Housekeeping 15/03/2016. Tissue Viability Intranet page LEARNING OBJECTIVES. Priorities in leg ulcer management. Tissue Viability Updates

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Doris Gallagher
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Compression therapy & management of leg ulcers 2016 Housekeeping Tissue Viability Updates 4 T.V. MODULES each ½ day.

complete Modules 1,2,3 every 3 years Module 4 yearly.levels 1 or 2 according to manager.

referral forms Preferred prescribing list - products for evaluation Tissue viability link group sessions Training dates and slides from presentations Wound

understand the importance of skin management To understand the theory & different types of compression therapy Be aware of potential complications of

1 Compression therapy & management of leg ulcers 2016 Housekeeping Tissue Viability Updates 4 T.V. MODULES each ½ day. Leg ulcer assessment, Compression therapy, Wound assessment and management, and Prevention of Pressure Ulcers All new staff to complete Existing staff to complete Modules 1,2,3 every 3 years Module 4 yearly.levels 1 or 2 according to manager. Carers training- level 1 basic prevention Tissue Viability Intranet page Wound management guidance Pressure ulcer guidelines Leg ulcer guidelines Contacts and referral forms Preferred prescribing list - products for evaluation Tissue viability link group sessions Training dates and slides from presentations Wound Clinic information - opportunity to attend wound clinic Follow us on Professionals link External to CWPT link LEARNING OBJECTIVES To understand the importance of skin management To understand the theory & different types of compression therapy Be aware of potential complications of compression therapy Participate in practical demonstation of compression therapies Priorities in leg ulcer management Correct the underlying cause Create optimum wound environment Improve wider factors that may delay healing Prevent avoidable complications Promote or maintain healed tissue Leg Ulcers 1

Look After the Whole Leg.. Essential Skin management Varicose eczema / Dry skin / Mature skin / Allergy/Irritancy Maintenance of skin integrity /Exudate management Skin Cleansing.

. Emollient therapy Protection / Avoidance Active treatments Maintenance Skin Cleansing - Aims To remove cellular debris and exudate from the wound bed - may assist in reducing bacterial burden Not

comfort Clean technique Lined bucket Tap Water Warm not hot Bath emollient Soak max 10 mins Wash limb Soap substitute Gently lift dead skin Pat skin dry do not rub Skin Hydration Emollient therapy

2 Look After the Whole Leg.. Essential Skin management Varicose eczema / Dry skin / Mature skin / Allergy/Irritancy Maintenance of skin integrity /Exudate management Skin Cleansing..Emollient therapy Skin Hydration.. Emollient therapy Protection / Avoidance Active treatments Maintenance Skin Cleansing - Aims To remove cellular debris and exudate from the wound bed - may assist in reducing bacterial burden Not just WATER Skin Cleansing To remove dead (dry, flaky) skin To remove / minimise excess exudate from skin surface Remove previous topical therapies & dressing materials Increase skin hydration Patient comfort Clean technique Lined bucket Tap Water Warm not hot Bath emollient Soak max 10 mins Wash limb Soap substitute Gently lift dead skin Pat skin dry do not rub Skin Hydration Emollient therapy Definition: Moisturiser which stays on the skin reducing scaling and water loss Davis, R.(2001) Anti Microbial (containing antiseptic e.g Benzalkonium chloride) Anti Pruritic (containing lauromacrogols) Surfactant stabilise water oil mix Humectant helps to retain moisture Low irritancy Hydrating agents (varying strengths of Urea) Emulsifying agents NPSA Increased risk Risk of Fire with Paraffin products Application of leave-on emollients Apply directly to the skin Apply liberally Apply frequently or when gaining access to limb Avoid vigorous rubbing After any bathing/ cleansing always apply an emollient (within 3-5 mins). Do not stop once condition is controlled - emollient therapy will help to prevent future exacerbation s Apply in the direction of hair growth 2

