Assessment and management of older people with venous leg ulcers
CPD    

Free Assessment and management of older people with venous leg ulcers

Marie Todd Lymphoedema clinical nurse specialist, Specialist Lymphoedema Clinic, NHS Greater Glasgow and Clyde, Glasgow, Scotland

A venous leg ulcer (VLU) is defined as the loss of skin below the knee on the leg or foot in the presence of venous disease, which takes more than two weeks to heal. The prevalence of VLUs is increasing, especially in older people, which will increase the demand for nursing care. Development of a lower leg ulcer should trigger immediate assessment of risk factors for chronic venous disease followed by action to identify the cause and initiate treatment, which should prevent progression to more complex and chronic problems. Justification for choice of appropriate wound management and application of compression therapy should be based on the assessment and diagnosis.

Management of patients with VLUs can be cyclical and lifelong, which highlights the importance of helping patients to understand the rationale for management strategies so that cooperation in self-care is achieved.

Nursing Older People. 30, 5,39-48. doi: 10.7748/nop.2018.e1004

Correspondence

Marie.Todd@ggc.scot.nhs.uk

Peer review

This article has been subject to external double-blind review and has been checked for plagiarism using automated software

Conflict of interest

None declared

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Published in print: 26 July 2018

Aim and intended learning outcomes

The aim of this article is to help you understand the assessment and management of venous leg ulcers (VLUs) in older people. After reading this article and completing the time out activities you should be able to:

  • » Define what is meant by a VLU.

  • » Identify the risk factors for development of a VLU.

  • » Discuss the importance of assessment before the application of compression.

  • » Outline the principles of skin care in older people with chronic venous disease (CVD).

  • » Discuss how important patient engagement is and how you can support ongoing concordance with management of VLUs in your patient group.

Relevance to The Code

Nurses are encouraged to apply the four themes of The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives to their professional practice (Nursing and Midwifery Council (NMC) 2015). The themes are: prioritise people, practise effectively, preserve safety, and promote professionalism and trust. This article relates to The Code in the following ways:

  • » The Code states that nurses must recognise and respect the contribution that people can make to their own health and well-being. This article highlights the importance of promoting a self-care approach to managing CVD in the long term.

  • » The Code requires nurses to keep clear and accurate records relevant to their practice. This article emphasises that all data from the assessment of a patient with a VLU should be recorded, dated and signed.

  • » Management of VLUs may involve debridement, which requires the expertise of an experienced nurse who has the required clinical competencies. The Code states that nurses must recognise and work in the limits of their competence by asking for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the limits of their competence.

  • » This article explores prescribing for the management of VLUs. The Code requires that nurses advise on, prescribe, supply, dispense or administer medicines within the limits of their training and competence, the law, NMC guidance and other relevant policies, guidance and regulations.

Introduction

A VLU is defined as the loss of skin below the knee on the leg or foot in the presence of venous disease, which takes more than two weeks to heal (National Institute for Health and Care Excellence (NICE) 2015a) (Figure 1). Various time periods are used to define ‘chronic’, but because of the need to expedite accurate diagnosis and appropriate interventions, NICE (2015a) defines chronic ulcers as those that remain unhealed after four weeks. Ulceration is caused by sustained venous hypertension as the result of chronic venous insufficiency (CVI) and/or an impaired calf muscle pump. VLUs are usually located in the gaiter area between the ankle and calf, usually on the medial aspect of the leg, and there are often chronic fibrotic and inflammatory skin changes in the presence of CVD (Scottish Intercollegiate Guidelines Network (SIGN) 2010, Agale 2013). The ulcer is often the result of minor trauma to the area, such as skin tears, knocks and bumps, and because of the chronic reduction in the supply of oxygen and nutrients, the healing process is delayed.

Figure 1

Venous leg ulcer

nop_v30_n5_19_0001.jpg

The clinical picture of chronic VLUs is often one of cyclical healing and recurrence, especially in older people (SIGN 2010). VLUs are common with an estimated prevalence of between 0.1–0.3% in the UK. They account for 60–85% of all leg ulcers (NICE 2015a). Researchers demonstrated that 1.5% of the adult population (730,000) in the UK presented with ulceration in the study year, resulting in a significant economic burden to the NHS (Guest et al 2015). In Scotland, the number of people aged over 65 is projected to be 63% greater in 2031 than in 2006; for those aged over 75, the projected increase is 83% (Scottish Government 2010). Therefore, the incidence of VLUs is also expected to rise. Furthermore, many older patients have co-morbidities that compound the problem, for example, obesity, diabetes and cardiovascular disease.

