIDELINES

LEG ULCER MANAGEMENT GUIDELINES Aim To ensure a standardised approach for the management of individuals with leg ulcers within Derby City PCT Background/Evidence Individuals with leg ulcers have much in common with patients with other chronic diseases. This may include social isolation, loss of income and reduced self esteem (RCN, 2006) Leg ulceration is a common condition and it represents a huge workload for community nursing teams. In 2002, Johnson estimated that leg ulceration currently affects 580 000 individuals in the UK at any one time and costs approximately 300-600 million per annum It is important to carry out an accurate and detailed assessment of every leg ulcer to diagnose the aetiology as this in turn will determine the most appropriate treatment. Venous leg ulcers are the most common form of leg ulcers accounting for up to 70 % of all leg ulcers. Venous pressure is raised as a result of venous damage (e.g Deep Vein Thrombosis or varicosities) this results in capillaries becoming distorted and more permeable allowing larger molecules than normal to pass into the extra vascular spaces. This can be contributory to skin breakdown or delayed healing in accidental injuries to the skin. (Vowden and Vowden, 1998) A significant number of ulcers (about 20%) are caused by some form of arterial disease (Thomas, 1997). Arterial, or ischaemic ulcers, are caused by failure of, or reduction in, the nutritional blood supply to the skin. Vowden and Vowden (1998) point out that this is often due to atherosclerosis, embolism or vascular spasms. Other ulcers include those of diabetic, malignant or vasculitic nature and as such need to be assessed and treated with caution. For patients with venous disease, the application of graduated external compression can help to minimise or reverse the skin and vascular changes described previously, by forcing fluid from the interstitial spaces back into the vascular and lymphatic compartments (Thomas, 1997) Graduated compression hosiery is accepted as an integral part of the management of venous leg ulcers, both as an active treatment for healing of ulcers and having an essential role in the prevention of venous ulcer recurrence. (Johnson, 2002) Thomas(1997) highlights that pressures of around 40 mmhg at the ankle are widely quoted in the literature for the prevention or treatment of venous leg ulcers. However, it must be stressed that patients are assessed individually and holistically to determine the pressure of bandages that they may be able to tolerate. For leg ulcers which are found to be of an alternative nature to venous ulcers, there is often a more complex need for investigation before deciding on an appropriate management plan. Page 1 of 14

Clinical Speciality Wound care Intended Users These guidelines are intended for use by appropriately qualified nurses within Derby City PCT Target Population These guidelines are intended to benefit all individuals presenting with leg ulceration within Derby City PCT Definition A leg ulcer is a loss of skin below the knee or on the foot which takes longer than six weeks to heal Dale et al (1993) Indications for use These guidelines should be followed for all community patients, including those treated within leg ulcer clinics and those who are nursed within the home setting Contraindications None Cautions Special care should be taken with children presenting with leg ulceration and specialist advice should be sought Community considerations All ambulant individuals with venous ulcers of more than six weeks duration should be referred to their local leg ulcer clinic for the most appropriate treatment References Dale, J et al (1995) The anatomy and physiology of the circulation of the leg. In : Callum, N and Roe, B (1995) Nursing Management a research based guide. London : Scutari Press Johnson, S (2002) Compression therapy in the prevention and treatment of venous leg ulcers www.worldwidewound.com Royal College of Nursing (2006) Clinical practice Guidelines : The nursing management of venous leg ulcers. London : RCN Thomas, S (1997) Compression bandaging in the treatment of venous leg ulcers www.worldwidewounds.com Page 2 of 14

Vowden, K and Vowden, P ( 1996) Peripheral arterial disease an update on epidemiology, pathology and aetiology of vascular disease. Journal of wound care June Vol 1 pp 23-26 Vowden, K and Vowden, P (1998) Leg ulcer assessment : The key to identifying ulcer aetiology and instigating successful treatment Educational leaflet Wound Care Society Vol 5 No 3 Written by Trina Parkin Tissue Viability Clinical Specialist Nurse Derby City PCT Ruth Le Bosquet Tissue Viability Clinical Support Nurse Derby City PCT PROCEDURE Training / Education Health care professionals treating individuals with leg ulcers must have undergone appropriate training and demonstrate competence in leg ulcer management Leg ulcer training is available through the leg ulcer management module, through the leg ulcer training programme within Derby City PCT or from suitably trained peers who are are willing to accept accountability for the training. Training should include : Pathophysiology of leg ulceration Leg ulcer assessment Use of assessment tools including Doppler ultrasound to measure ABPI Stages of wound healing (normal and abnormal) Compression therapy Dressing selection Skin care and use of emollients Health education Preventing recurrence Criteria for referral for specialist assessment Health care professionals with recognised training in leg ulcer RATIONALE The RCN (2006) state that there is no National guidance on what constitutes adequate levels of training for nurses involved in leg ulcer care. Therefore, the nurse conducting the assessment must feel confident and competent in the assessment and management of leg ulcers in order to take accountability for the care of each individual patient Page 3 of 14