3 Avoidance Why Topical Steroids? Sustained contact with exudate Contact with potential allergens To gain control of the symptoms and signs of skin disease Dehydration of skin Achieve maximum efficacy with minimal side effects Prolonged untreated inflammation Trauma to fragile skin / Newly healed wound Action of Topical Steroids Topical Steroid Preparations Anti-inflammatory Immunosuppressive Vaso-constrictive Anti-mitotic - decrease proliferation Readily penetrate the dermis Reduce inflammation, make the skin less red sore and itchy, and they speed up healing Ointments Creams Gels Lotions Mousse Tape Steroid only Steroid / antibiotic combinations Steroid / antifungal combinations Steroid / antifungal & antibiotic combination Steroid / Vit D derivative Steroid potencies Which steroid - factors to consider Group I. Group II. Group III. Group IV. Mild e.g. Hydrocortisone 1% OTC (over the counter) Mod (1 X OTC) e.g clobetosone butyrate Potent e.g betametasone dipropionate prescription only Very potent e.g clobetasol propionate prescription only Age/ Potency = adult, adolescent or child. Site = Absorption increased at certain sites Extent = localized or generalized Relative potencies compared to Hydrocortisone 1% (Grp I) Group x stronger Group 3-10 x stronger Group 4-50 x stronger Base = reduction of sensitizers / concordance. Wet / Dry Method = frequency of application / occlusion Experience of use = dexterity 3

4 Which steroid - factors to consider Absorption Rates Age/ Potency = adult, adolescent or child. Site = Absorption increased at certain sites Extent = localized or generalized Base = reduction of sensitizers / concordance. Wet / Dry Method = frequency of application / occlusion Eyelids and genitals absorb 30% Face absorbs 7% Armpit absorbs 4% Forearm absorbs 1% Palm absorbs 0.1% Genitals absorb 30% Sole absorbs 0.05% Experience of use = dexterity Finger Tip Unit 4

Compression history Compression bandaging has a history stretching back to the times of ancient Egypt Simple woven fabrics were often coated with adhesives, resins & medicaments

published a letter in The Lancet recommending the use of compression bandages in the management of varicose veins 1988 - Development of 4-layer compression bandage system at

brachial systolic pressure Doppler Readings 1.0 1.3 mmhg Normal Venous 0.8 1.0 mmhg Slight Arterial Impairment 0.6-0.8 mmhg Degree of arterial disease mixed ulceration 0.

5 Compression history Compression bandaging has a history stretching back to the times of ancient Egypt Simple woven fabrics were often coated with adhesives, resins & medicaments Pierre Dionis (17 th Century ) recommended rigid lace up stockings for the treatment of leg ulcers The first elastic bandages were manufactured mid 19 th century Callender published a letter in The Lancet recommending the use of compression bandages in the management of varicose veins Development of 4-layer compression bandage system at Charing Cross Hospital based on Stemmer s Theory DIAGNOSIS + ASSESSMENT Holistic assessment Ankle Brachial Pressure Index (ABPI) Highest ankle systolic pressure ABPI = Highest brachial systolic pressure Doppler Readings mmhg Normal Venous mmhg Slight Arterial Impairment mmhg Degree of arterial disease mixed ulceration 0.6 > Arterial Available treatments Venous Leg Ulcer Compression therapy Mixed Aetiology Seek advice Surgical treatments Varicose vein stripping Sclerotherapy Microablation Arterial Aetiology No Compression 5

6 Compression therapy Getting effective compression also leads to decrease in pain, increased mobility and generally better quality of life after ulcer has healed. It also impact on cost in NHS as it is seen as highly cost effective if done correctly EWMA 2003 Functions of compression External application of compression bandages impact on the haemodynamic and lymphatic functions of the lower limb Reduces vein diameter - improves valve function Reduces venous reflux Increases blood flow and venous return Reduces oedema - improves the re-absorption of interstitial fluid Significantly improves the venous pump (calf muscle and foot) Accelerates blood flow Reduces risk of stasis Improves lymphatic function Reduces oedema Improves skin condition Reduces friability / risk of ulcer HOW DOES COMPRESSION WORK? LAPLACE S LAW C T P = T N c (4630) CW P = sub bandage pressure T = bandage tension N = number of layers applied c = constant C = circumference of the limb W = bandage width W La Place's law states that sub-bandage pressure (P) is directly proportional to bandage tension (T) and inversely proportional to the circumference (C) of the limb to which it is applied. (Blair et al, 1988) GRADUATED COMPRESSION Graduated compression is when the bandages are applied at the correct compression up the leg The pressures fall as the circumference of the leg increases Providing the bandage is applied according to manufacturer instruction 20 mmhg 30 mmhg 40 mmhg ASSESSING THE LIMB Prior to applying compression you would assess the following: Skin condition Leg shape Observe pressure sites Ankle circumference Patient concordance Level of exudate 6