The chronicity of VLUs in terms of healing, duration and recurrence means that treatment and associated co-morbidity are estimated to cost the NHS £1.8 billion per year, and they account for 13% of all district nursing visits (Simon et al 2004, Guest et al 2015). While 93% of VLUs are likely to heal within 12 months, 7% remain unhealed after five years, and as many as 70% recur within three months after healing (Franks et al 2016). The long-term physical, psychological and social costs to patients are just as significant. A rising older population, coupled with an age-related increase in the prevalence of VLUs and compounding chronic polymorbidity, will have implications for nurses in all areas of practice in terms of recognition, assessment and management. These implications are most relevant for nurses in services specialising in the care of older people.

Anatomy of the venous system in the lower limbs

The venous system in the legs comprises superficial and deep veins connected by the perforating veins, so called because they ‘perforate’ the fascia that encapsulates the leg muscles (Meissner 2005) (Figure 2). The superficial veins consist of the great and small saphenous veins, while the deep veins are the femoral, popliteal, and anterior and posterior tibial veins. The pressure of venous blood flow is far less than arterial flow. This means that, especially in the lower limbs where venous blood has the greatest distance to travel back to the heart, there is hardly enough pressure to compensate for the gravitational force. Backflow into the distal veins is prevented by unidirectional valves in the lumen of many of the veins, especially in the limbs. In the legs, the valves are operated mainly by the action of the calf muscle. As skeletal muscles contract they squeeze the veins passing through them, which increases the venous blood pressure. This causes the valves to open and the increased pressure forces the blood forward proximally. Relaxation of the muscles causes the valves to close and backflow is prevented (Tortora and Grabowski 2000) (Figure 3).

Figure 2

Venous anatomy of the leg

nop_v30_n5_19_0002.jpg

Picture credit: Peter Lamb

Figure 3

Normal valve function of the leg

nop_v30_n5_19_0003.jpg

Picture credit: Peter Lamb

Box 1

Skin changes associated with chronic venous disease

  • » Dry skin

  • » Atrophie blanche – tiny, white, scarred areas thought to be caused by poorly vascularised tissues. They are painful and susceptible to trauma

  • » Hyperkeratosis – thickening of the skin causing dry or waxy scales that vary in colour from yellow to brown

  • » Venous eczema – this can be wet or dry

  • » Papillomatosis – small, blister-like protrusions on the skin caused by back pressure on the lymphatic system

  • » Lymphorrhoea/exudate – if there is oedema and a break in the skin, fluid can leak onto the surface of the skin. This is often called ‘wet legs’ and can cause moisture dermatitis or maceration

  • » Lipodermatosclerosis – fibrosis and induration of the skin giving a ‘woody’ feel especially around the ankle. Progressively results in an inverted champagne bottle shape to the legs of a long narrow neck and a larger ‘body’

  • » Red legs – caused by chronic inflammation and fibrosis, usually bilateral and not to be confused with cellulitis which is almost never bilateral

  • » Haemosiderin staining or hyperpigmentation – caused by escape of iron-containing blood from the veins into the tissue spaces, which results in brown staining of the limb

(Bianchi 2013, Salmon 2016)

Aetiology

CVI is the main cause of ulceration (Wounds UK 2016). When prolonged periods of standing or immobility occur, there is little calf muscle pump activity (Meissner 2005). This, and the protracted gravitational effect, causes pooling in the distal veins, which leads to venous hypertension and inefficient valvular action. In some patients there is normal muscular activity but due to hereditary or ageing factors there is valvular incompetence. If the valves in the perforator veins are ineffective, blood is forced back into the superficial veins (venous reflux) (Figure 4), which results in raised pressure in these vessels (venous hypertension). Chronic pooling in the veins causes overstretching and loss of elasticity, which means the valves cannot close properly and results in the development of varicose veins. Superficial veins are more vulnerable than the deep veins due to the lack of surrounding muscular support. Over time this leads to chronic inflammatory changes in the superficial and deep layers of the skin (Box 1), and if minor injury or trauma occurs it can lead to the development of a VLU. The presence of swelling and chronic inflammatory changes results in delayed healing. Several factors can increase the risk of developing a VLU (Box 2).