care should cascade their knowledge and skills to professionals awaiting leg ulcer training Health care professionals are accountable for their own practice following training and updates Holistic assessment Leg ulcer assessment should take into account a full holistic assessment, and never be based on individual aspects alone Language barriers should be overcome with the use of interpreter services Cultural beliefs must be acknowledged during the assessment process with particular regard to the removal of clothing for assessment purposes. A family member should also be invited to attend the assessment procedure Patient assessment All individuals with a wound below the knee of more than six weeks duration should have a full holistic assessment completed using the leg ulcer assessment document (See Appendix I) The assessment must be completed on the leg ulcer assessment / referral document in Derby City PCT district nursing records. All sections of the form must be completed The assessment document should accompany the patient with any referral in relation to their leg ulcer A full clinical history should be taken on all individuals presenting with either their first leg ulcer or a recurrent leg ulcer The following data should be recorded on leg ulcer The certificate obtained from the local leg ulcer clinics is for attendance only and shows the health care professionals competence at that point in time Diagnosis of aetiology should not be made in isolation of individual factors, especially on the basis of Ankle Brachial Pressure Index (ABPI) readings To promote equality, dignity and respect To promote equality, dignity and respect To allow appropriate intervention at an early time To promote standardised approach and maintain record keeping standards To promote continuity of care To ascertain the underlying aetiology and prescribe appropriate treatment plan It is important to recognise the nature of an ulcer as treatment varies according to Page 4 of 14

assessment document, and may be indicative of venous disease : Family history of ulceration Varicose veins History of deep vein thrombosis History of phlebitis History of surgery or fractures to the leg History of pulmonary embolus The following data should be recorded on leg ulcer assessment document, and is indicative of non -venous aetiology : Heart disease Stroke Transient ischemic attacks Diabetes mellitus Peripheral vascular disease Intermittent claudication Cigarette smoking Rheumatoid arthritis Ischaemic rest pain The person performing the assessment must be aware that a leg ulcer may be due to venous or arterial disease, mixed aetiology diabetes, rheumatoid arthritis or malignancy Clinical investigations should include blood pressure, weight and urinalysis Individuals pain levels should be assessed using the pain score on leg ulcer assessment document Leg ulcer assessment Both legs should be examined and observed for the following : Oedema Skin maceration Eczema Brown staining Atrophie blanche Cellulitis This must be documented on leg ulcer assessment form The location, size and underlying aetiology To ensure correct diagnosis and swift treatment To establish any underlying medical problem To ensure appropriate pain management plan is addressed These are signs of venous disease To allow accurate assessment and reassessment To allow accurate assessment and Page 5 of 14

measurements of ulcer should be documented on leg ulcer assessment form A photograph and/or mapping should be obtained at initial assessment, and mapping undertaken every 4 weeks until healed. Prior to mapping onto an acetate leg ulcers should be covered with cling film. A fine permanent marker pen should be used to outline the inner aspect of the wound edges. Patient details and date taken must be recorded on the acetate. Refer to Derby City PCT consent to wound photography guidelines. A monofilament sensory test should be performed and recorded on leg ulcer document. The monofilament should be used to touch all areas of foot as marked on leg ulcer assessment document and any areas without sensation should be documented and referred on as necessary. Skin assessment Skin observation is essential and must always be included in the assessment Individuals with darkly pigmented skin should be examined for the additional factors of heat, warmth, induration or differing colour tones Skin contact sensitivity should be identified on the leg ulcer assessment document and referral made for patch testing or dermatological opinion where appropriate Vascular assessment All individuals presenting with an ulcer should be assessed for arterial disease using Doppler ultrasound to detect Ankle reassessment To allow accurate assessment To monitor healing or deterioration To reduce the risk of cross infection Patients must consent to have wound photo taken for the purpose of reassessment To detect any neuropathy which may indicate arterial or diabetic aetiology Skin observations can indicate the aetiology of a leg ulcer Assessing individuals with darkly pigmented skin needs to take into account additional factors for a thorough assessment Patch testing is necessary to check for reactions to products which may be causing the skin damage Compression applied to legs with arterial insufficiency could result in pressure damage, limb ischaemia and even amputation. RCN (2006) Page 6 of 14