UNNATURAL LEG SHAPES Shaping the limb A natural shape leg is essential for

can be categorised in different ways: Long Stretch Bandages (LSB) Elastic

indicated for immobile patients as squeezes the leg Short Stretch Bandages

muscle activity pressing against the bandage Multi-layer Bandages (MLB)

inelastic bandages Maintains a medium resting pressure Give constant

(Riverside project,1988) FOUR LAYER BANDAGING Sub Bandage Wadding Wadding

Bandage (up to 20 mmhg) Layer 4 Cohesive Bandage Up to 20 mmhg K4 System

7 UNNATURAL LEG SHAPES Shaping the limb A natural shape leg is essential for correct compression bandaging Compression Bandage Types Compression bandages can be categorised in different ways: Long Stretch Bandages (LSB) Elastic Maintain pressure even when patient at rest Low SSI <10 Particularly indicated for immobile patients as squeezes the leg Short Stretch Bandages (SSB) Inelastic Pressure rapidly dissipates High SSI >10 Dependent on calf muscle activity pressing against the bandage Multi-layer Bandages (MLB) Original compression bandage system Uses a combination of elastic and inelastic bandages Maintains a medium resting pressure Give constant sustained graduated compression up to 7 days Layer 1 Layer 2 Layer 3 (Riverside project,1988) FOUR LAYER BANDAGING Sub Bandage Wadding Wadding Light Support Type 2 bandage Bandage Light Compression Type 3a bandage Bandage (up to 20 mmhg) Layer 4 Cohesive Bandage Up to 20 mmhg K4 System REDUCED COMPRESSION Used for patient with a mixed aetiology ulcer Used with patients who cannot tolerate 4 layer and Plus or 7

TWO LAYER SYSTEMS ETALONNAGE Designed to provide 40 mmhg in a 2 layer system

performance indicators to aid safe, accurate compression Indications As an

patients who cannot tolerate 4 layer For ankles from 18cm to 32cm in

becomes a circle correct stretch correct level of compression K-Press stretched

compression is better than no compression and multi-component bandages work

and meta-analysis of randomised controlled trials with data from individual

8 TWO LAYER SYSTEMS ETALONNAGE Designed to provide 40 mmhg in a 2 layer system safely and effectively K-Tech unstretched K-Press unstretched Printed with performance indicators to aid safe, accurate compression Indications As an alternative to four layer compression bandaging for Venous Leg Ulcers Ideal for patients who cannot tolerate 4 layer For ankles from 18cm to 32cm in circumference For patients with active lifestyles K-Tech stretched Ellipse becomes a circle correct stretch correct level of compression K-Press stretched Evidence based practice Poor bandaging The Cochrane Collaboration Applying compression is better than no compression and multi-component bandages work better than single component systems These systems appear to perform better when one part is an elastic bandage. O Meara et al 2009 O Meara S, Teirney J, Cullum N et al (2009) Systematic review and meta-analysis of randomised controlled trials with data from individual patients. BMJ: 338(7702) Potential Damage Use of Non Compression Bandages Support the limb Wool and K lite Bandage Toe to knee Secure appropriately Educate your patient 8

Wound assessment Assess the wound bed and dress appropriately and with in your wound care guideline Is there an infection /dead tissue Educate your patient Talk to your patient Explain Reassure Time

prevent recurrence 51 References *Dinn & Henry, 1995.

9 Wound assessment Assess the wound bed and dress appropriately and with in your wound care guideline Is there an infection /dead tissue Educate your patient Talk to your patient Explain Reassure Time line End goal Work together Hosiery Venous leg ulcers 70% will recur within 6 months without hosiery Recurrence reduced to less than 26% with hosiery Treatment with compression must be maintained to prevent recurrence 51 References *Dinn & Henry, Reduced at thigh Greatest at ankle How hosiery works Benefits of graduated compression hosiery Prevents recurrence of venous ulcers Prevents further deterioration of varicosities Aids with venous return Reduces pain & swelling Minimises the risk of DVT Reduces nursing time Patient is more involved Improves patients quality of life Cost effective 9

