Leg Ulcer Policy. Control Aseptic Technique Policy NSCP Wound Formulary Consent Policy Clinical photography. Safe Caring Effective Responsive Well Led

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1 Leg Ulcer Policy Author(s) & Designation Lead Clinician if appropriate In consultation with To be read in association with Ratified by Sarah Williams, Tissue Viability Specialist Nurse Mary Lewis, Director of Nursing and Therapies NSCP Policy Circulation List Policy on Standard Precautions for Infection Control Aseptic Technique Policy NSCP Wound Formulary Consent Policy Clinical photography Clinical Cabinet Forum Re-issue/Ratification date December 2016 Version 4 Review date December 2018 This policy supports compliance with the CQC 5 Domains: NHSLA Risk Management Standard(s): Safe Caring Effective Responsive Well Led If you require this document in a different format, please contact the Quality and Governance team on Page 1 of 107

2 Contents 1. Introduction 5 2. Guidelines Standards Aims of the Guidelines General Standards GP Practices 6 3. Assessment and Diagnosis Doppler Assessment Diagnosis 8 Flow Chart for Venous Ulcers 9 Flow Chart for Mixed Venous and Arterial Ulcers 10 Flow Chart for Arterial Ulcers General Management of Leg Ulcers Essential Skin Hygiene Local Wound Care Treatment of Infection Cellulitis Compression Bandaging for Venous Ulceration Laplace s Law Laplace Relationship The Multi-layer Elastic Compression Bandaging System The Short Stretch Bandage System Other Bandage Systems KTWO Calibrated 2-layer compression system- High compression M Coban 2- layer Compression System Juxta 22 Page 2 of 107

3 10. Prevention of Recurrence in Venous Ulceration Compression Hosiery (Appendix 7 & 8b) Recurrence of Ulceration Patient Education Care of Patients presenting with reoccurrence of Ulceration Invasive Treatments for Venous Insufficiency Surgery Other Treatments for Venous Disease Summary Trouble Shooting Tips Concordance Pain Difficulty Tolerating Compression Managing Exudate Footwear Problems Managing Varicose Eczema Contact Sensitivities Cellulitis Deep Vein Thrombosis (DVT) Hosiery Bandage Slippage Patient unable to attend Clinic Education, Training and Competence Aims of Education and Training Training should cover: Competence in Application of Compression Bandages / Hosiery 38 Page 3 of 107

4 14.4 Competence in Assessing Patients and Initiating Compression Therapy Development and Consultation Processes Acknowledgements References Bibliography Appendices 45 Appendix 1 General Assessment 46 Appendix 1a A Quick Assessment Guide to Managing Venous Ulcers Short Term 51 Appendix 1b Flow Chart Guide to Fitting Compression Hosiery 53 Appendix 2 Doppler Assessment 56 Appendix 3 Pain 59 Appendix 4 Emollients 61 Appendix 5 Steroid Ladder 64 Appendix 6 Compression Hosiery 65 Appendix 7 Competencies 73 Appendix 8 Competency Template for Compression Bandaging 74 Appendix 9 Competency Template for Compression Hosiery 78 Appendix 10 Competency Template for Compression Doppler 83 Appendix 11 Mixed Aetiology Leg Ulcer Pathway (Complex) 87 Appendix 12 Venous Leg Ulcer Standard Pathway 88 Appendix 13 Venous Leg Ulcer Pathway (Complex) 89 Appendix 14 Standard Venous Leg Ulcer Pathway Inclusion Criteria 90 Appendix 15 Leg Ulcer Care Pathway 91 Appendix 16 Equality Impact Assessment 105 Type of Document Guidance Title Author Date Version Ratifying Committee Clinical Guidance on the treatment of leg ulcer Linda Davies & BNSSG Wide Group Jan 13 2 Clinical Cabinet Forum Policy Leg Ulcer Policy Julie Dursley Oct 16 3 Clinical Cabinet Forum Policy Leg Ulcer Policy Julie Dursley Dec 16 4 Minor changes n/a to ratification Page 4 of 107

5 1. Introduction Definition of a Venous Leg Ulcer; An open lesion between the knee and the ankle joint that remains unhealed for at least for weeks in the presence of venous disease (SIGN 2010) A leg ulcer is defined as the loss of skin below the knee on the leg or foot which takes more than 2 weeks to heal (CKS revised 2016) Leg ulcers are a chronic and recurring condition that affect between people in every 1000 at any one time. (Graham et al 2003) The prevalence of leg ulceration increases with age and can be as many as 20 in every 1000 people over the age of 80, (Moffatt et al 2004) There is no single aetiology; however it is thought that approximately 70% of people with a leg ulcer are as result of venous hypertension (Moffatt and Franks, 1994, Chen & Rogers 2007) Arterial or mixed arterial/venous disease is responsible for a further 20% and the remaining are from other conditions such as diabetes, rheumatoid disease, malignancy and vasculitic conditions (Chen & Rogers 2007). Inadequate assessment and ineffective treatment may result in the persistence of ulcers for many years, some never healing (Harding K et al 2015). The annual cost to the NHS for chronic wounds is estimated at million per annum with a large proportion of this coming from nursing time (NHS Centre for Reviews and Dissemination, 1997; Bosanquet, 1992; Baker et al.1991 McCollum 2004). Some individual health authorities are spending 0.9m to 2.1 million (Carr et al 1999).The cost to the NHS for treating venous ulceration, alone, mostly in primary care and through community nursing services, are at least per year. (Posnett 2008). Not only is it time consuming and costly to treat, but there are psychological implications to the patient in that the ulcer increases social isolation through limited mobility, uncontrolled exudate and odour, together with pain. (Lindholm et al.1993; Charles 1995). Careful evaluation of causative and contributory factors is of great importance in the management of patients with leg ulcers (Sarker and Ballantyne, 2000). Research has shown that it is possible to heal up to 83% of venous ulcers with compression bandaging (Franks et al 1995). Page 5 of 107

6 2. Guidelines Standards 2.1 Aims of the Guidelines To ensure that all patients presenting with a leg ulcer receive a comprehensive assessment, and subsequent diagnosis, from a registered nurse who has additional competencies in leg ulcer management. To ensure that all patients diagnosed with a leg ulcer receive treatment according to agreed guidelines. 2.2 General Standards A guideline conforming to current best practice has been agreed by North Somerset Community Partnership (NSCP). Doppler machines must be available for each nurse undertaking leg ulcer assessment. An annual audit of the use of the leg ulcer management guidelines should be carried out by the Tissue Viability Service in NSCP. NSCP has at least one lead nurse to act as a source of expert advice. NSCP will work within these guidelines. NSCP has a responsibility to provide a nursing workforce who can offer assessment and multilayer bandaging as a skill and ensure their competency is maintained. 2.4 GP Practices Each GP practice has access to the Leg Ulcer Management Policy. Gp s are able to refer to the Tissue Viability Service through the appropriate route for patients with complex or non- healing leg ulcers 3. Assessment and Diagnosis The first step in successfully managing a patient with a leg ulcer is recognising the wound as a leg ulcer. Wounds that commonly fall into not being recognised as an ulcer are pre-tibial lacerations, (or other trauma wounds), and surgical incisions where veins have been harvested for coronary bypass grafts (Moffatt et al 2007). A detailed assessment of the patient s general health, and past medical history is essential when diagnosing and determining treatment of the ulcer, and should be Page 6 of 107

7 carried out using the assessment tool accompanying this policy. Assessment is not a one off procedure but an on-going one. It is paramount that underlying disease processes are addressed and stabilised (if possible) to ensure maximum potential to heal. Many textbooks state that compression therapy should not be used in patients with diabetes. This is because of the concern that sensory neuropathy will prevent a patient detecting whether the compression is causing trauma and the risk of concurrent Peripheral Arterial Disease(PAD). However, patients with diabetes are just as likely to suffer from a venous ulcer as patients without diabetes. Healing may take longer but generally does occur. So if compression is the treatment of choice it should be used (Moffatt et al 2007). It is intended that the assessment should be carried out by a nurse holding competencies in the theory and practice of the management of leg ulcers (RCN 2006, SIGN 2010). Leg ulcer assessment is a highly complex skill, and practitioners who lack the skill can tend to focus on the wound rather than the patient, not recognising the under- lying causes that need to be addressed. 3.1 Doppler Assessment Doppler Ultrasound / Ankle Brachial Pressure Index (ABPI) is an integral part of the assessment of leg ulceration. It enables an objective measurement of the blood flow to the limbs to be made. It supports the clinical findings and so aids the planning and implementing of a management regime. Doppler assessment is twofold, comprising of interpretation of both signals and pressure index (Warboys 2006 NICE 2012).This diagnostic test compares the ankle systolic pressure to the brachial systolic pressure. Patients who have a normal arterial circulation will have an ankle systolic pressure that is the same as, or higher than, their brachial pressure. Ankle pressures lower than the brachial pressures are indicative of arterial disease (See Appendix 2 & Appendix 7). These measurements need to be interpreted with caution in the diabetic patient. Full compression bandaging should not be applied until Assessment and Doppler ultrasound have been performed, and the blood flow to the limb is confirmed as being sufficient. Neither should be used in isolation. A period of practice with assessment by a mentor should follow. Peripheral Arterial Disease (PAD) occurs at an early age, and progresses more rapidly in patients with diabetes, compared with patients without diabetes. There is a difference in the distribution of disease in the patients with diabetes. Distal vessels, particularly the tibia and peroneal, are more frequently involved in patients with diabetes. In patients without diabetes, the femoral iliac and aorta are more commonly affected. Changes do occur in the micro circulation, particularly thickening of the capillary basement membrane that influences blood flow. Other regulatory mechanisms controlling local blood flow are affected, therefore influencing perfusion of the tissues. A Doppler assessment should be carried out as soon as possible after the initial presentation, but must be carried out within 4-6 weeks, as this is sufficient time to ascertain that there is delayed healing that requires investigation. Page 7 of 107

8 3.2 Diagnosis Having made an assessment of the patient, the ulcer and the foot circulation, a working diagnosis should be formulated. Treat patients according to the underlying pathology of their diagnosis using the following flowcharts. Patients, who have a mixed picture, may be treated along the lines of their predominant pathological presentation, often referred to as mixed aetiology leg ulcers. Patients where diagnosis is unclear should be referred to a specialist nurse in leg ulcer management. A referral form will need to be completed to Tissue Viability Service. Consultation opinion can be sought via GP referral to the Vascular Studies Department. Page 8 of 107

9 Flow Chart for Venous Ulcers Assessment including Ankle Brachial Pressure ABPI 0.8 and above Normal Doppler Index with Triphasic and Biphasic sounds and no other significant arterial factors Dress wound according to local wound formulary where possible this should be a simple non adherent dressing Apply full compression (40mmHg) at the ankle Normal Doppler Index with combined Monophasic and Biphasic signals with difficult or muffled sounds and significant arterial factors indicating possible arterial component. Dress wound according to local wound formulary where possible this should be a simple non adherent dressing. Reduced compression (20 mmhg) or short stretch initially) Increase to full compression (40 mmhg) if tolerated Address pain control Address underlying disease e.g. Diabetes, Rheumatoid Arthritis refer if unstable Address Dermatology issues refer to Specialist Nurse for advice Patient Education Ulcer Healed Prevent reoccurrence Fit with compression hosiery - class 2 or 3 German RAL mod/high oedema British Standard BS if minimal oedema Refer to Vascular surgeon for assessment of veins for treatment if ulcers reoccurring despite hosiery. Ulcer Not Improving or Deteriorating Reassessment and Re-Doppler ABPI Refer to Specialist Nurse for further assessment Page 9 of 107

10 Flow Chart for Mixed Venous and Arterial Ulcers Assessment including Ankle Brachial Pressure ABPI Monophasic combined with Biphasic signals with difficult or muffled sounds significant arterial factors Mixed venous / arterial ulcer Appropriate dressing selection according to local formulary Reduced Compression 20 mmhg All Monophasic signals and significant arterial components Predominantly Arterial Ulcer Appropriate dressing selection according to local formulary No compression refer to Specialist Nurse for opinion Address pain control Address underlying disease e.g. Diabetes, Rheumatoid Arthritis refer if unstable Address Dermatology issues refer to Specialist Nurse for advice. Patient Education Healed Not healed 0.5/0.6 Class 1 compression hosiery German RAL for Mod/high level s oedema BS for minimal oedema 0.7/0.8 Class 2 compression hosiery German RAL for Mod/high level s oedema BS for minimal oedema 0.5/06 Refer to Vascular Surgeon for assessment of arteries and possible surgical treatment 0.7/08 Refer to Specialist Nurse for advice Refer to Specialist Nurse if ulcers reoccurring Page 10 of 107

11 Flow Chart for Arterial Ulcers Assessment indicating Arterial Components including Ankle Brachial Pressure ABPI < 0.5 Urgent referral to Vascular Surgeon Appropriate dressing selection according to Wound Formulary Address underlying disease e.g. Diabetes, Rheumatoid Arthritis refer if unstable Address pain control No Compression but K soft and K lite of the compression system applied with a spiral technique will offer some support. Page 11 of 107

12 4. General Management of Leg Ulcers 4.1 Essential Skin Hygiene Essential skin hygiene and cleansing of the ulcer at each dressing or bandage change. Soak the leg for 10 minutes in a clean (plastic-lined) bucket of warm water, with an emollient to promote a healthy skin(see appendix 4) Dealey (1999) suggests that the aims of cleansing leg ulcers/legs are: To remove dry and flaky skin, especially when a bandaging system is in place. To remove the build-up of emollients/topical steroids. For patients well-being and comfort. Hyperkeratosis is thickening of the outer layer of the skin- the stratum corneum. It is associated with the over proliferation of the keratin producing cells over the surface of the skin (ILF 2012). Daily skin care hygiene regime is important for patient with hyperkeratosis. Patients should be encouraged to carry out this care and perform regular care. Promoting self-care where possible is important in promoting and maintaining skin health (Whitlaker 2012, Pidock and Jones 20103). RCN (2006) Clinical Practice Guidelines suggest cleansing of the affected leg should be kept simple using warm tap water and a non-lanolin based emollient (Tap water on exposed bone or tendon is not recommended - see Appendix 4). Dry scales should be removed from the legs particularly around the ulcer edge to allow new growth of epithelium (Sterile single use forceps should be used). NICE guidelines (NICE 2014) support the use of a monofilament debridement pad in the management of hyperkeratosis. Any traces of an emollient should be removed before using the monofilament debridement pad. Instructions on its usage should be read before its use. Unique Convenient Safe system of Care (UCS) is another device that can be used to promote good skin hygiene and the debridement of skin scales. A bland non lanolin moisturiser should be applied to the legs after cleansing and drying. The emollient will help to form a waterproof barrier over the skin surface, which helps to prevent the water within the skin evaporating and keeps the underlying skin hydrated (Coley, 2009). For additional information on skin care see Trouble Shooting Tips. (Pages 26 31). Standard Infection Control Procedures should be adhered to. See local policies re: Aseptic Non Touch Technique (ANTT) and Hand Hygiene. Page 12 of 107