Brachial Pressure Index Refer to Derby City PCT guidelines on using Doppler ultrasound to obtain ABPI Doppler ultrasound should also be undertaken : If an ulcer is deteriorating If an individual presents with recurrence Before recommencing compression therapy When individuals are included in the maintenance programme after ulcer healed As part of ongoing assessment Leg ulcer clinics All ambulant individuals with suspected venous ulcers should be referred to their local leg ulcer clinic: Kingsmead clinic, Revive clinic or Pear tree clinic ( Clinic information is regularly updated on the Derby City PCT tissue viability website) All referrals should be completed on the leg ulcer assessment document and forwarded to the appropriate clinic Housebound individuals must receive the same standards of care by the district nurse as those attending leg ulcer clinic settings. This is ensured by those nurses attending leg ulcer clinics for regular updates As part of the ongoing training programme, community nursing staff manage the local leg ulcer clinics on a rota system. Provider services management are responsible for developing and managing staff rotas. The Tissue Viability Specialist Team are responsible for the To ensue appropriate procedure is adhered to To detect any deterioration or improvement in arterial blood supply To promote equitable, standardised care Research studies indicate that not only is treatment provided at dedicated leg ulcer clinics cost effective, there are also the additional benefits of improving quality of life (Vowden and Vowden, 1996) To ensure that clinic leaders have patient details and thorough patient history to enable an accurate assessment and treatment plan To promote equitable care Nurses must attend to help in clinics on a regular basis to update their current skills and knowledge To maintain high standards within the clinics and audit Page 7 of 14

development and monitoring of standards within the leg ulcer clinics (See Appendix I) Chaotic lifestyles complex wound care clinics Service users with chaotic lifestyles are initially assessed within an environment appropriate to their needs, these include Bradshaw clinic, Padley Centre and working women clinic Service users should then be referred to an appropriate clinic environment such as local leg ulcer clinic Specialist referral Specialist medical referral may be appropriate for : Treatment of underlying medical problems Ulcers of non venous aetiology including diabetic and vascultic ulcers Suspected malignancy Reduced ABPI Increased ABPI Unexplained deterioration in ulcer Ischaemic foot Vascular referral should be considered for individuals with ABPI below 0.8. The leg ulcer referral pathway on the leg ulcer assessment document should be consulted for referring patients (See Appendix III) Patients should not be referred for specialist opinion using the ABPI in isolation. Advice should be sought from the Specialist Tissue Viability Team to ensure that vascular referral is appropriate. Management of ulcer All treatment plans should be developed in agreement with the individual and consent obtained To encourage equity of care To enable a more thorough, accurate assessment of the patient To establish or rule out arterial disease and possible contraindicatons for compression therapy To prevent inappropriate referrals This will allow patients to make informed choices about their treatment Page 8 of 14

as per Derby City PCT policy The leg with the ulceration should be washed in a bucket of tap water at body temperature, which is lined with a polythene bag Following skin assessment, prescribed emollients should be thinly and liberally to the skin using downwards strokes Primary wound dressings should be selected using the Derbyshire wound formulary 2008. Specialist advice should be sought for more complex wound dressings Graduated multi layer compression therapy should be the first line treatment for uncomplicated venous leg ulcers Cultural and religious beliefs should be taken into account when deciding on compression therapy Graduated compression should provide: Adequate padding for protection Adequate compression Sustained compression for up to week It is not necessary to change compression bandage systems more than weekly unless there is: Strike through of excessive exudate Excessive discomfort Slippage of the bandage Obvious contamination There are other compression systems available that can be considered following holistic assessment. Suitable training/advice should be sought before applying such systems The compression system should only be applied by a trained practitioner Evidence for use of tap water available from www.cochrane.org/reviews/en/ab003861. hmtl. If the temperature of the tap water is reduced this may delay the healing process To promote hydration and protection of the skin To prevent folliculitis To ensure dressings are selected with proven performance and cost effectiveness Studies have proven that compression is the most appropriate therapy for venous leg ulceration Some forms of religious worships require individuals to be barefoot for prayer Four layer bandaging system remains the gold standard of compression treatment, however treatment should be based on individual circumstances Frequent dressing changes may interfere with the natural wound healing process To prevent bandage problems such as skin damage and bandage slippage and to ensure correct level of compression is applied Page 9 of 14

Leg ulcer pain should be assessed and recorded at regular intervals and an effective management plan developed After Care Reassessment, including reassessment of ABPI, should be tailored to meet the needs of the individual and professional judgement of the nurse. RCN (2006) The leg ulcer clinics will only take responsibility for the after care of individuals whose leg ulcers have been healed within the leg ulcer clinics It is recommended that the ABPI is reassessed between 3 and 12 months after the ulcer has healed. The RCN recommend best practice as every 3 months, however, individual circumstances should be taken into account by the responsible practitioner The holistic reassessment should be recorded on the Derby City PCT reassessment document and all areas must be completed. Previous reassessments must be made available within patients notes During reassessment it must be ensured that the prescribed hosiery is still appropriate and patient education should be reinforced A further follow up reassessment date should be provided Unless compression hosiery therapy is monitored and adhered to, then reoccurrence of the ulcer is likely. RCN (2006) indicate that there can be a reduction in the ABPI due to arterial insufficiency that can become apparent between 3 and 12 months To promote continuity of care To enable comparison of previous data To ensure reassessment is a continuous process Page 10 of 14