Time out 1

Patient profile

Write a short profile of a patient who you have cared for with a VLU, drawing on the information in Boxes 1 and 2. How important is the patient history? How complex was the assessment?

Figure 4

Effect of valve damage on venous flow

nop_v30_n5_19_0004.jpg
Box 2

Risk factors for developing a venous leg ulcer

  • » Obesity or being overweight – increases the pressure in the leg veins, can lead to reduced mobility and/or sleeping in a chair and, in morbid obesity, a large abdominal apron that rests on the legs when sitting can act as a tourniquet which adds to the pressure in the leg veins

  • » Reduced mobility – venous return relies on the activation of the calf muscle pump during walking

  • » Varicose veins – stretched and enlarged veins compromise the valves allowing backflow of blood

  • » Previous deep vein thrombosis (DVT) – can also damage the valves that affect venous return

  • » Previous injury or surgery to the leg – can reduce mobility, cause DVT, damage the veins and lymphatic system or affect ankle mobility

  • » Family history of venous leg ulcers

  • » Increasing age – older people are more likely to develop conditions that impair mobility, for example, arthritis, stroke or respiratory disease

  • » History of intravenous drug misuse

(NHS Choices 2016)

Assessment and diagnosis

Development of a lower leg wound should trigger immediate assessment of risk factors for CVD followed by action to identify the cause and initiate treatment, which should prevent progression to more complex and chronic problems (Wounds UK 2016). A comprehensive and holistic assessment is a crucial prerequisite to reaching an accurate diagnosis, and should be carried out as early as possible (Wounds UK 2016). The assessment should focus on three areas:

  • » An overall clinical assessment.

  • » Physical examination of the legs.

  • » Assessment of the wound(s).

A clinical assessment should include all aspects of co-morbidity, physical and psychosocial effects of ulceration and outcomes or experience of any previous VLU treatment as this may affect further management (Miller et al 2011). Factors that may affect the management or outcome of treatment should be established, for example, mobility, dexterity, lifestyle issues and willingness to engage in self-care (Box 3).

Box 3

Patient factors that affect concordance with and outcomes of treatment

  • » Mobility – activation of the calf muscle pump will improve venous return

  • » Dexterity – aspects of self-care will require strength and dexterity, for example, applying compression hosiery and carrying out skin care

  • » Lifestyle issues – poor nutritional status, obesity, smoking, sedentary lifestyle/sleeping in a chair will have a negative effect on wound healing and oedema in the legs

  • » Support for self-care – lack of information, poor mobility and dexterity, pain, previous negative experience with VLU treatment and poor family/carer input will inhibit self-care

(Wounds International 2012)

Physical examination of both legs, the ulcer and the feet is essential to ascertain the aetiology of the ulcer and exclude any other local clinical issues that may require intervention, for example, oedema, skin changes, cellulitis and tinea pedis (fungal foot infection). The ability to differentiate between cellulitis and other conditions that result in red and inflamed legs, for example, lipodermatosclerosis, deep vein thrombosis and ‘red legs’, will reduce costly and unnecessary antibiotic prescribing and possible antibiotic resistance (Elwell 2014). Limb size and shape should be recorded to provide baseline data and to determine compression hosiery size and type required if appropriate. It is crucial to confirm or exclude the presence of any peripheral arterial disease (PAD) to ensure an accurate ulcer diagnosis is reached and to allow the application of safe levels of compression. A hand-held Doppler can be used to calculate the ankle brachial pressure index (ABPI) as part of the standard leg ulcer assessment (SIGN 2010) and should be carried out by a competently trained practitioner (Beldon 2010). The ABPI is the calculation of the ratio of blood pressure at the ankle compared with blood pressure in the arms (Vowden and Vowden 2001). An ABPI of less than 0.8 suggests reduced blood supply to the legs, indicating PAD (Wounds UK 2016). It is important to note that this diagnostic test is not used to identify venous disease, but to exclude arterial disease.

