Leg ulcers. continuing professional development

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1 By reading this article and writing a practice profile, you can gain a certificate of learning. You have up to a year to send in your practice profile. Guidelines on how to write and submit a profile are featured at the end of this article. Leg ulcers NOP638 Pat Morris, Ruth Sander (2007) Leg ulcers. Nursing Older People. 19, 5, Date of acceptance: 11 April 2007 Aim and intended learning outcomes Leg ulcers, especially venous ulcers, are a common experience for older people and nurses play the main part in care and treatment. The aim of this article is that readers should have a broad understanding of the development, treatment and experience of leg ulcers. After reading this article you should be able to: n Explain the difference between venous and arterial leg ulcers n Understand the need for different approaches to treatment depending on whether the ulcer is venous or arterial n Discuss methods used in the prevention of venous leg ulcers n Discuss the principle of treatment for venous leg ulcers n Understand the social and emotional impact of venous ulcers. Types of leg ulcers Leg ulcers are a common experience in older people and their care accounts for a large part of the role of nurses in the community. Treating them requires specialist knowledge and skills as incorrect treatment can make matters worse. The cost of leg ulcers is high in terms of both health service resources and the physical and emotional pain and disruption to everyday life. An ulcer is a defect in the skin as a result of an underlying physiological disorder (Peters 1998) and, according to Hampton and Collins (2004), 1 per cent of the UK population suffer chronic leg ulceration. The estimated cost to the NHS is 400 million a year and district nurses spend up to 50 per cent of their time treating them (Peters 1998). Studies have consistently shown that 70 per cent of leg ulcers are venous in origin, 5 per cent are arterial and 15 per cent have a mixed aetiology (Cheesbrough 2001). Arterial ulcers develop where the arterial vessels are damaged causing restricted blood flow to the leg; people with arterial disease, rheumatoid arthritis or diabetes being particularly at risk (RCN 2006). The underlying causes of venous ulcers include incompetent valves or venous stasis. There is often an association with deep vein thrombosis (DVT) or varicose veins (Peters 1998). Venous ulcers start after a knock or small injury so it may seem that this is the cause of the ulcer but it is really the underlying conditions that are to blame. According to Simon et al (2004) the main culprit is venous hypertension. This leads to oedema of the dependent limb making it difficult for metabolites from the microcirculation to reach the tissues which can become ischaemic. Mobilisation or elevation then allows blood to return to the tissues. This constant change sets up an inflammatory response which causes further damage to tissues and microcirculation. Now do Time out 1 Time out 1 Talk to people you know or care for who have leg ulcers. Ask them when the ulcer first developed and if they had problems such as DVT or swelling of their legs in the years before the ulcer developed. Authors Pat Morris MA, RMN, SRN, DN, is an independent nurse trainer Ruth Sander MSc, BA, RGN, PGCE-A, is senior lecturer, University of Portsmouth Summary This article aims to explain the difference between venous and arterial leg ulcers, methods of treatment and prevention for each kind of ulcer, and the social and emotional impact of venous ulcers. Key words n Elderly: nursing n Leg ulcers n Patients: psychology n Dressings These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review. Online For related articles visit our online archive at: Search using the key words above. June vol 19 no nursing older people 33

2 Box 1. Classes of compression hosiery Class 1 (14-17mmHg of For tired legs, varicose veins and mild oedema Class 2 (18-24mmHg of For severe varicose veins and prevention of ulcers Class 3 (25-35mmHg of For ulceration and very severe varicose veins Hampton and Collins (2004) Box 2. Medical conditions that may affect the rate healing Rheumatoid disease Heart disease Previous DVT Diabetes Smoking Steroid therapy Chemotherapy Hampton and Collins (2004) Prevention of venous ulcers Dry, rough skin can be breached more easily than supple, moisturised skin (National Eczema Society 2005). Daily use of simple moisturisers and avoidance of traditional soaps will help to prevent the abrasions that can develop into ulcers. Exercise