13 4.2 Local Wound Care Dressings do not heal leg ulcers but can be used to control symptoms such as odour or pain. They should be simple and cost effective; usually a Non-Adherent dressing is the initial dressing of choice. Refer to Local Wound Formulary or National Guidelines. 4.3 Treatment of Infection When clinically assessing wounds, the practitioner should always be mindful of the presence of infection (White et al 2011). Bacteria can usually be grown from a leg ulcer but in most circumstances they can be ignored as they don t interfere with healing. All broken areas of skin will rapidly become colonised with bacteria in any normal environment. Routine bacteriological swabbing is unnecessary (Harding et al 2015) unless there is evidence of clinical infection such as:- Inflammation/redness/cellulitis Increased pain, redness, swelling and exudate volume and viscosity, temperature to skin. Enlargement of the ulcer (RCN,2006) Delayed healing despite appropriate compression therapy Newly formed ulcers within inflamed margins, or extension of the wound margins (EWMA 2005) Discolouration ( for example dull, dark brick red) Friable tissue that easily bleeds Increase in malodour New onset dusky wound hue Sudden appearance of slough or increase Sudden appearance of necrotic black spots (EWMA 2005) Immunocompromised or clinical symptoms which necessitate a wound swab However some of the above signs are indicative of clinical inflammation resulting from high protease activity (White et al 2011). There may also be fever, malaise, neutrophil leucocytosis and high white cell count (raised CRP). Page 13 of 107

14 In most immunologically normal patients the infection is caused by Streptococcus pyogenes group A and/or Staphylococcus aureus. Pseudomonas aeruginosa is commonly grown but very rarely of pathological significance. Initial treatment should be with high dose oral antibiotics in line with BNSSG guidance. 4.4 Cellulitis Cellulitis is responsible for over 400,000 bed days per year, costing the NHS 96 million (Levell et al 2011). It is often misdiagnosed by physicians and can be a lower limb dermatitis, commonly eczema, fungal infection, lymphoedema or chronic oedema (Levell et al 2011). This is a bacterial infection of the skin and the tissues below the skin surface. It is an acute spreading infection of the subcutaneous tissue. Cellulitis is mostly caused by group A beta-haemolytic streptococci, but can be caused by other bacteria such as Staphylococcus aurous (See RCN 2006). Symptoms of cellulitis (Cutting and Harding 1994) Hot, Red, Tender, Painful, and Swollen. Cellulitis often accompanies skin trauma and is usually unilateral (Levell et al 2011). It occurs where bacteria gain access through fissures and damage to the skin surface (Gabillot-Carre and Roujeau 2007). The Patient may feel generally unwell, shivery or feverish. Investigations may include bloods - Full blood count, erythrocyte sedimentation rate, liver function tests, urea and electrolytes to identify any contributory underlying pathology and wound swab if clinically indicated for culture and sensitivity. Antibiotics are the main treatment for cellulitis, oral for a mild infection, but intravenous antibiotics can be needed if: There is a more severe infection The infection has not responded to oral antibiotics The patient has other health problems. Other treatment is aimed at: Treating any breaks in the skin that allowed the infection in. (e.g. dressing the ulcer or the fungal infection) Treating pain or swelling, with analgesia and elevation Page 14 of 107

15 Gentle cleansing with a soap substitute Elevation and resting the limb In patients with recurrent cellulitis, prophylactic penicillin is sometimes used; refer to nurse specialist re skin care management and advice. Local microbiological advice should be sought if the clinical condition is not improving. For further advice on infection issues see Troubleshooting. Bacterial swabs should only be carried out where there is clinical evidence of infection. A swab will only tell you what bacteria are present; it will not tell you if there is an infection. MRSA: see local Guidelines re wound care & MRSA 5. Compression Bandaging for Venous Ulceration Do not start compression bandage therapy if the ulcer is infected. If a venous ulcer becomes infected, and compression bandage therapy is already in use, ensure compression bandages are removed, and only recommence compression bandage therapy once infection has resolved (RCN 2006, SIGN 2010) The key to the successful healing of chronic venous ulcers is to correct the underlying venous hypertension using graduated compression therapy (EWMA, 2003, Moffatt 2007). The application of high compression bandaging exerts pressure on the underlying skin and tissues, reducing distension and pressure to the underlying superficial veins. This reduces oedema, and increases the blood velocity in the deep veins, aiding venous return, thereby counteracting venous hypertension. 40mmHg pressure at the ankle is considered the optimum pressure required to reverse venous hypertension, graduating the pressure to 17mmHg just below the knee (Moffatt, 2000). Compression may also be appropriate for the treatment of some other aetiologies: however caution should be taken where patients have evidence of the following conditions: arterial disease, diabetic ulceration, rheumatoid ulceration, peripheral neuropathy or loss of sensation to the lower limb. Full compression bandage systems should only be applied after a full assessment and Doppler studies have been carried out. The above patients who have these aetiologies may not be suitable for the mini assessment. At initiation of compression, patients should be reassessed for skin complications within 24-48hours (NICE CKS 2016). It is important that the science of bandaging is considered if safe and effective compression is to be delivered. Page 15 of 107

16 5.1 Laplace s Law This Law of Physics states that there are a number of important factors which determine the pressure achieved under any given bandage. P = TN x 4630 CW 5.2 Laplace Relationship The level of pressure exerted by a compression garment on the leg is dependent on: The Tension (T) of the bandage / hosiery material. The Number (N) of layers of the compression applied. The Width (W) of the bandages used. The Circumference (C) of the limb. Tension (T): is determined by the amount of elasticity of a bandage and the degree to which it is stretched. Number of Layers (N): the more the layers applied to a leg, the higher the subbandage pressure obtained. Width of bandage (W): higher pressures are achieved from narrow bandages and lower pressures than with wider ones. A 10cm bandage is appropriate in most cases. Circumference of the Limb (C): The thinner the leg, the higher the pressure that will be achieved from a given bandage. Dangerously high pressures can be obtained with compression bandages on thin legs. The larger the leg/ankle, the lower the pressure achieved from a given bandage. It is vital that this principle is taken into account when instituting a regime of compression, if therapeutic pressures are to be achieved in large limbs, or pressure necrosis is to be prevented in those patients with small ankles. Using Laplace s law, graduated compression is achieved because of the natural shape of the limb. Most legs are narrower at the ankle than the knee, so graduated compression is achieved automatically if a bandage is applied at the same tension and overlaps all the way up the leg. Where limbs are wider at the ankle than the calf due to oedema etc., padding needs to be applied to the calf to ensure it is approximately 10-14cm larger than the ankle. If this is not achieved it will reduce the effectiveness of the compression bandaging, and consequently the pressures achieved. Page 16 of 107

17 Always adhere to bandage manufactures recommendations regarding limb circumference. 6. The Multi-layer Elastic Compression Bandaging System The best-validated means of achieving sustained compression is by a multi-layer technique, such as that pioneered at the Charing Cross Hospital venous ulcer clinic. This comprises of multi layers of elastic bandaging over a non-adherent dressing. These layers build up to give pressures of 40mmhg at the ankle. Multi-layer systems vary in the levels of compression in layers 3 and 4. The current system in use, the K system from Urgo, produces 20mmhg in both compression layers. Iglesias et al (2005) found that multi-layer elastic bandages were more cost effective than multi-layer inelastic bandages for healing venous leg ulcers. The healing rates using the system were reported at 74% at 12 weeks compared with 30% healing with no compression and 45% with other elasticated bandages. Elastic bandages follow the shape of the limb maintaining a constant pressure. The bandages move with the muscle contractions therefore only minor variations in pressure occur as the limb moves. The elasticity of the bandages mean that as the limbs oedema reduces as a result of the compression, the bandages will follow the limb in as it reduces in size thus maintaining a constant pressure on the limb. This means that the bandages have a fairly constant working pressure with smaller variation between when the patient is moving and when they are resting than occurs with inelastic systems. The aim is to leave the bandages in place for a week; initially they may have to be changed more frequently if the exudate strikes through the bandage. Layer 1 - Orthopaedic wool: K SOFT This layer is applied directly over the primary dressing. It is laid on and no stretch applied during application. Its main functions are to protect bony prominences, act as an absorbent layer, and to reshape the limb. This layer applies no compression. Padding should be applied from the base of the toes to below the knee in a spiral. Layer 2 - Conforming bandage: K LITE This layer provides a second absorbent layer and smoothes the first layer in preparation for the 3 rd and 4 th layers. This layer should be applied in a spiral from the base of the toes to below the knee. This layer can be used in conjunction with layer one to provide support bandaging to limbs that are not suitable for compression. Layer 3 - Light Compression bandage: K PLUS This is the first compression layer, giving 20mmHg at the ankle when applied in a figure of eight pattern at 50% stretch with a 50% overlap, to a leg with an ankle Page 17 of 107

18 circumference between 18 and 25 cm. Apply with a 30-50% stretch on the foot depending on the level of oedema. Layer 4 - Elastic cohesive bandage: KO FLEX This layer gives a moderate compression of 20mmHg at the ankle when applied toe to knee in a spiral technique at 50% stretch with a 50% overlap to a leg with an ankle circumference between 18 and 25 cm. Apply with a 30-50% stretch on the foot depending on the level of oedema. The bandage is cohesive and helps to secure the bandage system in place and to maintain the compression for at least a week Table 1: Bandage Combinations for multi-layer elastic compression systems Ankle circumference Less than 18cm Layer 1 is used to bring the circumference of the ankle up to a minimum of 18cm cm cm Greater than 30 cm Bandage combination 2 or more K soft 1 x K Lite 1 x K plus 1 x Ko Flex 1 x K Soft 1 x K Lite 1 x K Plus 1 x Ko Flex 1 x K Soft 2 x K Plus (or 1 x K 3 C and 1 x Ko Flex Long 1 x K Soft 1 x K Plus 1 x K 3C 1 x Ko Flex Long NB: The ankle circumference must be checked after the wool padding has been applied and the bandage regime determined by that measurement. Large limbs or limbs with ankle oedema and an ankle circumference greater than 25cm require a high compression stronger elastic bandage as part of their multi-layer system to ensure adequate pressure is applied. The ankle circumference should be measured every time the bandages are reapplied as it may alter with reduction of oedema. Reduced compression levels can be used on limbs with ABPI s below 0.8 with advice from experienced practitioners. (See table 2) Page 18 of 107

19 Table 2: Bandage Combination for reduced compression using K system ABPI Bandage combination Ankle Circumference x layer 1 1 x Layer 2 1 x Layer 4 Approx. 20mmHg 1 x Layer 1 1 x Layer2 1 x Layer 4 Approx. 20mmHg 1 x Layer 1 1 x Layer 2 1 x Layer 3 1 x layer 4 Under 18cm Layer 1 is used to bring the circumference of the ankle up to a minimum of 18cm cm 25 30cm Approx. 20mmHg 2 x Layer 1 1 x Layer 2 1 x layer 3 Approx. 20mmHg 1 x Layer 1 1 x Layer 2 1 x layer 3 Approx. 17mmHg 1 x Layer 1 1 x Layer 2 1 x layer 4 Approx mmHg Depending on ankle size Under 18cm Layer 1 is used to bring the circumference of the ankle up to a minimum of 18cm cm cm Page 19 of 107

20 7. The Short Stretch Bandage System The short stretch bandaging system is a two-layer bandage system comprising of padding / reshaping layer and a compression layer. The short stretch bandages extend and recoil very little, so when applied at full tension they maintain a semi-rigid cylinder around the leg that does not give when the muscle beneath expands. Contraction and expansion of the calf muscle against this cylinder re-directs the energy, forcing it back into the leg to squeeze the veins, thereby promoting venous return. This creates a high working pressure. When the leg is inactive low resting pressures are exerted on the leg. Because the bandages do not exert constant pressure on the limb, it may be useful for patients who do not tolerate compression well. It also may be considered for patients with arterial or sensory impairment and cardiac failure. As the bandage is unable to follow the limb as it reduces in oedema it may slip initially and require reapplying more frequently. The aim is to leave the bandages in place for a week when there is no strikethrough or slippage. There are two types of short stretch bandage available, cohesive and non-cohesive. Layer 1 Orthopaedic wool This layer is applied directly over the primary dressing. The padding layer gives no compression. Its main functions are to protect bony prominences and other vulnerable areas, to act as an absorbent layer and reshape the limb. Layer 2 Short stretch bandage The bandage is applied with even tension at full-stretch overlapping the bandage by 50% from the ankle to knee. If applying a second bandage (where the ankle circumference is greater than 25cm) apply ankle to knee in the opposite direction to the first bandage. Page 20 of 107

21 Table 3: Bandage Combinations for short stretch bandage systems Ankle Circumference Bandage Regimen Under 18cms 2 or more layer 1 Layer 1 is used to bring the circumference of the ankle up to a minimum of 18cm 18 cms to 25 cms Greater than 25 cms 1 x Layer 2 1 x Layer 1 1 x Layer 2 1 x Layer 1 2 x Layer 2 NB: The ankle circumference must be checked after the wool padding has been applied and the bandage regime determined by that measurement. 8. Other Bandage Systems 8.1 KTWO Calibrated 2-layer compression system- High compression KTWO is a multilayer multi-component compression system, designed to ensure even distribution of pressure between two dynamic bandages. The system applies the effective therapeutic pressure required to treat venous leg ulcers and associated symptoms along with severe oedema in chronic venous insufficiency. Irrespective of leg shape the bandage system provides the correct level of pressure from the very first application thanks to its specific pressure indicator. The system consists of two separate dynamic bandages: K Tech (1 st layer) which is a composite layer formed of wading and a moderately elastic compression fabric. K Press (2 nd layer) which is applied over the first layer, is a cohesive bandage. KTWO is not recommended when an ABPI is below 0.8, K TWO reduced is advocated for these patients. Both the KTWO and the KTWO reduced come in two ankle sizes 18-25cm and 25-32cm. 10CM bandage width for leg ulcer management. Page 21 of 107

22 8.2 3M Coban 2- layer Compression System The system is latex free and has been specifically developed to overcome some of the challenges associated with other compression systems, such as foot wear problems. The system is 2 layer bandage system consisting of an inner comfort layer and an outer compression layer. The unique foam comfort first layer replaces the orthopaedic wool layer and is latex free. The cohesive compression layer provides effective sustained compression and is also latex free. Once applied the two layers bind together to form a slim, single layer bandage that is designed to resist slippage and enables the patient to wear normal foot wear. One size kit fits all ankle circumferences Suitable for patients with an ABPI of 0.8or above; for patients with an ABPI less than 0.8 there is the Coban 2 lite kit. The system is a kit that contains two rolls and is designed to be used together and not in conjunction with any other compression bandages or orthopaedic wool. Each layer of the Coban 2 layer system has a purple core to allow easy differentiation form the original Coban self-adherent bandage. 9. Juxta Juxtacure Equipment required: The Body of the garment A Velcro detachable spine clearly marked ankle at one edge and calf at the other edge Four cotton liners and four compression anklets A BPS card Velcro tabs to secure the spine if concerns regarding accidental removal of spine by patient One pack of juxtacures contains 1 body, 1 spine, 1 pair of liners, 1 pair of compression anklets, 1 BPS card and Velcro tabs Also available on prescription are pairs of liners and standard or large pairs of compression anklets. Measurements required to ascertain correct size; Length of limb to order short, standard or long juxtacures pack Once pack has been received Measure ankle circumference and calf measurement. To ascertain the correct size of the juxtacures take length (L) of the limb from above the lateral malleolus to two fingers width below the knee flexure. Page 22 of 107