10 Standards for Graduated Compression Hosiery BRITISH STANDARD EUROPEAN CLASS BS graduated compression hosiery Class I 14 17mmHg (at the ankle) Light compression Indicated for: Early varices Pregnant women Prevention of DVT on long haul flights BS graduated compression hosiery Class II 18 24mmHg (at the ankle) Medium compression Indicated for: Medium varices Mild oedema Prevention of recurrence Post Sclerotherapy / stripping / Laser Graduated compression hosiery Class III mmhg (at the ankle) Strong compression Indicated for: Gross varices Gross oedema Prevention of recurrence of ulcers 2-layer treatment product 10 mmhg liner plus mmhg stocking Liner Pack Hosiery kit Venus 1V Study RCT to compare clinical and cost effectiveness of 4 layer bandaging with 2 layer hosiery kits on 457 patients Results show that hosiery kits are equally as effective as 4 layer bandages Cost effective reduce nurse consultations by improving self management Improve patients quality of life 3 Liners per pack 10

Hosiery for active ulcers and lymphoedema European Class Hosiery Juxta fit Juxta cures an adjustable system for the treatment of venus ulcers Built-in

Insufficiency Chronic Oedema Lymphoedema Difference in Compression Values British Standard Class One 14-17mmHg Class Two 18-24mmHg Class Three 25-35mmHg

Aim to use the highest class possible Clinical Practice Guidelines: patients should be encouraged to wear class III compression, if this is not

11 Hosiery for active ulcers and lymphoedema European Class Hosiery Juxta fit Juxta cures an adjustable system for the treatment of venus ulcers Built-in pressure system guide Juxta fit adjustable compression for the management of lymphoedema; available in different sizes Juxta cures Uses: Venous Insufficiency Chronic Oedema Lymphoedema Difference in Compression Values British Standard Class One 14-17mmHg Class Two 18-24mmHg Class Three 25-35mmHg European Class Low Compression mmhg Class One mmhg Class Two mmhg Class Three mmhg What Class of Compression? Aim to use the highest class possible Clinical Practice Guidelines: patients should be encouraged to wear class III compression, if this is not contraindicated and they can tolerate it; otherwise the highest level of compression they will tolerate Improving practice: Improving care. The nursing Management of patients with venous leg ulcers

Selecting the best stocking for your patient Handy Hints Closed or Open Toe Patient preference choice aids

Below Knee or Thigh length Thigh length available with hold up to secure without the need of a suspender belt

veins behind the knee require thigh length Keep It Simple Let the patient choose the stocking Involve the patient

ankle Best practice to measure when patient is sat down on a chair with a bend in knee, then to stand if measuring

An abnormal limb shape Venous Insufficiency Champagne bottle shaped leg or no calf When standard hosiery has not

12 Selecting the best stocking for your patient Handy Hints Closed or Open Toe Patient preference choice aids compliance Open Toe advised if wearing for a week Do they have chiropody treatment? Below Knee or Thigh length Thigh length available with hold up to secure without the need of a suspender belt Patient preference Both as effective at aiding venous return Swollen Knee or if wearing Hosiery for a week Painful veins behind the knee require thigh length Keep It Simple Let the patient choose the stocking Involve the patient Demonstrate but let them do it Suggest appliances if needed The largest part of the calf The smallest part of the ankle Best practice to measure when patient is sat down on a chair with a bend in knee, then to stand if measuring for thigh length or tights. Measure in cm s Where to Measure Find the best fit for calf and ankle. An abnormal limb shape Venous Insufficiency Champagne bottle shaped leg or no calf When standard hosiery has not worked Best fit, first time. Made to Measure Application Correct application Turn stocking inside out Don t gather up Use of appliances Sockaid Corner of a plastic bag Rubber gloves 12

Rolly demonstration https://www.youtube.com/watch?v=iglfkxy ZG3o&feature=youtu.