is the most effective way to return blood to the heart and patients should be encouraged to walk as much as possible to activate the venous pump mechanism on the sole of the foot (Hampton and Collins 2004). Obesity is linked with a greater number of ulcers (Peters 1998) so general information about healthy living is important. Compression hosiery is the only preventative measure that has been definitively shown to prevent venous ulcers (Peters 1998). Compression stockings should be prescribed with care as they will increase the risk of ulcers if is there is any compromise to the arterial blood supply. Stockings with different pressures are available for different situations (Box 1). They should be fitted carefully as, if they are too long, they can roll down and cause a tourniquet effect which can increase the risk of deep vein thrombosis (Hampton and Collins 2004). If necessary, stockings can be made to measure. Compression hosiery can be difficult for elderly patients to put on. Talcum powder applied to the legs may help or a plastic bag can be put on the foot and removed once the stocking is in place (Hampton and Collins 2004). Patients should be advised that they will need to wear compression therapy for the rest of their lives (Dowsett 2005a) although, as Flaherty (2005) reveals, many people find them uncomfortable and difficult to use. It is important to reduce the irritation of varicose eczema that may be part of the syndrome of poor vascular return. Moffatt (2004) highlights the problem of patients scratching their legs and so provoking a recurrence. These patients may then be blamed for their own condition, potentially adding to the feeling of demotivation and failure. Now do Time out 2 Time out 2 These measures would not all be helpful for somebody at risk of developing arterial ulcers. What preventative measures would you suggest for these people? People at risk of developing arterial ulcers should take care of their skin in the same way as people at risk of venous ulcers. They should also check the skin of their feet and lower legs regularly and seek medical attention for any sore areas. They should not use compression stockings but should take good care of their general health by not smoking, eating a healthy diet and, if they are diabetic, carefully controlling their blood sugar levels. Assessment Cheesbrough (2001) believes that ulcers are often badly treated because of inadequate assessment. Hampton and Collins (2004) recommend getting patients to describe the ulcer in their own words so they can identify the symptoms that are giving them the most problem. They also suggest that a medical history should include asking about conditions likely to affect healing (Box 2) A careful medical history will also identify conditions such as arthritis that might exacerbate pain (Moffatt 2004). The RCN (2006) recommends an additional ulcer history including the questions found in Box 3. Visual assessment of the wound should include the site, shape, size, depth, type of tissue at the base and any clinical signs of infection (Dowsett 2005a). An objective recording should be made using a tracing or disposable tape measure or photograph. A formal record of the ulcer size and condition should be made at presentation and then at least once a month (RCN 2006) Differential diagnosis The conditions needed to heal an ulcer of venous origin and an ulcer with arterial involvement are totally different. The compression that is the mainstay of venous ulcer treatment can be highly damaging if arterial blood supply is already compromised so it is vital that the nurse can tell the difference. There are some indications that might suggest whether the ulcer is arterial or venous. Venous ulcers are more painful when the leg is dependent because of blood pooling in the lower extremities (Hampton and Collins 2004). Arterial ulcers are usually multiple with caved sides and can be anywhere on the leg or foot whereas venous ulcers usually occur between the ankle and the mid-calf (gaiter area) (Hampton and Collins 2004). There are some particular signs and symptoms that would point to either arterial or venous ulcer (Box 4) but this is not sufficient to confidently distinguish between the two ulcer types. It is also important to be aware that ulcers can be mixed with loss of function in both the arterial blood supply and the venous return. Now do Time out 3 Time out 3 Why would compression bandaging and elevating the leg be detrimental to the healing of an arterial ulcer? 34 nursing older people June vol 19 no