Time out 2

Arterial compromise

Discuss why it is important to assess the arterial status of patients before applying compression and the possible outcomes of applying compression to an arterially compromised limb

PAD affects up to 20% of the population aged 60 years and over, and incidence and prevalence increase with age, smoking, diabetes and coronary heart disease (NICE 2012). However, approximately 50% of those with PAD have no symptoms (Dhaliwal and Mukherjee 2007), which highlights the need to include arterial assessment as part of the overall VLU assessment regardless of other forms of arterial assessment (pedal pulses, limb temperature and colour, history of claudication).

Arterial blood is delivered under higher pressure than veins (average mean arterial pressure ranges from 65-110mmHg), making them less likely to be compressed by compression bandaging or hosiery (average pressure delivered at the ankle is 40mmHg and reduces gradually up the limb). Several factors affect the pressure in arteries, for example, cardiac output, compliance of the vessels (the ability to stretch), volume and viscosity of the blood and blood vessel and length, making it important to identify arterial disease before applying compression. However, some studies have shown that compression is beneficial to arterial flow because the venous flow is improved (Mosti et al 2012). Despite evidence to suggest that compression can improve arterial flow, applying inappropriate compression to an arterially compromised limb could result in ischaemia, amputation or even death (Chan et al 2001).

Assessment of the wound and surrounding skin should be carried out using a structured tool, for example, the TIMES checklist (European Wound Management Association 2004):

  • » Tissue (non-viable or deficient) – ascertain the quality of the tissue in the wound, for example, is there slough or necrotic tissue present?

  • » Infection or inflammation – look for signs of infection or presence of biofilm in the wound.

  • » Moisture imbalance – assess exudate consistency and volume to assist with dressing selection.

  • » Edge of wound – VLUs should have shallow or sloping edges. The presence of raised edges may indicate malignancy.

  • » Surrounding skin – check for skin changes, damage from exudate, signs of infection or poor hygiene.

It is important to measure the size of the ulcer as accurately as possible as this will help determine the classification and subsequent level of skill required to carry out management. Using time sequence photographs of the wound is a valuable adjunct to the assessment of wound presentation and progress, and may prevent differences in nurses’ subjective perception of qualitative wound characteristics (Terris et al 2011).

Time out 3

Assessment tools

Review any wound assessment tools you have in your workplace to ensure they cover all the relevant aspects of assessment above. If you do not use any, discuss with your colleagues the possibility of developing one that could be used – you may involve your local tissue viability or leg ulcer specialist team

All data from the assessment should be recorded, dated and signed (NMC 2015). Documenting the presentation and progress of wounds with photography is a helpful visual and measurement tool but patient consent must always be sought to store and use clinical photographs, and only using specific workplace equipment (Bryson 2013).

Categorisation

After diagnosis of the ulcer a categorisation is helpful in developing the care plan and predicting expected outcomes (Harding et al 2015) (Table 1). Using the categorisation shown in Table 1 requires review of ulcer progress at a minimum of four-weekly intervals to gauge any change. Failure to respond to best practice within the four-week period will inevitably mean the ulcer is reclassified as complex, which requires immediate referral to specialist VLU services (Harding et al 2015).

Table 1

Category of ulcer

‘Simple’ venous leg ulcer (VLU)‘Complex’ VLUMixed aetiology ulcer
Ankle brachial pressure index (ABPI) 0.8-1.3
Ulcer area <100cm2
Ulcer present for <6 months
ABPI 0.8-1.3
Ulcer area ≥100cm2
Ulcer present for ≥6 months
Controlled cardiac failure
Current infection and/or history of recurrent infections
Previous non-concordance with treatment
Ulcer has failed to reduce in size by 20-30% at 4-6 weeks despite best practice
ABPI <0.8 or >1.3 (<0.5 requires urgent referral to vascular services)
Symptoms of peripheral arterial disease, for example, intermittent claudication, rest pain, even if normal ABPI results
Diabetes/peripheral neuropathy Rheumatoid arthritis (vasculitic ulcer)
Uncontrolled cardiac failure
Primary care-based management by nurses competent in applying compression therapy (if not available, refer to specialist VLU service)
Healing targets: 12-18 weeks
Refer to specialist VLU service Healing targets: 18-24 weeksRefer to appropriate specialist for further investigation/management, for example, vascular/diabetic/cardiology. May be managed with reduced compression by nurse specialists Healing time: depends on underlying aetiology, comorbidities and lifestyle factors
(Harding et al 2015)

Management

Wound bed preparation and dressing are vital components of VLU management as VLUs are often characterised by moderate to severe levels of exudate and sloughy wound beds. Exudate causes maceration and further skin damage, and slough can harbour infection-producing bacteria, which prevents normal wound healing. Regular good hygiene of the wound and the surrounding skin will remove any debris and maintain a healthy peri-wound area. The wound can be cleansed with drinking tap water (Fletcher and Ivins 2015) and debridement pads or exfoliating gloves are useful in the management of hyperkeratotic skin plaques and mechanical debridement of biofilm.