23 The excess is then cut off. Applying the juxtacures Pull the Comfort TM Leg Liner over the leg and any dressings (if the length is past the knee, leave until the juxtacures TM has been positioned and anchored, and then fold the Comfort TM Liner back down over it). Page 23 of 107

24 Smooth out any creases The Comfort TM Anklet can be applied after the main body of the juxtacures TM has been fitted Once the spine has been adjusted, apply the garment to the leg with the black material towards the skin. When you are happy where it is positioned tighten the straps, starting from the bottom and finishing at the top. Adjusting of the juxtacures TM and setting the mmhg Identify the correct scale on the BPS relating to the ankle circumference and check the pressure applied. Repeat for the remaining three straps keeping the measure on the BPS consistent (e.g.; if the ankle is set at 40mmHg, all other straps must read 40mmHg). The patient should be reviewed within 24 hours to ensure that the device is comfortable; not compromising the skin/limb in any way and that it is not causing discomfort. It is expected that the limb will reduce in size and therefore a reduction in the oedema due to improved venous return. Therefore at each visit for the first 2 weeks, the ankle and calf circumference should be measured and documented. If there is a reduction in the volume of the leg the spin will need to be adjusted, to match the new ankle and calf circumferences. This adjustment may need to be daily initially. Infection Control The juxtacures is not a sterile system therefore the infection risk can be mitigated but not eliminated. The following measures will reduce the risk of infection. Prescribed for use on one named patient only, no part of the system can be used on another patient. Compression including the juxtacures is contraindicated where there is infection present in the leg. Page 24 of 107

25 Use of the most appropriate, potentially high absorbency, primary dressing to be used to contain the exudate. E.g. Eclipse. If there is gross strike-through of exudate them compression anklet and liner will be disposed. Washing and instructions: The liner material is treated with a polymeric antimicrobial that prevents bacterial growth in the fabric and it must be laundered and thoroughly dried after each use. The breathe-o-prene fabric for the juxtacures is a laminated fabric with a silver content on the black (skin facing) layer. The juxtacures, Comfort Leg liner and Comfort Compression Anklet should be washed in the washing machine and tumble dried on a cool setting or air dried on a flat surface. The socks and liners are designed to be laundered at up to and from 30 to 60 degrees and should be changed for a clean one at each dressing change. The juxtacures itself can also be machine washed at the same temperature range, this will be dependent on whether there has been any exudate strikethrough and therefore should not be necessary at every dressing change. Patient information: E-Book of patient information booklet GB/Phlebo/97C EV Broschuere Juxta CURES UK/blaetterkatalog/index.html?lang=en GB Training requirements Nursing staffs (Bands 4 7) who have attended the NSCP 2 day Leg Ulcer Management training days will have an hour on the use of Juxtacures. This will be given by the Tissue Viability nurses and/or Medi UK staff. The juxtacures training will be included in the 2 day Leg Ulcer Management training which is required every 3 years. Training will cover all aspects of the measuring and fitting of the device together with advice on subsequent adjustments to chase oedema where required. The nursing staff will have on-going support form tissue viability nurse and Mdi employees. This will be in the form of a follow up visit with the patient until the nurse is safe and competent to assess, adjust and readjust the device. Where a patient has chronic oedema or lymphoedema, Juxtafit would be more appropriate. Page 25 of 107

26 10. Prevention of Recurrence in Venous Ulceration While research relating to recurrence of ulceration remains sparse, studies suggest that the rate of recurrence is high (McDaniel et al 2002). Compliance with wearing compression hosiery has shown to affect the rate of recurrence (Erickson et al 1995). Education for patients regarding the need for life long support of the veins in their legs is paramount and should be emphasised from the beginning of treatment. It should also be stressed to the patient that healed ulcers will remain susceptible to breakdown following even minor trauma, or no trauma. Once venous ulceration has healed, it is essential that all patients are measured and fitted with compression hosiery. It is important to ensure that they are managing the hosiery and subsequent advice and support are given to ensure concordance. Patients are more likely to comply with compression therapy that is easier to use and reduces pain and discomfort (Dowsett 2011) Compression Hosiery (Appendix 7 & 8b) Patients should not be prescribed compression hosiery until their skin is sufficiently robust to enable the stocking to be drawn over the ulcer site. There are various classification standards. Currently available on prescription are the British Standard (BS) or German/ European Standard (RAL). It is important to be aware that the compression rates and the stiffness of the fabric are different for each classification standard. Hosiery is graded into three classes:- Class 1 BS Light support that gives mmhg pressure at the ankle Class 1 RAL mmHg Indicated for superficial or early varicose veins. Used as a treatment of reduced compression and in prevention of re-ulceration for people who cannot tolerate class II Class 11 BS Moderate support that gives mmhg pressure at the ankle Class 11 RAL 23-32mmHg - Indicated for varicose veins of medium severity, DVT Treatment, Prevention of recurrence of venous ulceration for those who have healed in reduced compression or cannot tolerate class III. Class 111 BS Strong support that gives mmhg pressure at the ankle Class 111 RAL mmHg Page 26 of 107

27 Indicated for severe varicose veins, Treatment of venous ulceration when bandages cannot be tolerated and prevention of recurrence. DVT treatment recurrent and when flying There are hosiery kits that give up to 40mmHg pressure at the ankle, which may be useful for those patients whose ulcers reoccur when they finish their treatment with bandages. They can also be used as prophylaxis on patients with healed ulcers who need to be maintained at 40mmHg. Selection of the correct size of stocking is very important. The patient s legs must be carefully measured and ideally a class selected that will give the level of compression required preventing further venous ulceration. Made to measure stockings are available for those whose measurements fall more than 1cm outside the ranges catered for. Ideally legs should be measured for stockings whilst still in compression bandages or first thing in the morning where bandaging has not been necessary, so that the legs are less swollen. N.B: The restrictions with regard to arterial disease and compression bandages also apply to the use of stockings. 11. Recurrence of Ulceration Once a leg ulcer patient always a leg ulcer patient. However, some patients may be suitable to have corrective surgery. Once a Leg ulcer has healed the patient needs lifetime compression therapy due to the underlying venous pathology. Despite the availability of compression hosiery ulcer recurrence rates varies from 33% to 67%. 67% will experience 2 or more episodes of re-ulceration. 21% will experience more than 6 episodes of re-ulceration. Ulcers which are greater than 10cm in size, the chronicity of an ulcer, a history of deep vein thrombosis, clotting disorders, arterial disease along with the unsuitability or non-concordance with hosiery are all risk factors that increase the chance of recurrence. Consider referral for vascular surgical opinion for recurrence of unknown cause. Practitioners fitting hosiery should have undertaken training in the measurement, selection and application of hosiery. This is essential to ensure maximum comfort and subsequent concordance from patients (Coull and Clark, 2005). Page 27 of 107

28 11.1 Patient Education Managing the transition from high compression bandaging to hosiery may be difficult. Oedema may occur if the pressure applied by the stocking is considerably less than that applied by the bandage (Moffatt, 2007). It is essential to ensure that patients understand the risk of their ulcers recurring and the importance of caring for their legs in order to reduce this risk. Key points to enforce include: The importance of complying with their hosiery Avoiding trauma to the delicate tissues in the healed ulcer. Regular exercise to improve circulation and improve the function of their foot and calf pump. Careful attention to foot hygiene, particularly in diabetics. The avoidance of ill-fitting footwear. Elevation of legs when sitting for long periods of time To seek treatment as early as possible if they notice any damage to skin on their legs Essential maintenance of skin. Renewal of Hosiery every 6 months Educate patient re care of hose and Aids of application Written information should be given to patients (and/or carers) relevant to their needs, as this has been found to be a factor in improving compliance Care of Patients presenting with reoccurrence of Ulceration It is important to re-assess the patient including a repeat Doppler assessment (as soon as possible). Remember that new processes may have developed, such as deterioration in arterial competence in a patient who previously had a venous ulcer. Patients whose ulcers recur may require additional psychological support as depression is a common factor in ulcer reoccurrence. For some patients particularly susceptible to reoccurrence it will be necessary to increase the level of compression hosiery once healed. It might require a higher compression hose or a stiffer fabric hose e.g. RAL. Page 28 of 107

29 12. Invasive Treatments for Venous Insufficiency 12.1 Surgery Compression bandaging and stockings form the mainstay of treatment directed at healing venous ulcers. Despite these treatments, ulcer recurrence rates run at over 1/3 of patients within one year. The reasons for this are not well understood, but probably include non-compliance and ill fitting (i.e. inadequate compression) compression hosiery as well as more severe pathology (total deep vein incompetence, arterial disease) and trauma. A recent trial has shown that the addition of surgery to compression therapy both normalises venous physiology (Gohel et al. 2005) and reduces ulcer recurrence rates at one year (Barwell et al. 2004). This trial and a previous smaller trial suggested that surgery produced better healing and recurrence rates when compared to compression over a 3-year period (Zambori et al. 2003; Barwell et al. 2000). However recent long term results of the ESCHAR trial (Gohel et al 2007) surgical correction of superficial venous reflux in addition to compression bandages does not improve ulcer healing, but reduces recurrence of ulcers at four years and results in greater proportion of ulcer free time. The ESCHAR trial (Barwell et al 2004, Gohel et al 2007) used sapheno-femoral ligation with stripping as standard therapy but also undertook sapheno-femoral ligation under local anaesthesia for those unfit for general anaesthesia. The results of this trial can be generalised to a population with venous ulceration and superficial venous incompetence. The message from these trials is that all patients with venous ulcers and venous disease should be considered for surgery after healing if there are problems of recurrence. Patients should be assessed by a trained vascular specialist. Venous ultrasound assessment may be required to supplement the examination findings if the diagnosis is in doubt. The trials described have looked at venous physiology and shown that changes produced by surgery change abnormal reflux patterns back to normal. Healing and recurrence rates can also be related to changes in venous reflux and to the efficacy of the calf muscle pump. The difference between individuals goes someway to explaining the variation in healing rates with compression and following surgery. Problems of surgery include, nerve injury, wound infection, DVT and recurrence of varicosities, rates of which vary from 10-25% at 10 years. Page 29 of 107

30 12.2 Other Treatments for Venous Disease To date the main trials have focussed on the role of open surgery, in the healing or prevention of recurrence of venous ulcers. There are now a number of newer minimally invasive treatments being offered to patients and this section attempts to provide an overview of less invasive alternatives to surgery. a) VNUS closure This technique involves passing a probe up the saphenous vein, using ultrasound to accurately guide placement. Once correctly located near the junction with the deep veins, the vein is then surrounding by a cuff of injected saline containing local anaesthetic for pain relief. The probe is then heated up and withdrawn slowly. The probe heats the vein to a high temperature and denatures the vein wall causing fibrosis. The technique has a good success rate of over 80% (Nicolini,2005). Further injections or phlebectomies may be required to remove residual varicosities. Problems with this technique include cost (may be cost effective if time off work considered) (Tero-Rautio et al. 2002), saphenous nerve injury, skin burns and DVT. Long-term durability is not known (NICE guidance September 2003). b) Endovenous laser therapy This technique is very similar to VNUS closure but uses a laser fibre passed into the vein under ultrasound guidance. Once correctly located, the leg is injected with saline and local anaesthetic to prevent heating of surrounding tissues and to minimise pain. The laser is then activated as the fibre is withdrawn, causing thermal injury to the vein wall. Subsequently, residual varicosities may need treatment. Again the technique has a good success rate of over 80% (Min Robert et al. 2003). Problems include, recurrence (related to laser energy used (Proebstle et al. 2004) phlebitis, pain and bruising. Long-term durability is not known (NICE, 2004). c) Ultrasound guided foam sclerotherapy Injection sclerotherapy has been promoted for the treatment of venous disease in mainland Europe for some years. The technique of creating foam by forcing air through sclerosing agents allows the injected foam to displace blood and come into contact with a significant proportion of the vessel wall. This makes it more effective than standard liquid sclerotherapy techniques (Hamel et al.2003). A needle is located in the saphenous vein under ultrasound guidance and then the foam injected. The ultrasound probe is used to compress the vein and limit the flow of foam into deep veins once it reaches the junction with the deep system. The technique may obliterate all varicosities or subsequent injection or phlebectomy may be needed to remove residual varicosities as in a) and b). Problems include chemical phlebitis, skin staining, transient neurological disturbance (micro-bubbles may traverse cranial vessels) and DVT. Long-term durability is not known. (NICE, 2003). Page 30 of 107

31 12.3 Summary There are a variety of treatments, suggesting that no one treatment is significantly superior to another. Practitioners looking after patients with venous ulceration are advised to consult the NICE website ( for further updates on currently available treatments. 13. Trouble Shooting Tips 13.1 Concordance Compression therapy is the cornerstone of treatment for venous leg ulceration and furthermore there is increasing evidence that patients quality of life is improved while receiving this treatment (Moffatt, 2000). These benefits are not always seen immediately and it is vitally important that Nurses spend time explaining the importance of bandaging to heal patient s legs and discuss expectations so that they understand the process. Often the first few weeks can be difficult for patients and they will need a lot of encouragement and support. Pain should be addressed immediately and reassessed at every bandage change. Building a rapport and getting the patient working with you is essential. Consider developing a contract between the patient and yourself. Tracings, measurements and photos are an essential tool to monitor progress and are useful to demonstrate improvement to patients. Patient education leaflets should be used to reinforce advice. Contact telephone numbers should be given to patients for both regular and out of hour s services so that they can contact a practitioner for advice Pain Health care professionals often overlook pain although 80% of patients do experience pain from leg ulceration (Hollingworth, 2001). It is important to remember that pain is individual and that venous and arterial ulcers can be equally painful. Knowing and understanding a patient s level of pain, and type of pain, is a vital element of leg ulcer assessment on two counts. One, it will help the practitioner in making a diagnosis; and two, even moderate levels of continuous uncontrolled pain can significantly impact on a person s normal day to-day activities work, rest, relationships and mental state which in turn can delay leg ulcer healing. Compression will improve pain over time for venous ulcers but sometimes pain levels can rise in the first few weeks, due to physiological changes in the central nervous system (Moffatt et al 2007). Analgesia should be addressed at the start of treatment (Appendix 3).The following factors should be considered: Page 31 of 107

32 Be aware of triggers that increase pain Remember that careful explanation is required for all procedures Handle the wound as little as possible and with great care Recognise that pain may extend some distance from the ulcer Recognise that cleaning, soaking and the temperature of the water may exacerbate pain Avoid wound exposure, which may cause pain Review dressing choice Cover the wound with cling film if waiting for the wound to be seen by a colleague Avoid draughts from windows or fans as these may also exacerbate pain Involve the patient in the procedure-this gives them a greater sense of control and will help to reduce pain and anxiety Allow patients to remove their own dressings if they wish Allow patients to halt or slow down procedures Some patients have stated distraction through music and deep breathing helps pain reduction Reassess pain and analgesia often. Regular analgesia is better than ad hoc administration Difficulty Tolerating Compression If a patient expresses concern over tolerating compression bandages, it is worth applying the bandages as a reduced compression regime. It is essential to try and engage patients with compression by compromising. A reduced regime is better than none and often the level of compression can be increased gradually. Short stretch bandages produce low resting pressures and so may be better tolerated in some patients. Using Liners and hose kit components are also a good way of playing with the compression levels to aid concordance Juxta cures aids mobility and ankle movement. Practitioners frequently report that patients do not adhere to compression therapy because of pain, despite them having adequate arterial circulation (Moffatt 2004b) the main factors causing pain in these circumstances are due to: Inappropriate choice of compression bandage system Page 32 of 107