3 Damaged tissue needs oxygen and nutrients to heal. These are brought to the wound by the arterial blood supply which must already be compromised for the arterial ulcer to develop. Compression would constrict the arterial vessels and elevation would remove the benefit of gravity which helps arterial blood to reach dependent limbs. Doppler ultrasound is the most important diagnostic tool available to the nurse. Its use should be a regular feature of assessment but Hampton and Collins (2004) found that 80 per cent of people in the community with leg ulcers had not had a Doppler assessment. Doppler ultrasound is used to exclude arterial disease and not to diagnose venous disease (Hampton and Collins 2004). It gives a measure of the ankle brachial pressure index (ABPI) showing the amount of arterial blood being delivered to the lower limbs. A healthy adult will usually show an ABPI of more than 1.0. Patients with a ratio of less than 0.8 should not have compression bandaging but should be referred for further vascular investigations (Dowsett 2005a). The walls of healthy arteries are elastic and rebound with each beat of the heart. This can be heard as three distinct or triphasic sounds. As the artery ages, elasticity decreases and the third sound is lost leaving only a biphasic sound. Once atherosclerotic plaques are laid over the arterial walls, the arteries lose elasticity completely leaving only one (monophasic) sound. The inelasticity forces the blood to enter and leave under great pressure and can be heard as a distinctive dull sound like the bark of a dog. If this sound is heard, the patient requires specialist assessment. Arterial ulcers are complex and difficult to heal because of the lack of arterial perfusion to the tissues (Hampton and Collins 2004) and surgery, including bypass or dilation of the vessel, may be the only option. Treatment for venous ulcers There is no evidence that the choice of primary dressing affects healing rate (Cheesbrough 2001). It is possible to manage with simple non adhesive dressings and absorbent wool. If there is a lot of discharge the surrounding skin should be protected with paste. Dermatitis can be treated with steroid ointment but skin that is merely dry can be treated with simple moisturisers such as soft paraffin. Wounds heal best if they are kept moist and warm and, unless there is heavy discharge, the dressing can be left in place for up to two weeks. Cheesbrough (2001) believes that dressings are often changed too frequently to the detriment of the ulcer and the nurse s time. Time and money are wasted taking bacterial swabs as it is not possible or desirable to achieve a sterile wound bed. The RCN (2006) says swabs should only be taken if there is evidence of: n Inflammation n Increased pain n Purulent exudates n Rapid deterioration of the ulcer n Pyrexia Cheesbrough (2001) points out that topical antibiotics should be avoided as they encourage bacterial resistance and dermatitis and do not improve healing rates. If cellulitis develops then systemic antibiotics are required. A red or pink wound with red lumps in the base suggest a healing wound that requires protection whilst persistent green, brown or red discharge suggests an infection (Hampton and Collins 2004). Once oedema is controlled, slough can be removed by surgical debridement, interactive dressings or maggot therapy (Cheesbrough 2001). The RCN (2006) highlights the fact that patients can become sensitised to elements of their treatment at any time (Table 1). New allergies can develop in people who have been happily using a product for several years. If sensitivity is suspected, the patient should be referred to a dermatologist for patch testing. Compression therapy Ulcers will not heal if the wound bed and surrounding tissues are waterlogged (Cheesbrough Box 3. Ulceration history Year ulcer first occurred Site of ulcer and any previous ulcers Number of previous episodes Time free of ulcers Past treatment method (both successful and unsuccessful Previous operations on venous system Previous operations that may have affected venous or lymphatic system eg hip or knee surgery. Previous and current use of compression hosiery RCN (2006) Box 4. Differential diagnosis Indications of arterial insufficiency Pain at night or when the leg is elevated Pain on walking relieved by rest Cold foot Numbness Leg is hairless with shiny, smooth, tautly stretched skin. Absence or decrease in foot pulses. Indications of venous disease Affects gaiter area of the leg. Dermatitis (eczema) Lipodermatosclerosis (brown staining and thickening of the skin due to fibrosis) Varicose veins Hampton and Collins (2004) Cheesbrough (2001) Atrophic blanche (white shiny scar tissue) June vol 19 no nursing older people 35