13 Rolly demonstration ZG3o&feature=youtu.be TO REPAIR TO HEAL TO REPAIR TO HEAL TO LOVE TO TOUCH TO LOVE TO TOUCH TO LIVE TO MOVE TO LIVE TO MOVE TO SHARE TO CURE TO SHARE TO CURE THANK YOU 74 Reference List British Association for Parenteral and Enteral Nutrition (2003) Malnutrition Universal Screening Tool: 'MUST', Redditch: BAPEN Callam MJ, Ruckley CV, Harper DR, et al. Chronic ulceration of the leg: extentof the problem and provision of care. Br Med J (Clin Res Ed)1985;290: costs- Posnett & Franks 2008 Deborah Simon, FrancisP.Dix. Charles. N McCollum BMJ of venous leg ulcers) Moffatt, C.J.Franks, P.J. Doherty, D.C.Martin,R.,Blewett,R & Ross,F.2004 Prevelance of leg ulceration in a london population.quaterly Journal of Medicine 97: Moffatt C (2001) Leg ulcers. In: MurrayS (ed) Vascular Disease: Nursing and Management. Whurr, London: Morison MJ, Moffatt C (2004) Leg ulcers.in: Morison MJ, Ovington LG, Wilkie K (eds) Chronic Wound Care: A ProblemBased Learning Approach. Mosby, Edinburgh: Williams, L., Leaper,D.J.Nutrition and wound healing. Clin Nut Update 2000; 5: 1, Nice guidelines for peripheral arterial disease accessed on Feb _ Venous 4 study link accessed on Feb 2016 NICE guidelines for diabetes accessed on Feb 2016 Sign Guidelines. Management of Chronic Venous ulcers References RCN (2006) The management of patients with venous leg ulcers. London; RCN. Vowden, P. and Vowden, K. (1996) Hand held Doppler assessment for peripheral arterial disease. Journal of Wound Care. 5(3): Vowden, P. and Vowden, K. (2001)Doppler and the ABPI: how good is our understanding? Journal of Wound Care. 10(6): in/files/ pdf REFERENCES Elastic properties of extensible bandages, British standard BS7505: 1995 Thomas S., 1998 Compression bandaging in the treatment of leg ulcers SIGN guidelines Morison MJ, and Moffatt C (2004) Leg Ulcers. In Morison MJ, Ovington LG and Wilkie K. Chronic Wound Care London, Mosby. Dale J.J. et al, 1985, Chronic ulcers of the leg: a study of prevalence in scottish community, Health bulletin, 41, Nelson E.A., 1996, The management of leg ulcers, JWC, 5(2), Blair et al, 1988, Sustained compression and healing of chronic venous leg ulcers, Br med J, 297, 1159, 1161 Netzer C. & Rudofsky G., 1991, Practical ambulant phrenology, Germany, Schorsch-Druck Nelson, Iglesias et al, 2004, Randomized, clinical trial of four layer and short stretch compression bandages for venous leg ulcers, BJS, Vol 91, No 10 Callam M.J. et al, 1987, Chronic leg ulcer of the leg: clinical history, BMJ, 294 (6584); Ballard K. et al, 2000, An evaluation of the Parema four-layer bandage system, BJM, vol. 9, No 16; Nelson et al, 1995, Improvements in bandaging technique following training, JWC, 4, 4: Taylor and Taylor, 1999, A comparison of sub-bandage pressures produced with two multi-layer bandaging systems, JWC, vol 8, No 9 SMTL, March 1999, Comparison of elastic properties and predicted sub bandage pressure of two cohesive bandages, 99/1076/1 Vowden et al, 2000, Comparison if the healing rates and complications of three four-layer bandage regimens, JWC, vol 9, No 6 Vowden et al, may 2001, The K-four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers, JWC, vol 10, No 5 Smith et al, 2004, Evaluation of Urgotul plus K Four compression for venous leg ulcers, BJN, vol 13, No 16 Hannah R. Sub-Bandage pressure measurements and usability between three compression bandage systems Hünger M. Interface pressures of three different multi-layer bandage systems in healthy volunteers Begnini Efficacy, safety and acceptibility of a new two layer compression bandage system in the management of venous leg ulcers 13

Housekeeping 15/03/2016 URGO MEDICAL, HEALING PEOPLE. Tissue Viability information. Tissue Viability Intranet page

Housekeeping 15/03/2016 URGO MEDICAL, HEALING PEOPLE. Tissue Viability information. Tissue Viability Intranet page TO REPAIR TO HEAL TO REPAIR TO HEAL TO LOVE TO TOUCH TO LOVE TO TOUCH TO LIVE TO MOVE TO LIVE TO MOVE TO SHARE TO CURE TO SHARE TO CURE URGO MEDICAL, HEALING PEOPLE Leg Ulcer Assessment 2016 Tissue Viability