Dressing prescription will be subject to wound presentation. Simple, non-adherent dressings should be prescribed to protect the wound and absorb any exudate (SIGN 2010). However, moderate to high levels of exudate will require alginate, gelling fibre or foam dressings. Debridement is necessary if the wound is sloughy and some types of dressing will produce autolytic debridement, for example, hydrogels (Harding et al 2015). Sharp debridement is required where there is extensive devitalised tissue and an increased risk of infection. It requires the expertise of an experienced nurse who has clinical competencies in knowledge of anatomy, recognition of viable or non-viable tissue, ability and resources to manage complications such as bleeding, and the skills to gain patient consent (Dowsett and Newton 2005).

Nurses involved in managing patients with VLUs must be aware of the specific properties of wound dressings for use under compression therapy (Activa Healthcare 2013, Harding et al 2015):

  • » Maintain a moist wound environment while able to absorb varying levels of exudate.

  • » Absorb and contain exudate under compression to prevent strikethrough.

  • » Low profile – leaves no indentation on the skin.

  • » Conforms to the wound bed.

  • » Non-adherent.

  • » Comfortable.

  • » Atraumatic removal.

  • » Hypoallergenic.

  • » Remains intact on removal.

  • » Cost effective.

Exudate levels may initially be high, however, successful compression therapy will improve venous and lymphatic return resulting in reduced oedema and inflammation, and subsequently reduce the exudate (Harding et al 2015). Frequency of dressing change should be dictated by frequency of compression bandaging application although initially, consideration may be required for more regular changes in heavily exuding wounds. However, selection of appropriate wound dressing products should allow optimal compression delivery for up to seven days.

In the area surrounding the VLU there may be changes in the skin that can be local to the VLU or affect the whole lower limb (Box 1). The skin should be reviewed often for any changes and managed appropriately. Washing with soap and water can alter the skin’s pH level, which affects the normal bacterial flora and increases the risk of colonisation by pathogenic organisms. Soap also removes the natural lipids on the skin’s surface, which can irritate and dry the skin resulting in itching. Soap substitutes cleanse the skin effectively without affecting the acid mantle and causing dryness.

Time out 4

Skin health

Reflect on how you assess and promote good skin health in your patients. Identify any areas that could be improved

The natural ageing process results in dry, fragile and thinner skin. Emollients are an important aspect of promoting skin health and reducing the risk of loss of integrity (Carville et al 2014). Twice-daily application of moisturiser after bathing is recommended, directly onto the skin and massaged in the direction of hair growth. This will help minimise the possibility of blocking the hair follicles and causing folliculitis (Penzer and Ersser 2010). Nurses must be mindful of the pressures applied in cleansing and moisturising fragile skin as too much force may cause tears or bruising.

Dry and hyperkeratotic skin can be treated effectively by gentle exfoliation (Wounds UK 2015), eczema should be treated with topical steroid therapy, and compression therapy will help reduce fibrotic skin changes (Wounds UK 2016).

Compression therapy

The application of compression is the gold standard treatment for VLUs (SIGN 2010). It should only be applied after a comprehensive assessment and by skilled practitioners. Compression therapy should be started as soon as possible in at-risk patients as it can prevent ulcer development (Wounds UK 2016). The aim of all types of compression is to reduce oedema, heal the ulceration and reverse venous hypertension (Partsch and Junger 2006). This is achieved by:

  • » Facilitating the action of the calf muscle pump.

  • » Preventing venous dilation during walking or standing.

  • » Increasing the velocity of venous blood flow, which prevents trapping of leucocytes therefore reducing inflammation.

  • » Reducing valvular insufficiency, which prevents venous backflow.

  • » Reducing capillary filtration, which decreases lymphatic load.