4 Table 1. Common allergies Allergen Group Lanolin Topical antibiotics Preservatives Vehicles Adhesives Rubber mixes 2001) so any leg oedema must be treated. Graduated multilayer compression therapy with adequate padding, to protect bones and tendons and shape the leg, is the treatment of choice in venous leg ulcers as it is cost effective and promotes faster healing rates (RCN 2006). It increases the venous return and allows the tissues to recover from the effects of venous hypertension (Hampton and Collins 2004). Full compression, achieving a pressure of 40mmHg at the ankle, works best but reduced compression is better than nothing (Hampton and Collins 2004). Nurses should measure the ankle as adjusting to the circumference is vital for optimum bandaging. Patients with an ankle circumference of less than 18cm should not be compressed without the use of wool padding to enlarge the circumference (Hampton and Collins 2004). Incorrect bandaging can cause dangerously high pressures, risking skin necrosis, in a narrow ankle (Simon et al 2004). Bandaging the large leg also requires special consideration if affective compression is to be established. There is a wide choice of bandages all applied by different methods and requiring different skills. No significant difference has been found in healing rates between the different systems available (Hampton and Collins 2004). Practitioners should not apply compression bandages unless they have been taught the specific skills required as inexperienced nurses have been found to apply bandages with inappropriate and highly variable pressures (RCN 2006). Patients given detailed information about compression bandaging are more committed and have faster healing rates. The patient will often complain that the bandage is too tight so it is important that they are given a full explanation of what to expect (Hampton and Collins 2004) and to formulate an individual plan that may consist of compression therapy, exercise, leg elevation and analgesia, to meet the individual needs of the patient (RCN 1998). It is vital to remember that incorrectly applied bandages can increase the size of the ulcer and inappropriate use on an ischaemic limb can be dangerous leading to tissue necrosis (Hampton and Collins 2004). Source Creams, ointments e.g. E45, Oilatum Sofratulle, Cicatrin powder, gentamycin cream Viscopaste, Quinaband etc. Cream preparations such as Flamazine, E45, Aqueous cream Sticking plasters and cohesive bandages Elastic tubular bandages, some bandages and elastic stockings Elevation Elevation has an important role to play in the treatment of venous ulcers but it may be hard to achieve if there are coexisting conditions that make it painful or difficult. Continuous leg elevation works by reducing oedema and improving flow in the microcirculation (Simon et al 2004). Elevation is particularly important but often neglected if the patient has cellulitis (Cheesbrough 2001). Pain control Patients in Persoon et al s study (2004) said that pain was the most notable aspect of their experience. For some the pain was mild but others had periods of intense pain. Pain was described by some as being worse at night leading to disturbed sleep. Pain became worse when the leg was swollen and some described it as fluctuating according to the weather. Standing and walking was found to aggravate pain so is avoided by some patients. Relief of pain is an important part of treatment as it improves quality of life and encourages people to mobilise (Heinen et al 2004) The process of dressing change can also be very painful. Patients judge the competence of the nurse partly on the extent to which they are able to touch and clean the wound without causing pain (Ebbeskog and Emami 2005). Social impact Having an ulcer can have a profound effect on the patient s self-esteem and self-image. It can cause a deterioration in general health and impairment in quality of life through pain, social isolation, depression and reduced mobility (Cheesbrough 2001). Oozing wounds cause embarrassment, particularly if they are smelly (Persoon et al 2004) and wet clothing and bed linen add to the everyday burden of living with a leg ulcer. The majority of leg ulcers are recurrent (Peters 1998). Flaherty (2005) found that patients viewed attendance at a healed leg ulcer clinic beneficial in preventing the recurrence of problems. Leg clubs can provide social support both during the 36 nursing older people June vol 19 no

5 treatment stage and when the ulcer has healed (The Lindsay Leg Club Foundation). Community nurses, who provide treatment, run Leg Clubs but they differ from conventional treatment in that they are held in a non-medical environment, they operate on a drop-in basis and they provide social support and a chance to chat to other people with similar problems. They also incorporate a well leg element encouraging attendance from people with healed ulcers so that they can support each other in what can be a difficult life-long routine. Edwards et al (2005) found significant improvements in healing rates in a Leg Club group when compared with a control group. They thought this might be because clients were more motivated to comply with treatment when they saw positive results in other group members. High motivation is particularly important in hot weather when wearing thick bandages can be very uncomfortable. Now do Time out 4 Time out 4 Imagine that you were told that you had to wear bulky bandages for the next few years. What social situations would you find most difficult or embarrassing. Your answer, of course, depends on what you enjoy doing. Swimming would be impossible and most sporting activities would be difficult. Female readers may realise that wearing pretty dresses or fashionable shoes would be awkward if not impossible. You may feel that most people with leg ulcers are older and so these things do not matter but this is not necessarily true. Few older women would happily wear trousers and trainers to their granddaughter s wedding. Patient education Now do Time out 5 Time out 5 List the areas that you think should be covered in an education session for people with leg ulcers. Patients need clear advice on what they should be doing to avoid recurrence (Peters 1998). Successful treatment is a partnership between the patient and their professional adviser. Concordance with therapy is a concept that Moffat (2004) sees as essential to leg ulcer management. She believes that patients must be treated as partners rather than just recipients of care and advice and that they must had adequate knowledge and support to enable them to be active participants. Patients in Persoon et al s (2004) study were not always satisfied with the level of education given. Stiffening of the ankle, for instance, is a common symptom in chronic venous ulcers. Patients should be taught to move their ankle properly when they walk as this improves the calf muscle pump which aids venous return (Cheesbrough 2001). Conclusion Leg ulcers are a common and often chronic problem for older people. Arterial ulcers often require surgical interventions but there is a great deal that nurses can do to treat and support people with venous ulcers. Although treatment of leg ulcers should only be undertaken by suitably trained nurses, all nurses working with older people should have an understanding of the underlying principles so they can offer appropriate advice and emotional support for this painful, embarrassing and socially isolating condition. n References Cheesbrough M (2001) Leg Ulcers. In: Rai GS, Mulley GP (eds) Elderly Medicine: A Training Guide. London, Taylor & Francis Dowsett C (2005a) Assessment and Management of patients with leg ulcers. Nursing Standard 19, 32, Edwards H et al (2005) Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention. International Journal of Nursing Practice 11, 4, Ebbeskog B, Emami A (2005) Older patients experience of dressing changes on venous leg ulcers: more than just a docile patient. Journal of Clinical Nursing 14, 10, Flaherty E (2005) The views of patients living with healed venous leg ulcers. Nursing Standard 19, 45, Hampton S, Collins F (2004) Tissue Viability. London, Whurr Publishers Heinen M et al (2004) Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions. Journal of Clinical Nursing 13, 3, Moffatt C (2004) Understanding patient concordance in the management of leg ulcers. Nursing Times 100, 32, National Eczema Society (2005) Eczema in Later Life. (last accessed May 10, 2007) Persoon A et al (2004) Leg ulcers: a review of their impact on daily life. Journal of Clinical Nursing 13, 3, Peters J (1998) A review of the factors influencing nonrecurrence of venous leg ulcers. Journal of Clinical Nursing 7, 1, 3-9 RCN (2006) Clinical Practice Guidelines for the Management of Patients with Venous Leg Ulcers. Liverpool, University of Liverpool. pdf/guidelines/venous_leg_ulcers.pdf (last accessed: May 10, 2007) Simon D et al (2004) Management of venous leg ulcers. British Medical Journal 328, 7452, The Lindsay Leg Club Foundation (nd) (last accessed: May 10, 2007). June vol 19 no nursing older people 37