33 Lack of adequate padding over bony and tendinous areas Failure to adapt the bandage to the limb size and shape Over stretching bandages at calf level causing a tourniquet effect Over stretching bandages below knee Too many or too few layers of bandage causing a lack of graduation Pressure damage to the skin Bandage slippage causing trauma Over stretching of bandage causing joint or muscle or joint pain Inability to wear shoes Trauma from foot wear over bandaging Pain may/can also be caused if infection is present Managing Exudate Patients who have heavily exuding legs may well experience exudate striking through the bandages daily or on alternate days initially, due to the compression. This should reduce in time. Patients should be reassured that the compression is working and that the leakage should reduce. Try using multilayer elastic bandages rather than short stretch as the layers provide more absorbency. Leave the bandages for as long as possible and supply the patients with large non sterile 20 x 40 cm dressing pads that can easily be wrapped around the outside of the bandage until the Nurse comes the following day. Good skin care regime is important to ensure the exudate is removed as it can act as an irritant to surrounding skin. A superabsorbent dressing could also be added short term to allow compression to stay in place longer and protect the surrounding skin. Theses dressing usually go directly on the ulcer and do not needed to be used once exudate is reduced. They should not be used as surgipads and never layered NB: Strikethrough of exudate should not be left uncovered as this provides a port of entry for bacteria You should also check that you have achieved full compression where appropriate, as this will improve reduction of exudate. Remember to measure ankle after the padding to maximise the effect. If strike through continues exclude varicose eczema as the cause before referring to a specialist nurse. The treatment of varicose eczema is a daily treatment for 7-10 days with emollient therapy depending upon the severity with a topical cortico-steroid. Page 33 of 107

34 13.5 Footwear Problems Reducing layers of bandages can ease this problem depending on the individuals requirements. A two layer system may be appropriate using either short stretch or elastic bandages. Hosiery kits that provide 40mmHg pressure at the ankle are available, but this would only be suitable for ulcers that were minimally exuding. It is important to find an alternative rather than taking the compression off. Keraped boot is now available on drug tariff and can last over 3 months, which are ideal for bulky dressings and bandages on the foot. These do not facilitate normal ankle movement and therefore patients tend to shuffle their feet which could delay ulcer progression (as it often leads to poor foot and calf pump activation, thereby impeding venous return Please note that the patients mobility status would need to be assessed if Keraped boot prescribed as they may contribute to a risk of falls Juxta garments will promote good ankle and calf movement. The compression solution is often what the person can tolerate, and mobilise with, as safely as possible Managing Varicose Eczema It is essential to provide a good skin care regime for patients with eczematous change, due to their reduced skin barrier function. Clinically this will appear as a dry, scaly and inflamed skin, which could be broken. The regime should comprise of emollients for skin cleansing i.e. soap substitutes. Avoid using potential irritants such as soaps. The choice of emollient is dependent on the clinical appearance of the skin. For example, a thick, dry and scaly skin would benefit from a grease based emollient whereas a wet and weepy eczema would require a lighter cream based emollient (Appendix 4 for recommended emollients). When inflammation is present a topical steroid would be necessary. When deciding on a cream or ointment base for topical steroids, the same rationale as for emollient choice should be used. Usually a moderate potency topical steroid should be used on eczema of the lower leg. This may be increased to a potent topical steroid if short term if severe inflammation is present. Wet and weepy eczema with a lot of excoriation may benefit from a steroid with an antibacterial component short term (Appendix 5). If the topical regime is only being applied once weekly due to compression bandaging, it may be necessary to increase frequency of dressings to daily for one or two weeks to obtain full benefit from topical therapy. Compression bandages should be maintained but change to a more appropriate cost effective system. It is not acceptable to apply daily multilayer. Occlusion may be used in the form of dry elasticated viscose stockinette or paste bandages to enhance the effects of the topical agents applied. Bandaging also acts as a mechanical barrier to prevent excoriation. If response is poor after the above treatment regime has been instigated, contact specialist nurses for further advice. Page 34 of 107

35 13.7 Contact Sensitivities When the lower limb is being treated for ulceration, 60% have the potential to develop contact sensitivity. If persistent inflammation is confined to a welldemarcated area, and does not respond to topical steroid therapy, contact sensitivity should be suspected and a comfinett liner can be added. Where there is a persistent reaction / sensitivity referral to a dermatologist should be considered Cellulitis Where cellulitis is present, individual assessment is required. Generally the oedema and pain associated with cellulitis can be eased with some compression. However if the cellulitis is extensive, consider reducing compression until the patient is able to tolerate existing compression regime. Close monitoring is required to ensure the cellulitis is resolving which will mean changing bandages more frequently. Advice should be sought from a Specialist Nurse or Medical Practitioner. In those patients that suffer recurrent cellulitis, compression hosiery can often prevent recurrence. Essential skin care should be maintained. For recurrent cellulitis it would be helpful to seek specialist nurse advice. Refer to local guidelines for antibiotic treatment. In uncomplicated cases of cellulitis (no ulceration), consider class 2 below knee compression hose for 4-6 months following acute phase, (hot swollen and pain) with emollients (Lindsay & Stephens 2007) Deep Vein Thrombosis (DVT) If a new episode of DVT is identified leave compression off until treatment has commenced and medical advice sought. There is no consensus of when compression can be reapplied but usually 2-4 weeks after onset Hosiery It is essential that hosiery is fitted well, and the patients can manage either independently, or with aid from relatives or carers. Fitting aids are available to help with application. It is important to follow patients up to ensure they are wearing their hosiery, as time and effort taken with this can make the difference between staying healed and a new episode of ulceration. Remember that for those patients who have difficulty either fitting or tolerating their hosiery a reduced compression is better than none (See appendix 6). If difficulties arise consider these options: Longer lengths of hosiery are available from some companies. Page 35 of 107

36 Open toe hosiery may be more comfortable for some patients. Large arthritic knees, measure to mid-thigh as this will be far more comfortable. Made to measure compression hosiery may need to be considered Bandage Slippage The rigid nature of short stretch bandages means that reduction in oedema sometimes allows bandages to slip down the leg initially, and so they may need reapplication. When applying any bandage regime ensure the gradient from ankle to calf is not too steep, the calf measurement should be 10-14cm (50%) larger than the ankle. Use the orthopaedic wool to pad out the ankle and improve the gradient. Coban Layer 2 has shown good results with slippage reduction. Try to ensure the limb has a good leg shape, use as many layers 1 as needed to achieve this good shape. If slippage is not addressed, either for bandages or hosiery, significant skin damage can occur resulting in pressure damage Patient unable to attend Clinic If patients want to go on holiday or if they are unable to attend clinic for other reasons consider using hosiery instead of bandages if the exudate is manageable. Page 36 of 107

37 Flow Chart for non-healing Venous Ulcers (No Progression in Healing) Perform a full reassessment Correct if possible any detected abnormality Doppler ABPI. To rule out the advancement of Arterial Disease. Blood screening. To rule out new organic causes, such as anaemia, diabetes, hypothyroidism and low albumen levels. Wound bed assessment. To rule out wound infection, critical colonisation with bacteria and possible other aetiology of ulcer. Refer to specialist nurse if unsure No Abnormality detected on reassessment Re measure ankle circumference Has the correct bandage regime been applied for the ankle circumference and Doppler ABPI result? Yes No Is the gradient of the lower leg normal? Apply correct bandage regime Page 17 Yes No Have you padded the lower leg with the wool layer to achieve a normal gradient? Yes No Refer to specialist nurse Shape the leg with the wool layer to mimic the shape of the normal lower leg (Calf 50% larger than ankle measurement). Page 37 of 107

38 14. Education, Training and Competence 14.1 Aims of Education and Training The aim is to ensure nurses receive up-to-date evidence based training in order that: Patients with leg ulcers are appropriately assessed and managed according to their ulcer aetiology. Resources are appropriately used Promoting continuity and reducing variation in practice is minimised Optimum health of the patient/client is maintained The cost of intervention is a proven effective resource Training should cover: The Leg Ulcer Care Guidelines (this document) Pathophysiology of leg ulceration Leg ulcer assessment Introduction to the use of Doppler ultrasound for ABPI Normal and abnormal wound healing Compression Therapy theory, management and application Dressing selection Skin care Health Education Prevention of recurrence Criteria for referral for Specialist assessment Hosiery measuring, fitting, application 14.3 Competence in Application of Compression Bandages / Hosiery To be competent to apply compression bandaging unsupervised, candidates must have attended their organisation s Leg Ulcer management course covering the above, and be assessed on core competencies of the course by a Nurse who has achieved level 5 in the competency framework (Appendix 8). A registered nurse who has undertaken the study days and is currently practicing and experienced in Leg Ulcer Management will act as a mentor. A delegation of duty should be made in conjunction with the duty of delegation policy. If this is difficult in the candidates own work area, alternative mentoring must be found i.e. another work area. Page 38 of 107

39 14.4 Competence in Assessing Patients and Initiating Compression Therapy To be competent in assessing patients and initiating compression therapy the candidate must first have achieved the core competencies for application of compression bandages, management of leg ulceration and Doppler ABPI assessment. The candidate will need to identify a mentor who will supervise those assessing patients until competence has been gained, and they can be assessed on the core competencies for assessment of patients with leg ulceration and Doppler ABPI. 15. Development and Consultation Processes These guidelines were based in part on the Avon Leg Ulcer Care Programme, issued in September 1995, version 2 Leg ulcer Guidelines (2005), and version 3 (2008) The Leg Ulcer Guidelines were reviewed by North Somerset Community Partnership issue Viability Service and Bristol Community Health wound care service; Sarah Williams TVN North Somerset Community Partnership Julie Dursley TVN North Somerset Community Partnership Gail Powell CNS & Lead Leg ulcer service Bristol Community Health Val Helliar Wound care Specialist Nurse Bristol Community Health 16. Acknowledgements Mr David Mitchell Vascular Consultant Bristol North 17. References 1. Activa Compression hosiery training modulehttp:// 2. Baker S.R, Stacey M.C, Jopp-McKay A.G, Hoskin S.E. and Thompson P.J. (1991) Epidemiology of chronic venous ulcers. British Journal of Surgery. 78: Barwell J R et al (2004). Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet. 363: Page 39 of 107

40 4. Barwell-J-R et al (2000). Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers. European journal of vascular and endovascular surgery {Eur-J-Vasc- Endovasc-Surg}. 20. (4): Bosanquet N. (1992) Costs of venous ulcers - from maintenance therapy to investment programs. Phlebology. 7: BSN medical 7. Carr L, Phillips Z, & Posnett J (1999) Comparative cost effectiveness of four- layer bandaging in the treatment of venous leg ulceration. Journal of Wound Care 8 (5): Casey G. (1998) Overcoming the barriers to effective pain control. Nursing Standard. 13. (12): Charles H. and Lindsay E. (2004) Principles of Leg Ulcer Management and Prevention: Educational Booklet. The Wound Care Society. 1.(4): Chen WY, Rogers AA (2007) Recent insights into causes of chronic leg ulceration in venous disease and implications on other types of chronic wounds. Wound Rep Regen 15: Coley C (2009) Skincare for leg ulcers. Journal of Community Nursing. March 2009, 23, 3, Coull, A Clark M (2005) Best Practice Statement for Compression hosiery. Wounds UK vol 1(1) May Cutting KF, Harding KG (2004) Criteria for identifying wound infection. J Wound Care 3 (4): Dale J.J, Callam M.J, Ruckley C.V, Harper D.R. and Berry P.N. (1983) Chronic ulcers of the leg: a study of prevalence in a Scottish community. Health Bulletin.41: Dealey C (1999) Wound Care: Cleaning rights and wrongs. Nursing times 95,43, Dowsett C, ( (2011) Treatment and prevention of recurrence of venous leg ulcers using RAL hosiery. Wounds UK vol 7 no Douglas V. (2001) Living with a chronic leg ulcer: an insight into patients experience and feelings. Journal of wound care. 10.(9): Erickson C A et al (1995) Healing of venous ulcers in an ambulatory care programme: the roles of chronic insufficiency and patient compliance. J Vasc Endovasc Surg 22: Page 40 of 107

41 19. European Wound Management Association (EWMA) (2003). Position Document: Understanding compression therapy. [online] [2nd September 2005]. 20. European Wound Management Association (EWMA) (2005) Position Document. Identifying criteria for wound infection. MEP Ltd London. Available online at Franks P, Moffatt C, Connolly M, Bosanquet M, Oldroyd R, Greenhalgh R, McCullum C. (1995) Factors associated with Healing Leg Ulceration with High Compression. Age and Aging: 24; Gabillot-Carre M, Roujeau JC (2007) Acute bacterial skin infections and cellulitis. Curr Opin Infec Dis 20 (2): Gohel M.Setg al(2005). Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)-- haemodynamic and anatomical changes. British journal of surgery {Br-J- Surg}. 92: Gohel MSet al.(2007) Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised control trial. BMJ published online 1 June 2007; doi: /bmj BE 25. Graham I,D et al (2003) Prevalence of lower limb ulceration a systematic review of prevalence studies. Advances in Skin and Wound Care, 16 6, Ham, S. Padmore, J. (2006) Two layer compression for patients with venous ulceration. Nursing Standard vol 20(45) 19 July p Haynes-Stephen, J. (2006) An Overview of compression therapy in leg ulceration. Nursing Standard vol 20(32) 19 April p68,70,72,74, Hamel DC et al (2003) Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: initial results. Dermatologic surgery {Dermatol-Surg}. 29: Harding K et al Simplifying venous leg ulcer management. Consensus recommendations. Wounds International Available at Hofman D. (1997) Assessing and managing pain in leg ulcers. Nurse Prescriber/Community nurse. July Hollingworth H. (2001) Pain relief: approaches that reduce pain and aid wound healing. Nursing Times.97.(28): Page 41 of 107

