Leg ulcer assessment and management

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Karin Blair
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Leg ulceration The views expressed in this presentation are solely those of the presenter and do not necessarily represent the views of Smith & Nephew.

1 Leg ulceration The views expressed in this presentation are solely those of the presenter and do not necessarily represent the views of Smith & Nephew. Smith & Nephew does not guarantee the accuracy or reliability of the information contained in this presentation. Responsibility for obtaining permission to use images contained in this presentation is that of the presenter, not of Smith & Nephew.

2 Leg ulcer assessment and management

3 Presentation content Aetiology of leg ulceration Principles of leg ulcer assessment Management of venous disease Management of arterial disease How to avoid skin damage on the lower leg from becoming a chronic ulcer

5 Causes of leg ulcers VENOUS DISEASE 70% ARTERIAL DISEASE 10 15% MIXED 10 15% DIABETES 5% VASCULITIS 2% TRAUMA 1% MISCELLANEOUS 1% (Callum et al 1985) (SIGN 2010)

6 Venous leg ulcers Venous leg ulcers are defined as open lesions between the knee and ankle that occurs in the presence of venous disease and takes more than 2 weeks to heal. NICE (2013) It is essential that they are diagnosed and managed quickly to reduce the risk of becoming chronic wounds. 1.5% of the UK adult population have leg ulceration with 1:170 adults having a venous ulcer. Guest et al (2015) Recurrence of ulceration 12 month rates estimated at between 18 28% Ashby et al (2014)

7 Causes of Venous disease Calf muscle pump dysfunction, caused by prolonged periods of immobility, surgical trauma or obstruction by a thrombus Valvular incompetence in the deep veins (primary) where valves are damaged beyond repair ~ thrombotic episode Valvular incompetence in the communicating veins and/or superficial veins (secondary) cusps of valve fail to meet due to increase in vein diameter. Maybe restored when vein returns to normal size.

9 Contributory factors Obesity increases pressure in the lower limb veins Reduced mobility compromises calf pump activity DVT results in damaged valves Varicose veins caused by damaged veins Previous injury / surgery to lower leg causes damage to veins / DVT Increasing age reduced mobility Chronic oedema compromises skin integrity Family history IV drug use

10 Signs and Symptoms of Venous Disease Varicose Veins Pigmentation of the gaiter area Ankle flare Skin atrophy Eczematous changes Woody indurated tissue Champagne bottle leg appearance Warm, well perfused extremities Palpable pulses Shallow ulcers with flat margins

11 Assessment criteria Assessment must be a practical way of triggering an action The initial assessment of leg ulcers should be undertaken as a three part process: 1. General holistic assessment 2. Leg assessment 3. Wound and skin assessment Wounds UK 2016

12 1. General holistic assessment : Medical history / comorbidities Family history Social history / lifestyle / occupation / nutrition Presenting symptoms Current quality of life and expectations Mobility / dexterity

13 2. Leg assessment: Assessment of peripheral perfusion is a fundamental requirement in leg ulcer management a recent study (Guest 2015) found that only 16% of cases of leg or foot ulcer patients had a Doppler assessment undertaken. Determine past and current vascular history Diagnostic assessment ABPI should be undertaken where possible on all patients with lower limb injury to exclude arterial disease and ensure safe practice. Doppler assessments are to be used to support clinical findings Duplex scans / Toe pressure index and Angiography are also available

How to Calculate the ABPI ABPI calculations Highest ankle systolic pressure Highest brachial systolic pressure Right ABPI = 85 150 = 0.

14 How to Calculate the ABPI ABPI calculations Highest ankle systolic pressure Highest brachial systolic pressure Right ABPI = = 0.57 Brachial Brachial Left ABPI = = 0.80 Posterior Tibial 80 Posterior Tibial Dorsalis Pedis Normal ABPI ratio is equal or greater than 1.00 but not greater than 1.3

15 Interpretation of abpi ABPI RESULT DOPPLER SOUNDS OUTCOMES TREATMENT PLAN Tri phasic Unlikely to be arterial Apply Compression Tri phasic Bi phasic Bi phasic Mono phasic < 0.5 Dampened > 1.3 Mono phasic Pulseless Mild PVD Significant arterial disease Severe Arterial disease Apply Compression Reduced compression can be applied with caution Do not compress refer to vascular surgeon

of arterial disease ie pallor, hairless cool limbs / feet Record shape and

16 Leg Assessment Cont d Limb related factors: Limb temperature erythema, pallor Signs of venous insufficiency ie ankle flare, oedema, hyperpigmentation Signs of arterial disease ie pallor, hairless cool limbs / feet Record shape and size of limb and ankle movement Observe skin condition ie dry, flaky, crusty, moist

Use the TIME framework to establish the nature of the wound tissue.