  • » Increasing interstitial pressure, which results in oedema being reabsorbed into the venous and lymphatic system.

  • » Stimulating lymphatic contractions.

  • » Improving efficiency in blood flow resulting in improved flow of nutrients to the skin, which speeds up ulcer healing.

Optimal compression therapy is applied in a graduated fashion (graduated compression), that is, the maximum pressure is exerted at the ankle and slowly reduces towards the knee. However, some researchers have studied a ‘progressive compression’ method and advocate that applying higher pressures over the calf muscles where most of the venous blood is contained could be a more productive way to enhance venous return (Mosti and Partsch 2012). Further research is required to establish the efficacy in managing patients with VLUs and presently this method should only be used by specialists.

There are various bandaging and hosiery systems available for prescribers and the four-layer system is advocated by guidelines (SIGN 2010). However, the terminology surrounding layers is inaccurate as there will always be some overlap when applying bandages, giving at least two layers of material at any point on the bandaged leg and therefore a single-layer bandage cannot exist.

The term component may be more accurate to describe individual products that are used to create a compression system (World Union of Wound Healing Societies 2008). Stiff, inelastic, multicomponent bandaging systems are preferred as they produce the greatest improvements in venous blood flow and provide higher working pressures and lower resting pressures, making them more comfortable to wear (Wounds International 2013, Harding et al 2015). Multicomponent compression bandaging systems may contain high stiffness (inelastic/short-stretch) and low stiffness (elastic/long-stretch) components. However, when applied to a leg, a multicomponent system usually functions as a high-stiffness system. The individual components include a:

  • » Layer of padding to protect the vulnerable areas and improve the shape of the limb.

  • » Layer(s) of elastic and/or inelastic bandages.

Additionally, compression hosiery kits (Brambilla et al 2013) and Velcro compression wraps (NICE 2015b) can be just as effective (Adderley 2015), although they may not be suitable for heavily exuding wounds (Activa Healthcare 2013). Despite these choices several factors must be taken into consideration when prescribing compression systems (Box 4).

Box 4

Factors that influence choice of compression system

  • » Training and experience of staff

  • » Wound status/amount of exudate

  • » Patient mobility and dexterity

  • » Concordance with treatment

  • » Patient’s lifestyle and work

  • » Level of pain

  • » Access to delivery of service

  • » Level of compression required

  • » Availability of compression systems

(Harding et al 2015)

These considerations must include aspects of patient choice, for example, ability to wear their own shoes, minimal effect on mobility, comfort and aesthetic acceptability. Clinically effective compression provides therapeutic levels of compression, minimal slippage, good anatomical fit and is non-allergenic (Harding et al 2015). Skin fragility and integrity should also be considered as applying compression hosiery may cause damage or pain in some older patients. Compression bandaging can remain intact for up to seven days unless there is a reduction in oedema that may cause slippage, difficulties with discomfort/pain or exudate strikethrough, which will indicate the need for more frequent application.

Once the ulcer is healed preventive strategies should be implemented to avoid recurrence. These should include regular monitoring and support, and prescription of compression hosiery. Hosiery manufacturers use different standards of compression in their garments. Hosiery strength relates to the level of pressure provided by the garment and is measured in millimetres of mercury (mmHg) (Table 2). It is important to be aware of these different standards and compression classes, and to ensure the correct pressure is being applied, for example, if class 1 stockings are to be prescribed are they British, French or RAL (German) class? To avoid confusion, it may be prudent to include the mmHg required in the prescription (Todd 2012). In addition, there is a wide range of compression hosiery available for nurses to prescribe including size, circular or flat knit, with or without toe-cap, variety of colours, with or without silicone bands and ready to wear or custom made. This wide range is helpful in considering patient choice, strength and dexterity, level of mobility, patient size and skin quality. Fitting and prescribing details can be found on the manufacturers’ websites. The involvement of patients in the treatment decision-making process will improve concordance and reduce the cost of unused garments.