42 32. Husband L.L. (2001) Venous ulceration: the pattern of pain and the paradox. Clinical effectiveness in Nursing. 5: Iglesias C, Nelson E.A and Cullum N.A. (2005) 4 Layer elastic bandages were more cost effective than multilayer in elastic bandages for healing venous leg ulcers. Evidence based nursing. [online] [2 nd September 2005]. 34. Johnson, S (2002) Compression hosiery in the prevention and treatment of venous leg ulcers. Journal of Tissue Viability vol 12 no 2 p Kulik JA,Mahler HIM (1993) Emotional support as a moderator of adjustment and compliance after coronary bypass surgery, a longitudinal study. J Behav Med 16: Levell N J, Wingfield CG, Garioch J J. (2011) Severe lower Limb Cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care: Epidemiology and Health Services Research. British Journal of Dermatology 164, Lindholm C, Bjellerup M, Ole B. C. and Zederfeldt B (1993) Quality of life in chronic leg ulcer patients: an assessment according to the Nottingham health profile. Acta Derm Venereol (Stockh). 73: Linsay E & Stephens F Effective skin care Chap14P Leg ulcers and Problems of the Lower Limb: An holistic approach. Ed E Linsay and R White (2007) Wounds UK. 39. Lymphoedema Framework, (2006) Template for Practice: Compression hosiery in lymphoedema. London: MEP Ltd 40. McDaniel HB, Marston WA, Farber MA, Mendes RR (2002) Recurrence of chronic venous ulcers on the basis of clinical, etiologic, anatomic, and pathophyiologic criteria and air plethysmography. J Vasc Surg 35: Medi formulary guide July Min-Robert-J, Khilnani-Neil, Zimmet-Steven-E. (2003). Endovenous laser treatment of saphenous vein reflux: long-term results. Journal of vascular and interventional radiology {J-Vasc-Interv-Radiol}. 14: Moffatt, C. (2007) Compression Therapy in Practice. Aberdeen. Wounds UK 44. Moffatt C. (2000) Compression therapy. Journal of Community Nursing. 14. (12) [online] [2 nd September 2005]. Page 42 of 107

43 45. Moffatt C, J, Franks, PJ, Doherty, DC, Martin, R, Blewett, R & Ross, F. (2004a) Prevalence of Leg ulceration in a London population. Quarterly Journal of medicine 97: Moffatt C. and Franks P. (1994) A prerequisite underlining the treatment programme; risk factors associated with venous disease. Professional Nurse. 9. (9): Nash R, Yates P, Edwards H, Fentiman B, Dewer A, McDowell J. and Clark R. (1999) Pain and the administration of analgesia: what nurses say? Journal of clinical nursing. 8: National Institute for Health and Clinical Excellence (2004) Endovenous laser therapy of long saphenous vein. [ ] 49. National Institute for Health and Clinical Excellence (2012) Lower limb peripheral arterial disease: diagnosis and management guidance.pdf 50. National Institute for Health and Clinical Excellence (2003) Ultrasound Guided Foam Sclerotherapy for Varicose Veins. (target date for publication of guidance March 2006)[online] [28 November NICE Clinical Knowledge Summaries (2016) 52. Nicolini P.H. and the Closure Group. (2005).Treatment of primary varicose veins by endovenous obliteration with the VNUS closure system: results of a prospective multicentre study. European journal of vascular and endovascular surgery {Eur-J-Vasc-Endovasc-Surg}. 29. (4): Posnett,J,Franks,PJ (2008) The burden of chronic wounds in the UK. Nursing Times; 104: 3, Proebstle-Thomas-M, Krummenauer-Frank, Gül-Doendue, Knop-Juergen. (2004). Nonocclusion and early reopening of the great saphenous vein after endovenous laser treatment is fluence dependent. Dermatologic surgery {Dermatol-Surg}. 30: Royal College of Nursing Institute (1998) Clinical Practice Guidelines: the management of patients with venous leg ulcers. leg ulcers.pdf [online] [26th November 2004]. 56. Royal College of nursing. (2006) Clinical practice guidelines: The nursing management of patients with venous leg ulcers Recommendations. London. Royal College of Nursing Page 43 of 107

44 57. Ruff, D. (2005) Conservative management of varicose veins Nursing Times vol 101(4) p Sarkar P.K. and Ballantyne S. (2000) Management of leg ulcers. Postgraduate Medical Journal. 76: SIGN 120 Management of chronic venous leg ulcers. A national clinical guideline (2010) 60. Tero-Raut et al. (2002). Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. Journal of vascular surgery {J-Vasc-Surg}. 35. (5): Tyler, P. Hollinworth, H. Osborne, R. (2005) The wearing of compression hosiery for leg problems other than leg ulcers British Journal of nursing (Tissue Viability supplement ) vol 14 (11) ps21 S White R et al, (2011) Evidence in venous ulcer management: a new consensus recommendation. Wounds Uk vol World Health Organisation (1996) Analgesic ladder. WHO World Health Organisation (1996) Cancer Pain Relief. WHO. 2 nd ed. Geneva [online] [28 November 2005]. 65. Zamboni-P et al(2003). Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. European journal of vascular and endovascular surgery {Eur-J-Vasc- Endovasc-Surg}. 25. (4): Bibliography Charles H. (1995) The impact of leg ulcers on patients' quality of life. Professional Nurse. 10: Cullum N, Nelson E.A, Fletcher A.W. and Sheldon T.A. (2001) Compression for venous leg ulcers. The Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD DOI: / CD Fowkes F.G.R. and Callam M.J. (1994) Is arterial disease a risk factor for chronic leg ulceration? Phlebology. 9: Page 44 of 107

45 Lees T. and Lambert D. (1992) Prevalence of lower limb ulceration in an urban district. British Journal of Surgery. 79: Logan R. (1997) Common skin conditions of shins and feet. Medicine (International). 25: National Institute of Clinical Excellence Guidelines (2001) Debriding Agents for difficult to heal surgical wounds. [online] [2nd September, 2005] Nelzen O, Bergqvist D. and Lindhagen A. (1996) Prevalence of lower limb ulceration has been underestimated. British Journal of Surgery. 83.(2): Nelzén O. (2000) Leg Ulcers: Economic Aspects. Phlebology. 15: Pankhurst S. (2004). Should ABPI be measured in patients with healed venous leg ulcers every three months? Journal of Wound Care. 13. (10): Scottish Intercollegiate Guidelines Network (1998). The care of patients with chronic leg ulcer: a national guideline. SIGN publication number 26: [online] [26th November, 2004] Simon D.A, Freak L, Williams I.M, McCollum C.N. (1994) Progression of arterial disease in patients with healed venous ulcers. Journal of Wound Care. 3. (4): Stevens J (2004) Diagnosis, assessment and management of mixed aetiology ulcers using reduced compression. Journal of Wound Care. 13. (8): Thomas S. (1998) Compression bandaging in the treatment of venous leg ulcers. [online] [19th March 2005] Vowden K. and Vowden P. (2002) Hand-held Doppler ultrasound: the assessment of lower limb arterial and venous disease. Hunt Leigh Healthcare. Vowden K.R, Goulding V. and Vowden P. (1996) Hand-held Doppler assessment for the peripheral arterial disease. Journal of Wound Care. 5. (3): Appendices Page 45 of 107

46 Appendix 1 General Assessment It is intended that the assessment of leg ulceration is carried out by a Registered Nurse trained in the theory and practice of the management of leg ulceration. A detailed assessment of the patient s general health is paramount in order to determine cause and maximise the patient s potential to heal. 1. General Assessment Age. Leg ulcers are more prevalent in the elderly and the ability to heal is decreased due to a delayed immune response to initiate healing, thinning of skin and delayed epithelialisation. There is also an increased risk of arterial involvement in the elderly. Weight and Height. - Malnutrition both in anorexia and obesity will affect healing BP / Pulse. - To detect hypertension and cardiac arrhythmias Capillary Blood Glucose. To detect raised blood glucose levels. FBC, TFTs, U&E. - Anaemia, hypothyroidism and low albumin can delay healing (Rheumatoid factor does not exclude vasculitis, as there will be many false positives.) 2. Medical History Arterial Related Peripheral Vascular disease Arterial surgery Diabetes Myocardial Infarction/Angina Stroke / Transient Ischaemic Attacks Rheumatoid Arthritis Ulcerative Colitis Venous Related Varicose Veins / surgery Pregnancy Phlebitis Previous DVT Period of prolonged bed rest Trauma or orthopaedic surgery 3. Medication e.g. Warfarin Therapy. Steroids - Can thin skin, delay healing and can induce diabetes Page 46 of 107

47 Anti-inflammatory drugs - Can affect inflammatory phase of healing. Immunosuppressant drugs - Increased risk of infection 4. Allergies Medication Dressings Latex It is important to know of any interactions to previous treatments. 5. Mobility Ability to mobilise / Distance Use of aids Abnormal walking gait Ability to use foot and calf pump. Sitting for long periods of time with legs dependant induces oedema and inability to use foot and calf pump contributes to venous hypertension. 6. Clinical Examination & Investigation Both legs should be examined at the initial assessment. Examination should note: Colour staining / erythema / cellulitis Temperature of legs Condition of surrounding skin eczema / maceration from exudate Oedema? Cardiac failure / Immobility Rash vasculitic Page 47 of 107

48 Venous Disease Oedema Eczema Ankle flare Lipodermatosclerosis Varicose veins Atrophy blanche Usually shallow Usually gaiter area Arterial Disease Shiny taut skin Dependent rubor Pale or blue feet Gangrenous toes Cold legs / feet Punched out ulcers Poorly perfused wound bed It should be noted how the ulcer occurred and its site and duration. Venous ulcers tend to deteriorate slowly. The longer an ulcer is present, the harder it is to heal due to chronic changes that occur in the wound bed and the exudate. Site It is important to record the site accurately. Venous ulcers are common in the gaiter area, whereas arterial and diabetic ulcers are more commonly present on the foot. Small patchy painful ulcers are often indicative of vasculitis. Atypical distribution of ulcers or ulcers with abnormal appearance should be referred to either a General Practitioner or Dermatologist. Biopsy may be indicated. Condition of ulcer bed this should be assessed for the presence of slough, necrosis or granulation and wound care products used appropriately to prepare the ulcer bed to heal using the local Trusts Formulary. A simple non-adherent dressing is recommended under compression for venous ulcers. Exudate note the colour, consistency and amount of exudate produced. This may give an indication of bacterial burden if purulent, malodorous or excessive. Measurement The ulcer should be traced or measured and/or photographed using acetate, grid camera or camera using a tape measure in the photo. Digital photos should be stored as per clinical photography policy (2016). See also Part 15 for consent of photographs. 7. Nutritional Status Appetite. Dietary intake Special dietary requirements Malnourishment Obesity Page 48 of 107

49 A person with a wound needs 10 20% more energy than a healthy person at rest. A balanced diet including Carbohydrate, protein, Vitamins A and C, zinc and iron is essential. 8. Smoking Status Arterial risk factor 9. Pain appendix 3 Type of pain and when it occurs Location Use pain assessment tool in pathway Current analgesia Formulate individual management plan. 10. Psychological Status The psychological effects of painful ulceration should not be underestimated. Depression, even of a mild degree, may be exacerbated by pain and social isolation. The patient s quality of life will be adversely affected these issues. This may make it difficult for the patient to comply with treatment. Strategies to help to break the cycle of poor concordance in non-healing ulcers may heal some that appear resistant to treatment. Kulik and Mahler (1993) claim: Well supported patients are more likely to comply with treatments emotional support reduces emotional distress which can itself impair treatment and recovery. 11. Patients Understanding of the Ulcer Patients understanding and involvement in their treatment is essential. Education leaflets are useful to reinforce. Consider use of contract between nurses and patient to enhance concordance. How is it affecting their quality of life; what can be realistically achieved? 12. Social Assessment Personal hygiene Family support Employment; prolonged standing or sitting. Page 49 of 107

50 Accommodation, heating, living standards Financial concerns regarding prescriptions etc. Page 50 of 107

51 Appendix 1a A Quick Assessment Guide to Managing Venous Ulcers Short Term Quick Assessment must include General Assessment from leg ulcer pathway part 2 Family history (CHD / Diabetes may be significant) Smoking history Past medical history Blood pressure Age Arterial risk increases with age <50years unlikely to have significant arterial disease > 80 years it is highly likely that there will be an element of arterial disease No arterial risk factors or other aetiology suspected < 2 arterial risk factors and no other suspected aetiology > 2 arterial risk factors Check ankle circumference Fit up to 20mmhg compression until full assessment Take blood ready for full assessment Full Assessment before applying any compression Date given for Full assessment within 2 weeks Alter compression levels as appropriate This quick assessment guide has been designed to be used as a first line option, when as a practitioner; you know that compression applied as soon as possible will promote effective wound healing. Page 51 of 107

52 IT IS NOT DESIGNED TO TAKE THE PLACE OF THE FULL LEG ULCER ASSESSMENT PATHWAY AND A FULL ASSESSMENT SHOULD BE UNDERTAKEN WITHIN TWO WEEKS. If a full assessment cannot be done within this time frame a quick assessment guide should not be considered. When using these guidelines if you are unsure of your findings or the safest way to proceed please exercise caution and contact the leg ulcer specialist nurse or any of the specialist nurses., The quick assessment guide must include: Part 2 of the leg ulcer care pathway form (General patient assessment) This must be completed. These are actual arterial risk factors and must not be ignored. The arterial signs and symptoms need careful consideration. Age It is generally considered that any person under the age of 50 years old it is unlikely to have developed significant arterial disease. It is likely that someone over the age of 80 years will have developed some element of arterial disease. Therefore you need to consider age as a potential risk factor. The higher the age the greater the arterial risk. Family history If someone has a strong family history of coronary heart disease or diabetes again you need to consider this as a potential risk factor. Smoking If they are a smoker this is a risk factor and with age the risk of arterial disease is increased. If they have quit, being a past smoker however long ago still needs to be considered. Past medical history anything of significance that might lead you the practitioner to consider this ulcer may have other aetiology. If so do not apply any compression. Blood pressure If this is raised it could be significant. Monitor further and consider when assessing the risk factors. If you have the resource, skill and opportunity it is worth using the Doppler machine to listen to the foot pulses. If you consider they are monophasic, do not use these guidelines but undertake a full assessment before applying compression. This does not replace doing a full ABPI assessment but may be a helpful tool as part of your quick assessment. Page 52 of 107

53 Appendix 1b Flow Chart Guide to Fitting Compression Hosiery When using these guidelines if you are unsure of your findings or the safest way to proceed, please be cautious and contact the leg ulcer specialist nurse or any of the named nurses with a specialist interest for advice and support. These you will find named in the appendix. The assessment guide must include: Part 2 of the leg ulcer care pathway form (General patient assessment) This must be completed. These are actual arterial risk factors and must not be ignored. The arterial signs and symptoms need careful consideration. Age It is generally considered that any person under the age of 50 years old is not likely to have developed significant arterial disease. It is likely that someone over the age of 80 years will have developed some element of arterial disease. Therefore age is an increasing arterial risk factor and needs to be considered with other arterial risk factors. Family history If someone has a strong family history of coronary heart disease or diabetes again you need to consider this as a potential risk factor. Smoking If they are a smoker this is a risk factor and with age the risk of arterial disease is increased. If they have quit, being a past smoker however long ago still needs to be considered. Past medical history anything of significance that might lead you the practitioner to consider this ulcer may have other aetiology. If so do not apply any compression. Blood pressure If this is raised it could be significant. Monitor further and consider when assessing the risk factors. If you have the resource, skill and opportunity it is worth using the Doppler machine to listen to the foot pulses. If you consider they are monophasic, do not use these guidelines but undertake a full assessment before applying compression. This does not replace doing a full ABPI assessment but may be a helpful tool to use as part of your assessment. Page 53 of 107