17 3. Wound and Skin assessment Establish the cause of the wound did it just appear, was it caused by Trauma? What has made it worse? Use the TIME framework to establish the nature of the wound tissue. What does the surrounding skin look like? Is it erythematous, dry and scaly, itchy, eczematous.

18 What is the problem with this leg?

Classification of disease severity SIMPLE VLU ABPI 0.8 1.

19 Classification of disease severity SIMPLE VLU ABPI <100cm2 Present for less than 6 months COMPLEX VLU ABPI outside of Area > 100cm2 Failure of wound to reduce in size (20 30%) Present for more than 6 months Wounds UK 2016 Infection Cardiac failure Non concordance Fixed ankle / foot deformity Unmanaged pain

20 Management of Venous leg ulcers Compression therapy should be the first line treatment for Venous leg ulcers and started as soon as possible. Those patients deemed at risk of Venous disease should be using hosiery as a preventative option. Compression therapy choice will depend on individual patient assessment taking into account application and removal, level of oedema and pain. The aim should be to use full compression systems when the arterial supply is good to prevent delays in healing. Lower pressures may not provide effective compression profiles to heal the ulcer.

21 Early intervention WOUNDS UK 2016 Any patient presenting with acute lower limb wounds are candidates for immediate compression in order to reduce risk of chronicity. Patients can be prescribed up to 17mmHg compression (Class 1) in the absence of a full vascular assessment as long as there are no risk factors for arterial disease. There should however be a diagnosis, intact sensation, no signs of limb ischaemia, good leg shape. If the wound then fails to heal in 2 weeks a full assessment including vascular should be carried out.

22 Clinical Case study

23 After 2 weeks

24 After 4 months

Compression therapy options Hosiery kits first line treatment

Facilitates self care Compression wraps allows for easy

suitable for most limb shapes Variety of types High stiffness

25 Compression therapy options Hosiery kits first line treatment but depends on local protocol. Facilitates self care Compression wraps allows for easy adjustment as limb volume decreases Compression bandages suitable for most limb shapes Variety of types High stiffness systems (inelastic) provide the greatest improvement in venous blood flow. Dependant on technique as skill required

26 Compression therapy options Scenario Hosiery Kits Adjustable wraps Bandages Normal leg shape YES YES YES Low / Moderate exudate YES YES YES Self care patient YES YES NO Carer YES YES NO involvement Oedema NO YES YES High exudate NO NO YES Deep skin folds NO NO YES Best practice statement Wounds UK Nov 2016

27 Monitoring outcomes Failure to respond to best practice within 4 weeks would automatically mean that the wound has become complex rather than classed as simple. Best practice suggests therefore that all Venous leg ulcers should be measured at a minimum of 4 weekly intervals. (Wounds UK 2016) Use local policies on how to measure and record leg ulcer progress.

28 Case scenario Patient with Venous leg ulcers develops bilateral red legs. Is this infection? unlikely as it is on both legs Is this allergy? likely as bilateral and very itchy This patient has an allergy to the topical creams that are being applied. Patient with venous disease are ultra sensitive to some allergens in certain products. Creams contain preservatives therefore need to be avoided.

29 Arterial disease

30 Causes: Arterial leg ulcers occur as a result of reduced arterial blood flow and subsequent poor tissue perfusion. The femoral, posterior tibial and perineal arteries all supply blood to the lower legs. Atheroma or plaque development can be caused by smoking, obesity, hyperlipidaemia, hypertension and diabetes and usually affects men over 45 years and women over 55 years. The flow of oxygen and nutrients is decreased as a result A reduction in blood supply can cause death of tissue which can occur quickly compared to venous disease which is a slower process.

31 Arterial disease

a patient can tolerate up to 70% occlusion in the lower limb without ill effects.