Table 2

Differences in compression standards

ClassBritish standardFrench standardGerman (RAL) standard
114-17mmHg10-15mmHg18-21mmHg
218-24mmHg15-20mmHg23-32mmHg
325-35mmHg20-36mmHg34-46mmHg
4N/A>36mmHg>49mmHg
(Hopkins 2008)

Time out 5

Training needs

Examine your skill and knowledge in VLU management – can you identify any training needs that would allow you to improve your practice? You may wish to discuss possible training with your line manager, practice development team and local leg ulcer specialist. Training may be delivered through formal teaching, online training or by shadowing nurse specialists

Self-care approach

CVD is a long-term condition (LTC) and requires a balanced management strategy of clinical intervention and self-care. Self-care is a dynamic and empowered method of LTC management and relies on several factors (Long-Term Conditions Alliance Scotland 2008):

  • » The patient must be willing, health literate and central to the decision-making and delivery process.

  • » The nurse must provide support and information throughout the patient’s journey.

  • » There must be suitable resources to accommodate this approach. While a self-care approach to LTCs can reduce the impact on NHS resources, it is not a cost-free alternative.

The self-care approach for patients to comanage their CVD/ulceration and prevent recurrence involves a multifaceted programme. As the need to wear compression therapy on the leg(s) is lifelong, nurses must continually explain the rationale for treatment choices and the importance of cooperating with agreed treatment goals. For example, there should be a commitment to elevate the legs if prolonged dependency is an issue, and avoid long spells of standing and/or sitting in one position. Regular skin moisturising, smoking cessation, maintaining a healthy weight and cardiac status, good diet, regular exercise and maintaining strong psychological support systems are also vital components of good CVD self-management (Shenoy 2014).

Time out 6

Self-care

Using the case study in time out 1 can you identify any possible barriers to concordance/self-care in an older patient undergoing treatment for VLU? How can you help support this patient to improve his or her ability to participate in self-care?

Some patients are physically or mentally unable to self-manage their condition. For example, washing and moisturising legs, applying compression hosiery and mobilising in bandaged legs can be challenging for older people especially if bending is difficult, they have breathing problems, poor grip and dexterity of the hands and unsafe flooring in the home. Lack of time with nurses, poor communication and lack of understanding also hinder patients’ willingness to carry out self-care (Mayor 2006).

Adhering to the ethos of the chief nursing officer’s framework (Department of Health 2016) will ensure compassion, understanding and high-quality care are the foundation of each patient interaction. It may be that carers or family members are required to support some degree of self-care for those who are unable to do so themselves.

Despite the array of literature highlighting the magnitude of financial and psychosocial effects of CVD and VLU, there is little emphasis on early intervention to prevent progression of CVD to ulceration. Untreated venous disease will progress and more severe signs and symptoms will occur. It is essential that early signs are recognised and appropriate treatment initiated to prevent progression to a more complicated disease state. Nurses must be aware of the disease progression trajectory so that a more efficient and effective treatment plan is put in place.

A venous disease progression tool has been developed to assist nurses in early detection through a comprehensive assessment that leads to appropriate treatment decisions to manage or halt disease progression (Timmons and Bianchi 2008). Nurses are in an ideal position to identify potential venous disease through their everyday encounters with patients, for example, washing legs and feet, giving injections and delivering healthcare advice. Incorporating a joint nurse/patient self-care model to prevent venous disease progression may lead to reduction in VLU incidence. However, as with other lifestyle change strategies, this will require several approaches including adopting behaviour change models.

Conclusion

The increase in the older population resulting in greater numbers of VLUs means that nurses are encountering these patients more often in their daily practice. Despite the significant effect of VLUs on patients, NHS budgets and nurses’ workload, there is little emphasis on preventive strategies. Therefore, early identification and intervention are vital. This requires skill and knowledge in the physiology of the leg especially the possibility of arterial problems, through to how the information gathered from the assessment will give reasoned justification for the type of wound management and compression system chosen. Any gaps in skill and/or knowledge should be addressed to avoid unnecessary prolonged treatment, poor healing rates and high recurrence rates.

Patients have a responsibility to avoid lifestyle choices that cause or compound venous disease, and cooperate in self-care otherwise successful treatment-related outcomes will be reduced. However, this requires a full explanation of the rationale for the care approach and suitable ongoing support.

Time out 7

The Code

Nurses are encouraged to apply the four themes of The Code (NMC 2015) to their professional practice. Consider how assessment and management of older people with VLUs relates to The Code

Time out 8

Reflection

Now that you have completed the article you might like to write a reflective account as part of your revalidation. Guidelines to help you are at rcni.com/reflective-account

Further resources

Related RCNi articles

Related RCNi learning module

References

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