54 Assessment must include: General Assessment from leg ulcer pathway Part 2 Age Arterial risk increases with age Family history (CHD / Diabetes may be significant) Smoking history Past medical history Blood pressure No arterial risk factors 2 or less arterial risk factors More than 2 arterial risk factors <50 years >50 years <50 years >50 years Full Assessment before applying any compression Fit up to 24mmhg compression. Class 1 RAL. Class 1or 2 British hosiery No follow up unless you identify reasons for concerns Fit up to 24 mmhg compression with close monitoring Class 1 RAL. Class 1or 2 British hosiery 80 years and above will require close monitoring Fit up to 21mmhg compression hosiery until full assessment Date given for full assessment using leg ulcer care pathway within 2 weeks Alter compression levels as appropriate Educate Ensure good fit of hosiery Any aids required helping concordance? Arrange for re issue Importance of getting assistance if concerned Must know if worried to remove / cut off hosiery and seek help at the earliest opportunity Review annually Page 54 of 107

55 The assessment guide must include: Part 2 of the leg ulcer care pathway form (General patient assessment) This must be completed. These are actual arterial risk factors and must not be ignored. The arterial signs and symptoms need careful consideration. Age It is generally considered that any person under the age of 50 years old is not likely to have developed significant arterial disease. It is likely that someone over the age of 80 years will have developed some element of arterial disease. Therefore age is an increasing arterial risk factor and needs to be considered with other arterial risk factors. Family history If someone has a strong family history of coronary heart disease or diabetes again you need to consider this as a potential risk factor. Smoking If they are a smoker this is a risk factor and with age the risk of arterial disease is increased. If they have quit, being a past smoker however long ago still needs to be considered. Past medical history anything of significance that might lead you the practitioner to consider this ulcer may have other aetiology. If so do not apply any compression. Blood pressure If this is raised it could be significant. Monitor further and consider when assessing the risk factors. If you have the resource, skill and opportunity it is worth using the Doppler machine to listen to the foot pulses. If you consider they are monophasic, do not use these guidelines but undertake a full assessment before applying compression. This does not replace doing a full ABPI assessment but may be a helpful tool to use as part of your assessment Page 55 of 107

56 Appendix 2 Doppler Assessment Doppler assessment 1) Procedure: a. The patient should lie as flat as possible and be allowed to relax for at least 15 minutes before any Doppler readings are taken to allow the blood pressure to equalise throughout the body. Any deviation from the patient lying flat should be recorded. The procedure can be explained and the patient history can be taken during this time. b. Using the appropriate Doppler probe instead of a stethoscope, record the brachial systolic pressure in both arms. c. Cover the ulcer with cling film and place the sphygmomanometer cuff around the leg just above the ankle. The sphygmomanometer bladder must circle two thirds of the leg. If it does not then a larger / smaller cuff will be needed. d. Identify the Dorsalis pedis, anterior tibial and posterior tibial pulses. Using plenty of ultrasound gel, locate the pulses with the Doppler probe and record the pressures on two of the pulses on each limb, even if only one limb is ulcerated. e. Note the quality of the pulses and what type of signal is heard; i.e. triphasic, biphasic, monophasic or muffled sounds. If all pulses are equal sound & strength, pump up on the PTA and one other pulse. f. Calculate the Ankle: Brachial Pressure Index (ABPI), by dividing the highest ankle pressure for that limb by the higher of the two brachial pressures. g. For the patient with diabetes ABPI needs to be interpreted with caution due to the risk of micro vascular and macro vascular circulation problems. Page 56 of 107

57 Table 4: Interpretation of ABPI ABPI Signal Interpretation >1 Triphasic Normal > 0.8 Triphasic/Biphasic No significant arterial disease. Considered safe to apply compression therapy > 0.8 Monophasic Incompressible arteries. In this instance ABPI will not give an accurate indication of arterial flow to the foot (false high reading) Mono/biphasic (unlikely to hear triphasic) Mono/biphasic (unlikely to hear triphasic) <0.4 Monophasic (unlikely to hear bi/triphasic) Mild to moderate arterial disease. Consider reduced compression and monitor closely. Moderate to severe arterial disease. Severe arterial disease. Symptoms i.e. rest pain may warrant urgent vascular referral 2) What to do about the ABPI? The ABPI cannot be taken alone as an indicator of the safety of applying compression bandaging. It is important to remember that other factors are involved as identified in the holistic assessment. Oedema and/or induration in the leg can give a false high reading because greater pressure is required to compress the artery under the accumulation of fluid in the limb. The ABPI may be within normal indices in some patients with a history of arterial disease e.g. history of intermittent claudication pain. These patients should be referred for a stress or exercise tolerance test to detect arterial insufficiency. In patients with disease affecting their small blood vessels such as rheumatoid arthritis and diabetes, the large vessels may be patent giving a good ABPI, but there may be severely compromised blood flow in the micro-vessels. Patients with calcified arteries, common in diabetes, the blood vessels will be very difficult to compress with the sphygmomanometer cuff, and therefore, artificially high ABPI s will be obtained. TBPI (toe pressures) may be indicated, which will give a more accurate result in some conditions. If there is any doubt as to the significance of the Doppler readings consult a specialist practitioner. Page 57 of 107

58 3) Frequency of Doppler Assessments Patients who are healing well under compression will be appropriate for 6 12 monthly reassessments All patients with an open ulcer in compression bandages should have their ABPI monitored; the frequency of this should be individually assessed. Patients whose ulcers are static should be reassessed according to LU care pathway. Patients whose ulcers are deteriorating should have an urgent reassessment in response to this. Patients that have an elevated risk of their arterial circulation becoming compromised should have a reassessment performed 3 6 monthly. Page 58 of 107

59 Appendix 3 Pain Pain Pain can have a detrimental effect on a person s health and quality of life as a result of the physical, psychological and social consequences of suffering pain. The development of pain may indicate a number of possible causes including a change in aetiology of the ulcer, as is the case in deteriorating peripheral arterial occlusive disease. It may also indicate that an infection is developing or that treatment is not suiting the patient. In some cases it may signal that the treatment is being poorly or inappropriately applied, such as over tight compression bandages. Assessment of pain is an important aspect of nursing documentation (Nash et al.1999), found pain management is the key function of health care professionals and as nurses spend more time with patients than any other healthcare professional group have a major role to play in its management. A review of the literature asserts that despite pain being the main feature of leg ulceration, venous and arterial, there is evidence to suggest, that it is an aspect that is ignored by healthcare professionals (Husband, 2001; Douglas, 2001). Varying patterns of pain and discomfort and experienced by patients with venous disease. Patients report aching heavy legs, particularly in the calf region, which is often relieved when the patient can lie or sit with their limb elevated and is worse during the summer. The symptoms are probably directly linked to the development of venous hypertension (high pressure in the superficial veins and micro circulation which is relieved on high elevation. Casey (1998) suggests that pain assessments should be carried out at every treatment of the wound. A pain scale should be used when assessing patients pain, (National Pain Society) Hofman (1997) found that patients are usually pleased that their pain is understood and is being taken more seriously. Concordance is encouraged and patients more likely to tolerate treatments such as compression bandaging. Pain assessments can help to demonstrate effective treatment. Normally as an ulcer heals, so the pain gets less, therefore pain charts alongside tracings and wound documentation can show progress and deterioration. Pharmacological therapy The World Health Organisation has created guidelines to assist clinicians to use a variety of drugs available for the pharmacological management of pain. A stepwise method of symptomatic therapy, known as the analgesic ladder WHO (1996). For mild to moderate pain, regular oral Paracetamol are appropriate. If this fails to bring relief, they should be replaced by the regular administration of codydramol, cocodamol. Page 59 of 107

60 If this fails to bring relief, they should be replaced by the regular administration of a drug from the next rung a weak opioid, i.e. codeine, dihydrocodeine (special care in elderly). If pain relief is still not achieved with the maximum recommended dose, then movement upwards towards the next strong analgesic rung opioids. Non-opioid analgesics (non-steroidal anti-inflammatory drugs) are effective in treating mild to moderate pain when an inflammatory component is present, i.e. Ibuprofen, Diclofenac Sodium, Naproxen. Adjuvant analgesics may be effective without concurrent analgesics i.e. anticonvulsants e.g. Carbamazepine, Gabapentin and Amitriptyline (Tricyclic drug) are used for the treatment of burning, stabbing pains Gabapentin is a class of drug called anticonvulsants and relieves the pain by changing the way the body senses pain. Amitriptyline works by increasing the amounts of natural substances in the brain and changes the way pain is felt. Amitriptyline should be introduced in small doses and due to their sedative action, be taken at night. Doses in excess of 30mgs may be required and it may take several weeks before the correct dose is achieved. Nurses and doctors should examine their goals for pain relief, and work with the patients to achieve appropriate outcomes of pain management. Pain can be multidimensional and analgesia is just one aspect of management. Patients should be taught how to manage their pain effectively. Analgesia should be used regularly rather than waiting until pain has developed. Practical strategies such as written instructions and dosette boxes can significantly improve pain therapies. A comprehensive approach to pain control advocated to pain control advocated by the WHO (1996) should be adhered to, working, as a team is crucial for optimum care. Page 60 of 107

61 Appendix 4 Emollients Emollients Emollients- this includes some of the commonly used emollients, however there are others available on prescription and /or over the counter Refer to Emollient Use Patient Guide Medicine Management team (2015) Criteria for choice Avoid soap, bubble bath and shower gels which strip skin of natural oils Emollients- listed from bath oils and light creams to greasy ointments. Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling skin conditions. The affects are short lived and they need to be re-applied frequently. Emollients should be applied in the direction of hair growth to prevent folliculitis. Severity of condition, patient preference, site of application and time available will influence the choice of emollient. Bath Additives: Hydration can be improved by soaking in the bath for minutes. Warning: They can make people and surfaces slippery Oilatum Balneum Hydromol bath and shower emollient* Dermol 600 ** QV Bath Oil and wash Dermol 200 shower* emollient Spray: useful for hard to reach areas, very light, care is needed with application as this can be sprayed onto surfaces as well as skin. Lotions: Useful for application to large hair bearing areas or treatment of exudative areas. Have a cooling effect, can sting when used over broken areas of skin if in alcohol basis preparation. Gels: Have high water content particularly suitable for Emollin Dermol 500** Aveeno lotion QV Lotion Double base Gel Page 61 of 107

62 application to scalp and face. Quick and easy to apply and absorbs well. Does not have the tacky messy feeling as with grease based products. Creams: Generally well absorbed into the skin more cosmetically acceptable than ointments because less greasy and easier to apply, may contain anti-bacterial or fungicides. Can cause sensitivity reactions due to the preservatives Cetraban cream* Hydromol cream Epaderm cream* Dermol cream** QV cream Aveeno cream Unguentum M* Ointments: Greasy and more occlusive than creams, ideal for chronic dry skin conditions. Encourages hydration often have mild ant inflammatory effect and lock in the skins natural moisture and acts as a barrier to irritants. Can mark clothing and fabrics. Very effective but sometimes difficult for patients to use. May be cosmetically unacceptable to some patients. Good under bandaging when left for a week. Hydromol Ointment * Epaderm Ointment* Emulsifying Ointment White soft paraffin liquid paraffin 50/50 PATIENTS MUST BE WARNED THAT PARAFFIN CONTAINING PRODUCTS THAT ARE FLAMMABLE THIS SHOULD BE DOCUMENTED IN NOTES. Aqueous cream: Should only be used as a soap substitute not as leave on emollient as can cause irritation (Cork et al 2003). The * denotes emollients suitable for use as soap substitute. This can also be used as a moisturizer unless a lighter or greasier moisturiser is preferred. As a general rule the drier the skin the greasier the moisturiser Emollients with specific properties Antibacterial- **Dermol range useful for infected/excoriated eczema and MRSA. Should not be used as long term emollient therapy. Containing Urea a hydrating agent, useful for scaly conditions. May cause stinging. Aquadrate, BSN acute 5% & 10% Urea, Calmurid or Eucerin. Urea enhances Page 62 of 107

63 absorption of topical steroids. Balneum Plus contains urea and Lauramacrogols that have a local antipruritic action. References BMA and Royal Pharmaceutical Society of Great Britain (2009) British National Formulary (BNF 60) September BMA and Royal Pharmaceutical Society of Great Britain London. Best Practice In Emollient Therapy: A Statement for Health care Professionals Dermatological Nursing 2007 An Audit of adverse drug reactions to aqueous cream in children with atopic eczema: M.J Cork et al Pharmaceutical Journal, Vol November 2003 Looking after elderly skin- a simple guide, British Association of Dermatologists Patient information sheet, Prepared by the Senior Skin Group, October 2006 Best Practice Wounds UK BPS Care of the Older Persons Skin Page 63 of 107

64 Appendix 5 Steroid Ladder Very Potent Dermovate Dermovate NN Potent Betnovate Betnovate C Synalar Betnovate N Diprosalic Elocon Locoid Locoid C Cutivate Diprosone Fucibet Moderate Betnovate RD Eumovate Trimovate Calmurid HC Haelan Synalar 1:4 Mild Hydrocortisone 0.5%, 1% & 2.5% Fucidin H Nystaform HC Canestan HC Synalar 1:10 Alphosyl HC Daktacort Timodene Page 64 of 107

65 Appendix 6 Compression Hosiery Compression Hosiery The use of hosiery in the management of leg ulceration has expanded in recent years. The three areas in which it is predominantly used are: Healing Secondary prevention - Maintaining a healed state Primary prevention Healing There are now hosiery systems available that can be used instead of compression bandages where concordance maybe an issue. These systems with a liner and below-knee sock provide approximately 40mmHg pressure at the ankle. It is also possible to use off-the-shelf or made-to-measure hosiery to achieve a healed state. It is important to be aware of the levels of compression that are being applied if using hosiery. Using hosiery, while effective, tends to have a slower healing rate. It is not always suitable for heavily exudating and /or large leg ulcers. Compression rate /Classification 40mmhg RAL (Stiffer fabric) Ankle 18cm 32cm Calf 28cm 52cm Petite and regular length Manufacturer Mediven leg ulcer kit 20:20 (Medi) Liner constant 20mmhg Sock 20mmhg while active. Supplied with 2 liners and 1 sock. Liner sock available separately (2 per box) Comments First choice when considering using hosiery kit due to fabric stiffness Beige colour only 7 sizes available Inc. and regular and extra wide calf size. Will need renewing 6 monthly Needs to be fitted correctly around heel to ensure correct compression rates Page 65 of 107

66 40mmhg British (Softer fabric) Ankle cm Calf cm 40mmhg RAL (Stiffer knit fabric) Ankle 18cm 39cm Calf 29cm 60cm Activa Leg ulcer hosiery kit Liner 10mmhg Sock average 30mmhg Supplied 2 liners and 1 sock Liners available separately (3 per box) Jobst Ulcercare (BSN) Liner and sock compression rates individually not available Liners available separately (3 per box) Available in black or sand 5 sizes available Will need renewing at 100 washes or approx. 3 months Available in black and beige 7 sizes Available with or without zipper needs to be opposite side to ulceration Not recommended to wear over sock during bed rest Custom made available discuss with wound care service before ordering. Secondary prevention - Maintaining a healed state Once a leg ulcer has healed the patient needs lifetime compression therapy due to the underlying venous pathology. Recurrence rate varies from 33% to 67%. 67% will experience 2 or more episodes of re-ulceration 21% will experience more than 6 episodes of re-ulceration Ulcers which are greater than 10cm in size, the chronicity of an ulcer, a history of deep vein thrombosis and clotting disorders, along with the unsuitability or nonconcordance with hosiery are all risk factors that increase the chance of recurrence. The patients should be fitted hosiery with compression levels at 25 33mmhg at the ankle. RAL / European standard class 2 or British standard class 3. (RCN 2006) Page 66 of 107

67 If this is not possible the patient needs to be fitted with the highest level of compression they will tolerate but there will be an increased risk of re-ulceration. (RCN 2006) A lower compression level will need to be used if you have healed the patient in reduced compression. Close monitoring and caution if fitting hose to mixed aetiology/arterial ulcers. Compression Standards / Hosiery Pressure Comparison Table Mmhg at ankle RAL /European standard British standard Class 1 Class 2 Class 3 Class 1 Class 2 Class Ideal Adapted from Medi UK Ltd July 2012 Patients should not be fitted with compression hosiery until the skin is sufficiently robust enough to enable the stocking to be drawn over the ulcer site. The patient or carer will require a hosiery fitting aid that suits them, due to fabric stiffness and level of compression in the hosiery. See appendix A. Education for patients regarding the need for life long support of the veins in their legs is paramount and should be emphasised from the point of assessment Page 67 of 107

68 Recommended hosiery Manufacturer Classification Comments Medi Activa Medi Mondi BSN Elvarex Activa Actilymph MTM RAL (European) standard Mediven range Inc. socks for men 7 sizes available for both regular and extra wide calf circumference Thigh circumference also in extra wide Petite and regular lengths Foot length standard all sizes British standard Duomed (stiffer fabric than normal British std hose) European standard Actilymph range 5 sizes available size ranges overlap for calf and thigh measurements Petite and regular lengths Foot length variable British standard Activa range Inc. unisex socks for men 5 sizes available One length Foot length variable Made to Measure Available as British or European standard First choice when considering using hosiery due to fabric stiffness Will need renewing 6 monthly More information er-limb Activa is a finer knit hosiery that will pull into creases and deformities Actilymph is a stiffer knit fabric. Will need renewing at 100 washes or approx. 3 months More information sion-hosiery For standard shape and length legs the above listed ready - made hose will suit If you need to use made to measure use the correct form of the manufacturer, they are not interchangeable. Available from company web sites There can be a long manufacturing time. Speak to the wound care service or the rep for advice. BSN - - other web addresses above Page 68 of 107

69 Fitting Hosiery Hosiery should be fitted by a practitioner who can demonstrate a knowledge and understanding of compression hosiery and is competently trained in hosiery application. It is essential that it fits well. Ideally hosiery should be removed at night and reapplied first thing in the morning. Advocating good skin care before reapplying is essential, along with checking the feet and legs for any damage. If this is not possible an extended wear time of up to 7 days is possible. Patient dexterity, their cognitive ability and agility need to be considered when fitting hosiery. It may be that the patient needs supervision to apply their hosiery or it may need to be fitted by a carer. The use of various aids can also be a valuable tool for application, fitting and removal (see table in Aids section) Measurement Ideally measurements should be taken in the morning, following removal of compression bandages or after keeping the limb suitably elevated to reduce oedema. Initial measurements need to be on bare legs and include: Ankle the narrowest point just above the malleolus (approx. 5cm). If there are ankle deformities the narrowest point may be too high up the leg to be accurate Calf the widest point Foot length Thigh the widest part or 5 cm below the groin, if stockings are required, rather than below the knee Below the knee width 2 fingers below where the back of the knee creases (required for some kits) If the patient does not fit into an off-the-shelf range then made-to-measure needs to be considered. It is important to use the correct measuring guide for the company you have chosen to ensure the correct fit. Fabric Stiffness A stiffer knit fabric is preferable as it is less likely to cut into or cause a tourniquet effect to the limb. (Lymphoedema Framework 2006). British Standard items tend to be knitted using thinner yarn that produces a finer finish. Cosmetically may be more suitable but are more likely to cut in or tourniquet. RAL / European standard items tend to be knitted with a thicker yarn that gives a stiffer and thicker finish but are less likely to cut in or tourniquet. Style It is important to work with the patient to find what will suit their lifestyle, be comfortable and aid concordance. Open or closed toed - this can be the patients choice providing there is not a clinical need for open toed. Page 69 of 107

70 Colour - again this should be the patients choice. It is important to remember that the darker the colour of the hose the increased chance of skin sensitivities developing due to the dyeing process. Below knee hosiery is usually suitable. Thigh length hosiery is required if the patient has varicosities or oedema around the knee joint and / or the thigh area. Patients with arthritis may find thigh length more comfortable. Most manufacturers have a range of compression socks for men - these are designed for the male foot, ankle and leg shape. If the unaffected leg does not have significant arterial disease and the ABPI supports this, it is best to fit hosiery to both legs. If the unaffected leg is fitted with hosiery at the start of using compression bandages many of the problems can be overcome prior to the affected leg being suitable for hosiery when it is healed. It is important that hosiery is renewed regularly to maintain the correct compression rates. Skin care products and regular washing will cause the hosiery to deteriorate. Generally one pair of hosiery will last between 3-6 months. The overall performance of hosiery will be affected if they have tears, ladders or holes. RAL / European last longer than British standard. All wrinkles need to be removed and this can be done by smoothing upwards using a pair of household rubber gloves. Hosiery must never be folded over at the top band. Hosiery should be washed in non-biological detergents and should not be dried over direct heat. Prescription information Do not order hosiery generically on prescription. Ensure the prescription has. Manufacturer and range, Class and Standard, Size, Length, Open or Closed toes, Colour and any aid required. Education This needs to start at the point of the assessment and should include: The importance of skincare Importance of a good fit Care of hosiery Renewal of hosiery Importance of concordance with hosiery Early referral with possible skin break downs Avoidance of self- treatments from over the counter Maintaining mobility and exercise Footwear Diet Page 70 of 107

71 Aids available to aid application, removal or wearing Patients who are having hosiery applied by home care services need to have an applicator aid prescribed when hosiery is ordered on prescription. Bath / Shower Aid Type / manufacturer Comment Limbo Slim build Slim build /short leg Normal build Normal build / short leg Large build Large build / short leg FP10 Short leg suits height normal leg height Slim build 35 39cm leg circ Normal build 39 54cm leg circ Large 52cm 6 Applicators Open Toes Closed toes & Open toes Seal tight Adult short leg Adult short wide leg (leg circ >16 Chinese slippers Supermarket carrier bag Easy slide - Credenhill Act glide Medi 2 in 1 Venotrain glider FP10 Heel to seal length 23 for both Available with some hose FP10 FP10 FP10 Non prescription Closed toe Easy slide Caran - Credenhill General Household rubber gloves Removal Aids Easy off Medi Medi 2 in 1 Non prescription Non prescription FP10 Frames Avoid slippage Sockade - urgo Valet - Medi Suspenders Silicone bands Glue Waist Attachments FP10 Non-prescription various sizes FP10 Can be added to some hose Non FP10 Available with some thigh length hose Page 71 of 107

72 Primary prevention This might present opportunistically and prevention is always a better option than cure. GP s will sometimes request fitting hosiery rather than using diuretics for oedema. It may be that this group of patients can be managed in class 1 British or RAL standard, but it will depend on the level of oedema. Use the Guideline to fitting hosiery flow chart Appendix 1b when considering fitting compression hosiery, especially as a preventative measure. Page 72 of 107

73 Appendix 7 Competencies Competencies Roles and Responsibilities for Students undertaking practice competencies: Compression Bandaging/Doppler assessment These core competencies should be used in conjunction with the Leg ulcer programme. To be competent you must have attended the two day leg ulcer study days and fulfilled the criteria for assessment with your mentor. It is expected that the competencies should be completed within a six month frame work or earlier. During this period you are expected to practice with a mentor and be supported until you are confident and competent in your practice ready for assessment. A mentor is someone who has undertaken the study days and has been deemed competent to practice normally in your own work area. This may prove difficult for some and so an alternative mentor must be found i.e. another work area. Students must carry out self-assessment scale at the beginning of the competency programme. Competence is achieved at level 3 Advanced practitioners, who will be at a level to sign off practitioners, will achieve levels 5. Page 73 of 107

74 Appendix 8 Competency Template for Compression Bandaging Generic Competencies - Delivering high quality CARE through COMPETENCE "Competence is having the knowledge and skills to do the job and the capability to deliver the highest standards of care based on research and evidence."* Note: Prior to completing the following competencies: *The relevant training must have been attended *Both Practitioner and Assessor are to sign in the competency boxes below. Assessors must award a score *It is important that both practice and theoretical knowledge are assessed *Practitioners must have a minimum of one supervised practice signed prior to formal assessment. Knowledge base: Competency Framework for Compression Bandaging Name of practitioner to be assessed: Name of Assessor: Competency sign off date: Scoring system: 1 = Minimal knowledge and skills 2 = Competent with input 3 = Competent 4 = Competent to a high standard 5 = Competent, experienced and able to teach others Page 74 of 107

75 1 Knowledge Identify and describe own professional accountability. Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessme nt Initial and Date 1st 2nd Initial and Date and Score Identify relevant local and national policies; and research to aid practice. 3 Demonstrates knowledge of comprehensive assessment (I.C.P) and ABPI results. 4 Demonstrates an awareness of Laplace s law in clinical practice. 5 Discuss bandage system for all leg sizes. 6 Demonstrates knowledge of purpose of each layer. 7 Demonstrates knowledge of limb reshaping. 8 Demonstrates a knowledge and purpose of each layer. 9 Discuss patient information and health promotion that should be considered when treating patients with leg ulceration. 10 Discuss the decision making pathways you would take to decide if you need to refer on Page 75 of 107

76 Skills Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessme nt Initial and Date 1st 2nd Initial and Date and Score Communicates with individuals and carers in a manner which encourages an open exchange of views and information whilst treating them with dignity and respect. 2 Demonstrate the individual understands the intended assessment is fully informed and has capacity to give consent and records this accurately. 3 Provides appropriate management to the ulcer site and surrounding skin. 4 Accurately measures the ankle circumference. 5 Assemble correct bandage system pertaining to patient circumstances and/or aetiology. 6 Demonstrates correct padding of the leg. 7 Demonstrates accurate application of compression with each layer applied. 8 Achieves appropriate and accurate graduated compression therapy. 9 If appropriate offers appropriate health promotion and educational advice to the patient and/or carer. Page 76 of 107

77 10 Develops strategies for managing potential problems in negotiation with the patient. 11 Correctly documents management system used. 12 Implements an appropriate management strategy for the patient and healthcare teams. Attitude 1 Adhere to professional code of conduct and act professionally at all times. Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Compassion - Maintain respect, dignity and equality at all times. 3 Communication - Act as an advocate for the patient involving them in decisions and providing them with the all information to enable informed consent. 4 Be accountable for practice, work within limitations and be able to seek advice. 5 Acknowledge responsibility in maintaining competence in this skill. 7 Courage - Demonstrate the knowledge of how to report poor practice. 8 Commitment - Demonstrate a commitment to achieving competency. *Developing the Culture of Compassionate Care - NHS Commissioning board and Department of Health Page 77 of 107

78 Appendix 9 Competency Template for Compression Hosiery Generic Competencies - Delivering high quality CARE through COMPETENCE "Competence is having the knowledge and skills to do the job and the capability to deliver the highest standards of care based on research and evidence."* Note: Prior to completing the following competencies: *The relevant training must have been attended *Both Practitioner and Assessor are to sign in the competency boxes below. Assessors must award a score *It is important that both practice and theoretical knowledge are assessed *Practitioners must have a minimum of one supervised practice signed prior to formal assessment. Knowledge base: Competency Framework for Compression Hosiery - Doppler ABPI Name of practitioner to be assessed: Name of Assessor: Competency sign off date: Scoring system: 1 = Minimal knowledge and skills 2 = Competent with input 3 = Competent 4 = Competent to a high standard 5 = Competent, experienced and able to teach others Page 78 of 107

79 Knowledge 1 Identify and describe own professional accountability. Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Identify relevant local and national policies; and research to aid practice. 3 Demonstrates knowledge of comprehensive assessment (I.C.P) and ABPI results. 4 Knowledge and awareness of hosiery selected should be appropriate to the presenting needs of the patient. 5 Selection of styles available. 6 Practitioners have the knowledge of hosiery available on FP10/GP10. 7 Demonstrate an awareness of the difference between German RAL classification and the British Standard classification and understand when each should be used. 8 Demonstrates knowledge of hosiery application. Page 79 of 107

80 Skills Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Communicates with individuals and carers in a manner which encourages an open exchange of views and information whilst treating them with dignity and respect. 2 Demonstrates the ability, knowledge and understanding to explain the principles of compression hosiery to the patient and obtains consent. 3 Appropriate management of skin. 4 Accurately measures for stock sizes of Hosiery. 5 6 Accurately measures for custom made hose using appropriate documentation. Selects appropriate hosiery according to lower limb assessment size and shape. 7 Demonstrates fitting of stock hosiery. 8 Demonstrates fitting of Custom hosiery. 9 Able to teach patients and carers in the application of hosiery. Page 80 of 107

81 10 Patients and carers are aware of the wear time. 11 Correctly documents care planning re aftercare and follow up for re ordering and replacement. 12 Implements an appropriate management strategy for the patient and healthcare teams. Attitude Date trained Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Adhere to professional code of conduct and act professionally at all times. 2 Compassion - Maintain respect, dignity and equality at all times. 3 4 Communication - Act as an advocate for the patient involving them in decisions and providing them with the all information to enable informed consent. Be accountable for practice, work within limitations and be able to seek advice. 5 Acknowledge responsibility in maintaining competence in this skill. Page 81 of 107

82 7 Courage - Demonstrate the knowledge of how to report poor practice. 8 Commitment - Demonstrate a commitment to achieving competency. *Developing the Culture of Compassionate Care - NHS Commissioning board and department of Health Page 82 of 107

83 Appendix 10 Competency Template for Compression Doppler Generic Competencies - Delivering high quality CARE through COMPETENCE "Competence is having the knowledge and skills to do the job and the capability to deliver the highest standards of care based on research and evidence."* Note: Prior to completing the following competencies: *The relevant training must have been attended *Both Practitioner and Assessor are to sign in the competency boxes below. Assessors must award a score *It is important that both practice and theoretical knowledge are assessed *Practitioners must have a minimum of one supervised practice signed prior to formal assessment. Knowledge base: Competency Framework for Doppler ABPI Name of practitioner to be assessed: Name of Assessor: Competency sign off date: Scoring system: 1 = Minimal knowledge and skills 2 = Competent with input 3 = Competent 4 = Competent to a high standard 5 = Competent, experienced and able to teach others Page 83 of 107

84 Knowledge 1 Identify and describe own professional accountability. Date train ed Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Identify relevant local and national policies; and research to aid practice. 3 Demonstrates knowledge of comprehensive assessment (I.C.P). 4 Knowledge of appropriate position and rest period. 5 Demonstrate knowledge of effect of the immediate environment on the procedure. 6 Demonstrates an understanding of need to check and maintain equipment. 7 Demonstrates knowledge of all ABPI results and associated pathways of care. Page 84 of 107

85 Skills Date train ed Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Communicates with individuals and carers in a manner which encourages an open exchange of views and information whilst treating them with dignity and respect. 2 Demonstrate the individual understands the intended assessment is fully informed and has capacity to give consent and records this accurately. 3 Demonstrates an ability to take a comprehensive patient assessment. 4 Provides appropriate management to the ulcer site. 5 Assemble correct equipment with appropriate probe. 6 Selects correct gel for procedure and uses appropriately. 7 Distinguish arterial and venous blood supply. 8 Distinguish normal and abnormal sounds. 9 Select correct readings to calculate ABPI. 10 Perform calculation appropriately and reaches correct answer. Page 85 of 107

86 11 Interpret the results and explain the significance of the findings. 12 Correctly documents the results. 13 Implements an appropriate management strategy for the patient and healthcare teams. Attitude 1 Adhere to professional code of conduct and act professionally at all times. Date train ed Initial and Date Observed Practice Supervised Practice Initial and Date Formal Assessm ent Initial and Date 1st 2nd Initial and Date and Score Compassion - Maintain respect, dignity and equality at all times. 3 Communication - Act as an advocate for the patient involving them in decisions and providing them with the all information to enable informed consent. 4 Be accountable for practice, work within limitations and be able to seek advice. 5 Acknowledge responsibility in maintaining competence in this skill. 7 Courage - Demonstrate the knowledge of how to report poor practice. 8 Commitment - Demonstrate a commitment to achieving competency. *Developing the Culture of Compassionate Care - NHS Commissioning board and department of Health Page 86 of 107

87 Appendix 11 Mixed Aetiology Leg Ulcer Pathway (Complex) Mixed Aetiology Leg Ulcer Pathway (Complex) (ABPI ) (Please refer to Inclusion Criteria and Leg Ulcer Guidelines) Initial leg ulcer assessment Diagnosis of Mixed Aetiology Ulceration Free from devitalised tissue and / or infection Critically colonised (with or without thick fibrinous slough) Treat with Antimicrobial dressing (refer to NSCP Wound Management Formulary) and reduced compression for 4 weeks. Refer to Tissue Viability Service if wound still appears Critically Colonised after 4 weeks Treat with Atrauman AND appropriate Reduced Compression (compression hosiery or bandaging see Leg Ulcer Guidelines 2016) 6 week assessment has there been a wound area reduction of 20% Continue with Atrauman Commence Urgo start contact. Request supply from Formeo Re-assess at 12 weeks If <20% wound reduction refer to Tissue Viability Service Week 12 re-assessment, if no wound reduction stop the Urgo start contact and refer to Tissue Viability Service Re-assess at 18 weeks continue with Atrauman *If <20% wound reduction refer to Tissue Viability Service 24 week assessment Page 87 of 107 Document date of healing if sooner than 24 weeks and inform Tissue Viability Service

88 Appendix 12 Venous Leg Ulcer Standard Pathway Venous Leg Ulcer Standard Pathway (Please refer to inclusion criteria and leg ulcer guidelines) Initial leg ulcer assessment Diagnosis of venous ulceration and full compression indicated Free from devitalised tissue and / or infection Critically colonised (with or without thick fibrinous slough) Treat with Antimicrobial (refer to NSCP wound management Formulary) and appropriate compression for 4 weeks. Refer to Tissue Viability Service if wound still not improving after 4 weeks Treat with Atrauman and appropriate compression bandaging. Only use a superabsorbent if absolutely necessary, and do not use surgipads. Use Cutimed Siltec Foam Dressing if using hosiery kits. Re-assessment at 6 weeks Re-assessment at 12 weeks Re-assessment at 18 weeks (Refer to leg ulcer guidelines and care-pathway to aid assessment) At each re-assessment 6, 12, 18 weeks Has progression been achieved? Aiming for at least a 30% reduction in wound surface at each re-assessment Not following expected healing progression? <30% reduction in surface area of wound in 6, 12, 18 week re-assessment Continue with Venous Leg Ulcer Standard Pathway Move to Venous Leg Ulcer Complex Pathway or refer to Tissue Viability Service Week 24 re-assessment Refer to Tissue Viability Service if not healed. Page 88 of 107

89 Appendix 13 Venous Leg Ulcer Pathway (Complex) Venous Leg Ulcer Complex Pathway (Please refer to Inclusion Criteria and Leg Ulcer Guidelines) Initial leg ulcer assessment Diagnosis of Venous Ulceration Free from devitalised tissue and / or infection Critically colonised (with or without thick fibrinous slough) Treat with Antimicrobial dressing NSCP Wound Management Formulary and appropriate compression for 4 weeks. Refer to Tissue Viability Service if wound still appears Critically Colonised after 4 weeks or exudate not reducing. If improved Treat with Atrauman and appropriate Compression 6 week assessment has there been a wound area reduction of 20% or more? Continue with Atrauman Commence Urgo start contact. Request supply from Formeo Re-assess at 12 weeks Is there a 20% wound reduction since 6 week assessment? Yes Continue with Atrauman No Return to start of Complex Pathway Re-assess at 18 weeks If <20% wound reduction since 12 weeks refer to Tissue Viability Service Re-assess at 12 weeks if reduction of 20% continue with Urgo Start Week 24 week assessment Document date of healing if sooner than 24 Weeks and inform Tissue Viability Service Page 89 of 107

90 Appendix 14 Standard Venous Leg Ulcer Pathway Inclusion Criteria Standard Venous Leg Ulcer Pathway Inclusion Criteria Ankle Brachial Pressure Index 0.8 and above with Biphasic / Triphasic Sounds First episode of ulceration Less than 3 episodes of infection or cellulitis Ulcer less than 10cm sq. Patient currently in or willing to have full compression (40mmHg) Complex Inclusion Criteria Ankle Brachial Index 0.8 and above with Biphasic / Triphasic Sounds Ulcer greater than 6 months old More than 3 episodes of cellulitis or infection Ulcer any size Possibility of raised protease activity with the wound being chronic Patient currently in or willing to have full compression (40mmHg) Mixed Aetiology / Complex Inclusion Criteria Ankle Brachial Pressure Index Biphasic Sounds (if Monophasic, discuss with Tissue Viability service. See NSCP Leg Ulcer Guidelines 2016) Any duration of ulceration Any size ulceration Possibility of raised proteases Patient in or willing to be treated in reduced compression (20mmHg and below) Exclusion Criteria for Treatment Pathway Ischaemic or ABPI lower than 0.6 Patient non-concordance Inability to optimise management of underlying comorbidities (e.g. persistent anaemia, hyperglycaemia, Active Rheumatoid Arthritis) End of Life status Page 90 of 107

91 Appendix 15 Leg Ulcer Care Pathway Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Address: This Care Pathway Form should be used as part of the holistic assessment of patients with a leg ulcer. It in no way replaces clinical judgement. Where space is limited use the continuation sheets at the back. This will be filed in the medical notes. Part 1: Demographic Details GP Name: Tel No: Surgery: DN / Name Nurse: Address: Tel No: Date of Assessment: Name of Assessor: Place of Assessment: Signature: Source of Referral: GP Self Relative Hospital PN DN Other: NOTE CLINICAL FINDINGS FROM THE HOLISTIC AND ULCER ASSESSMENT MUST BE CONSIDERED ALONG WITH A.B.P.I. WHEN MAKING A DECISION ABOUT TREATMENT NURSING DIAGNOSIS OF LOWER LIMB AETIOLOGY (please circle) Venous / Arterial / Mixed / Traumatic / Malignant / Diabetic / Rheumatoid / Other (please state).... Is sustained graduated compression indicated? Yes No Is referral to a specialist indicated? Yes No Specialist Nurse agreement of treatment plan / application of compression bandage system. Signature Specialist/Registered nurse Signature of Assistant Practitioner: Print Name: Date: Print Name: Date: Comments: Page 91 of 107

92 Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Address: Part 2 General Patient Assessment Past Medical History: Current medication & dose: Known drug allergies: Allergies to dressings / topical preparations (including rubber) Evidence of Neuropathy No Yes: BP: P: HB: Glucose: Other bloods: Venous Related Risk Factors Left Right Left Right Deep vein thrombosis Y N Y N Thrombophlebitis Y N Y N Past surgery Y N Y N Varicose veins Y N Y N Past venous surgery Y N Y N Prior venous ulceration Y N Y N Lower leg fractures Y N Y N Orthopaedic surgery Y N Y N Multiple pregnancies (3+) Yes No Varicose veins Y N Y N Induration (hard woody feeling in skin) Any prolonged periods of bed rest Venous Related Signs / Symptoms Yes Left Right Left Right Pigmentation (brown staining) No Y N Y N Y N Y N Varicose eczema Y N Y N AtrophIe blanche Y N Y N Ankle flare Y N Y N Oedema Y N Y N Itching over varices Y N Y N Ulcer over malleolus Y N Y N Ulcer with gaiter area Y N Y N Aching or heaviness in legs Y N Y N Arterial Related Risk Factors Peripheral vascular disease Yes No Arterial surgery Yes No Rheumatoid arthritis Yes No Intermittent claudication Yes No Diabetes mellitus Yes No Angina Yes No Ischaemic heart disease Yes No Myocardial infarction Yes No Trans ischaemic attack Yes No CVA (Stroke) Yes No Smoker Yes No Amount & duration Page 92 of 107

93 Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Address: Arterial Related Signs / Symptoms Left Right Left Right Capillary refill time >3s Y N Y N Dusky skin colour on foot Y N Y N Foot / toes blanche when foot raised Y N Y N Cold foot Y N Y N Loss of hair on leg Y N Y N Atrophic, shiny skin on shin Y N Y N Muscle wasting in calf / thigh Y N Y N Thickened toe nails Y N Y N Ulcers on toes Y N Y N Gangrene on toes Y N Y N Loss of pedal pulses Y N Y N Is there any family history of above? Pain in lower leg / foot when raised Y N Y N Mobility: Full mobility Partial mobility Mobile with aids Immobile Does patient walk heel to Yes No toe? Ankle movement: Mobile Reduced Fixed Left Ankle movement: Right Mobile Reduced Fixed Is patient able to elevate legs? Yes No Does the patient sleep in bed? Yes No Please provide comments re patient mobility issues / sleeping difficulties: If mobility is affected consider referral to Physiotherapy Part 3: Physiological Assessment How did ulcer start? Left Leg / Foot Right Leg / Foot Duration of present ulcer Previous compression regimes How long did previous ulcers take to heal Current dressing regime Ankle circumference (cms for compression therapy) Calf circumference (cms for compression hosiery) Page 93 of 107

94 Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Address: Does the patient have pain? Is sleep disturbed Y N Part 4: Pain Assessment Y N At night Y N At rest Y N On movement Y N Patients own description of pain: Creeping / Pins & Needles / Heaviness / Gnawing / Aching/Shooting/sickenin/punishing/Cruel/Splitting/Burning/stinging/stabbing. Other patients own words; What helps to relieve pain? Current pain relief? What makes pain worse? Has the pain become worse in the last 2 weeks Yes No Does the patient experience night pain in the lower limbs Yes No Does hanging legs down help relieve the pain? Yes No Has the pain affected the patients activities of daily living? Yes No Pain analogue scale 0 = No pain / 1-2 = Mild pain /3-4 = Moderate pain / 5-6 = Severe pain / 7-8 = Very severe pain / 9-10 = Worst pain ever Day Night At dressing change Constant Intermittent Part 5: Nutrition Does the patient eat a well balanced diet (i.e. food from each of the following food groups: bread / cereals, fruit & vegetable, meat / alternatives, dairy products) Yes No Does the patient have a reduced appetite Yes No Does the patient appear: (please circle see BMI Frail Underweight Normal Overweight Is the patient well hydrated Yes No Is weight loss deliberate Yes No How much weight loss in last 3 months Is this significant for the patient? If weight loss is significant, Nurse to do a nutritional assessment and refer to dietician. NB overweight patients may also benefit from dietician referral for weight reducing advice. Over what period of time Yes No Dietician referral indicated Yes No Page 94 of 107

95 Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Ulcer Number Address: Part 6: Ulcer Description Site of ulcer Measurements in cms (width x length) W L W L W L W L Depth (superficial, dermal, deep dermal, tendon exposed, bone exposed etc.) Edges of ulcer (shallow, rolled, punched out. Detail shape of ulcer i.e. regular or irregular) Type of tissue in ulcer bed (necrotic, sloughy, granulating, infected. Calculate in total % of wound) Appearance of ulcer bed (black, red, yellow, pink, green) Exudate (slight, moderate, copious. Indicate strike through how many layers of dressing) Colour of Exudate Malodorous Y N Y N Y N Y N Signs of infection (redness, inflammation, purulent discharge, pyrexia, patient unwell) Microbiology swab taken: If yes include date Result of microbiology swab + resistance + sensitivities Ulcer traced (retrace ulcer every 4 6 weeks. If no improvement re-evaluate care) Y N Y N Y N Y N Y N Y N Y N Y N Ulcer photographed Y N Y N Y N Y N Part 7: Condition of Surrounding Skin Left right Left right Skin intact Y N Y N Y N Y N Dry eczema Y N Y N Y N Y N Wet eczema Y N Y N Y N Y N Cellulitis (red, swollen, hot, painful) Y N Y N Y N Y N Skin excoriated from ulcer exudate Y N Y N Y N Y N Dry & flaky skin Y N Y N Y N Y N Macerated, white, wet skin Y N Y N Y N Y N Have you checked heels for pressure ulcers Y N Y N Y N Y N Page 95 of 107

96 Name: Integrated Care Pathway Leg Ulcer Care Pathway Form Address: Doppler Assessment Date: Part 8: Doppler Assessment Headphones used: yes/no Position of patient for readings: Supine / sat with legs raised / sat - legs downward angle (delete as appropriate) Ideally patient should be lying supine for 15 minutes prior to commencing Doppler Assessment. Take the systolic brachial pressure in both arms and 2 of 4 of the following points (Key Tri Triphasic / Bi Biphasic / Mono Monophasic Use of Doppler for all pulses including brachial Strength Sound Left Right Sound Strength Brachial DPA ATA PTA Pero A.B.P.I Calculation: Highest Ankle Pressure = A.B.P.I Highest Brachial Pressure If A.B.P.I is equal to or greater than 0.8 and venous disease is determined to be the underlying aetiology, then compression is indicated. If A.B.P.I is greater than 1.3 and monophasic consider referring the patient for vascular assessment If A.B.P.I is less than 0.6 refer patient for vascular assessment NB If the patient is diabetic possible calcification of medial artery wall may give a high reading Part 9: Diagram of Ulcer Position * Ankle brachial pressure index Peroneal bifurcates Posterior tibial, over lateral below & behind malleolus medial malleolus Anterior tibial Dorsalis pedis (alongside first metatarsal) Anterior tibial Left Medial View Posterior View Anterior View Left Lateral View Left Leg Right Lateral View Posterior View Anterior View Right medial View Right Leg Page 96 of 107