32 Ischaemia Degree of ischaemia and symptoms experienced depend not only on the site of occlusion but on whether collateral circulation has developed e.g. a patient can tolerate up to 70% occlusion in the lower limb without ill effects. Exercise can increase the demand for oxygen in the muscle causing intermittent claudication Ischaemic pain at rest indicates that the vessel is likely to be 90% occluded.

skin is pale, shiny, no hairs Patients describe pain as cramp

33 Signs and Symptoms of Arterial disease Ulcerated areas usually punched out Acute onset May occur in unusual places Surrounding skin is pale, shiny, no hairs Patients describe pain as cramp like, night pain, rest pain, claudication. Weak thready pulses / absent pulses

34 History Location Ulcer Surroundi ng Skin Capillary refill time ABPI Shallow diffuse edge, generalised oedema, exuding, varicosities may be present, some pain, granulation tissue.pulses normal Often pigmented, atrophe blanche, lipodermatosclerosis,ecze ma, hyperkeratosis, warm, Differential Diagnosis Venous ulcer Arterial ulcer MixedAetiology History of smoking, intermittent claudication. Painful, especially after exertion and leg Past history of varicose veins +/- DVT,trauma,surgery to leg, parity. Aching and swelling worse at the end of the day - relieved with leg elevation. Between the malleolus and the lower calf. Majority of venous ulcers are located over the malleolus. Normal (<3 seconds) Normal. An ABPI of 0.8 or higher is normal elevation Frequently occurs distally and over bony prominences but can affect any part of the Punched out appearance, deep cliff edge with sharply demarcated border.localised oedema but may be dry with necrotic bed. Extend to tendon and bone.pain greater at Pale, loss of hair, shiny and atrophic skin, cold feet, A prolonged capillary refill time (>4-5 seconds) An ABPI. <0.5 severe disease Mixed ulcers can be defined as being of both venous and arterial aetiology. A mixed ulcer involves venous and arterial i ffi i ABPI of Neuropathic History of numbness, paresthesia, burning. Loss of sensation in the foot. Common in patients with DM Sites of pressure (eg. Metatarsal heads, toes, heels Variable depth, partial to full thickness ulcer involving tendon, fascia, joint capsule and bone Callus, sinus tract formation. Infection associated with osteomyelitis Normal if no associated arterial disease Normal if no associated arterial disease

35 Management plan Identify degree of vascular impairment through Doppler or Duplex scan and Clinical assessment Identify and manage the pain Refer to vascular surgeon for re vascularisation if possible Undertake wound management following T.I.M.E.* assessment to manage symptoms Ensure there is a robust follow up plan involving Vascular surgeons and specialist nurses where appropriate. *Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and T.I.M.E. are clinical concepts supported by Smith & Nephew

36 Mis diagnosis Ulcer present for 12 months + Despite debridement always re sloughs Normal ABPI Compression therapy for 6 months with no reduction in ulcer size Is this a Venous leg ulcer?

37 Summary Accurate and thorough assessment is key to ensuring the right treatment plan is in place when a patient presents with lower limb ulceration. The earlier the treatment is commenced the better the outcome in order to avoid the wound becoming chronic. It is important to differentiate between venous and arterial ulceration as the management plan is very different. Be aware of those lower leg wounds that fail to heal they may be malignant / inflammatory or have a different pathology.

38 Useful reading

39 What percentage of leg ulcers are deemed to be venous in origin? % 2 55% 3 70% Callum et al (1985) Chronic ulceration of the leg; extent of the problem and provision of care. British Medical Journal,

40 What percentage of leg ulcers are deemed to be venous in origin? 1 90% 0% 2 55% 0% 3 70% 0% Callum et al (1985) Chronic ulceration of the leg; extent of the problem and provision of care. British Medical Journal,

41 What is the mainstay of venous ulcer management? 00 1 To elevate the leg? 2 To apply compression therapy? 3 To walk 2 miles a day? Wound UK (2016) Best practice statement. Holistic management of Venous Leg Ulcers. Wounds UK. London

42 What is the mainstay of venous ulcer management? 1 To elevate the leg? 0% 2 To apply compression therapy? 0% 3 To walk 2 miles a day? 0% Wound UK (2016) Best practice statement. Holistic management of Venous Leg Ulcers. Wounds UK. London

43 How often should you be measuring leg ulcers? 00 1 Every 2 weeks? 2 Every 4 weeks? 3 When ever you feel there is an indication to? Wound UK (2016) Best practice statement. Holistic management of Venous Leg Ulcers. Wounds UK. London

44 How often should you be measuring leg ulcers? 1 Every 2 weeks? 0% 2 Every 4 weeks? 0% 3 When ever you feel there is an indication to? 0% Wound UK (2016) Best practice statement. Holistic management of Venous Leg Ulcers. Wounds UK. London

Appendix D: Leg Ulcer Assessment Form

Appendix D: Leg Ulcer Assessment Form Nursing Best Practice Guideline Appendix D: Ulcer Assessment Form Person Completing Assessment: Date: Client Name: Caf # CM# VON ID #: District CCAC ID # Address Telephone Home: Work: Date of Birth Y/M/D: