Wound Care People Ltd. Holistic assessment and

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1 Understanding compression: part 2 holistic assessment and clinical decision-making in leg ulcer management Georgina Ritchie, Helen Taylor The second in this four-part series exploring leg ulcer management and understanding compression therapy examines the role of assessment as the basis for optimal clinical practice. The authors explore how the findings of thorough assessment can influence treatment choice. Adopting an holistic, person-centred approach to assessment, which includes taking an ankle brachial pressure index (ABPI) reading and involves the patient in decision-making will help nurses to make effective clinical decisions and plan care in partnership with patients. This article discusses a three-stage assessment and clinical decision-making process, which involves looking at the whole person, assessing the leg and the wound. The next article in the series will examine compression hosiery and adjustable wraps for the management of the lower limb. KEYWORDS: Ankle brachial pressure index Compression Holistic assessment Leg ulceration Holistic assessment and accurate diagnosis are the first steps in the clinical decision-making process in leg ulcer management and should be undertaken by a suitably experienced nurse who is competent in wound and limb management (National Institute for Health and Care Excellence [NICE], 2015; Atkin and Tickle, 2016). Holistic assessment should identify the causes of the leg ulcer, incorporating a wholeperson approach to discover what the patient regards as important in terms of their care. This approach fits with NHS England s Leading Change, Adding Value framework (NHS England 2016, 2018), which strongly encourages partnership Georgina Ritchie, senior lecturer, district nurse, Queen s Nurse and member of the Association of District Nurse Educators, University of Central Lancashire; Helen Taylor, district nurse, Lancashire Care NHS Foundation Trust working with patients and asking the question: What matters to you?. Holistic assessment is essential when planning care with the patient to achieve successful management of the lower limb. Holistic assessment should be completed in all patients who have a break in the skin of the lower limb between the foot and the knee if the wound has not healed within two weeks (NICE, 2015). This can be undertaken in three stages, as discussed by the Scottish Intercollegiate Guidelines Network (SIGN, 2010): Assess the patient Assess the leg Assess the ulcer. This framework has been used as a foundation for the assessment pathway outlined within this article. However, first the authors explore the importance of appropriate early intervention and shared decision-making. EARLY INTERVENTION It has been suggested that people in the UK who have experienced loss of skin below the knee on the leg or foot are currently waiting longer than two weeks for a holistic leg assessment and ankle brachial pressure index (ABPI) measurement (Guest et al, 2017). In the authors clinical experience, during this two-week wait patients are often managed using wool and crepe bandages and, while they wait for a full assessment, including ABPI measurement, there is a significant risk of wound deterioration. ABPI readings can exclude arterial disease, meaning that any lower limb symptoms may be due to venous disease, which, in turn, indicates the use of compression therapy (see below for a full explanation of ABPI). According to Guest et al (2017), it is quite possible that only 16% of patients who have a lower limb ulcer receive ABPI assessment, which could mean that many patients are sustaining significant harm while healthcare professionals attempt to identify the appropriate treatment. Without ABPI assessment and the provision of appropriate compression therapy, lower limb ulcers will not heal and may even deteriorate. There is emerging evidence that, in some patients, rather than waiting for ABPI assessment, a light compression of up to 17mmHg should be applied until an ABPI measurement is available, which could prevent deterioration of the wound (Wounds UK, 2015). To be considered for this form of early intervention, patients would require a diagnosis, intact sensation of the lower limb, absence of signs of critical ischaemia and a normal limb shape. Similarly, one best practice statement recommended that all patients who 22 JCN 2018, Vol 32, No 3

2 L td MESI ABPI MD ing ABPI read inute! within 1 m ou nd Helps you with your assessment and allows you to compress with confidence. Step 2 Press START button to run measurement LEFT Results ABI RIGHT ABI Brachial pressure SYS: DIA: 125 mmhg 75 mmhg Heart rate 80 bpm Step 3 See the results W Step 1 Place cuffs on arm and legs 09:15 Distributed by medi UK Ltd medi. I feel better. Discover the medi Wound Care Therapy Chain within the medi World of Compression Manufactured by MESI, development of medical devices, ltd. Ca re Pe op le No resting g! tin before tes

3 present with lower limb wounds, for example, a pre-tibial laceration, may be suitable for immediate light compression (Wounds UK, 2016). In practice, this means that, in appropriate patients, British Class 1 standard hosiery stockings could be provided without a full vascular assessment, providing that a full assessment was undertaken at the two-week point if the wound had not healed. Any intervention of this type should always be carried out at the practitioner s discretion. Many patients, however, would be excluded due to multiple comorbidities such as diabetes and heart failure until after a full assessment has been undertaken. SHARED DECISION-MAKING Shared decision-making between the nurse and patient is vital for effective leg ulcer management, and adopting a what matters to you approach is recommended as an important method of ensuring that patients remain at the centre of care (NHS England, 2016). NICE (2018) states that when a nurse and patient work together to design and agree a treatment plan, the outcome is usually more successful in terms of concordance and effectiveness than if the nurse dictates the treatment. This concept is particularly important within the field of leg ulcer management, where ongoing care is required for a lifelong condition. Subsequently, the relationship between nurse and patient may extend over a long period of time and so mutual trust and respect is vital (Green et al, 2017). Concordance with compression therapy is fundamental to the successful healing of venous leg ulcers. However, the discomfort which may be experienced by wearing compression therapy or issues with application can make concordance difficult. Stanton et al (2016) proposed that concordance can be achieved by ensuring that the patient is central to any decisionmaking or planning that effects their care. In practical terms, this might mean patients being involved in decisions about treatment options, for example whether to choose multilayer bandage systems, hosiery or wraps (Stanton et al, 2016). Jin et al (2008) stated that factors which affect concordance with treatment frequently include the patient s knowledge of their condition, their health literacy (for example, their understanding of the implications if they choose not to concord with their treatment plan), and whether they believe that the therapy will be beneficial. Therefore, patient education is a key element in concordance and should not be overlooked by nurses. For nurses themselves, balancing their professional judgment and expertise with the needs and wishes of patients receiving care is the first principle of shared decision-making (NICE, 2018). ASSESSMENT PROCESS Assess the whole person As discussed previously in this series, it is important to remember that lower limb ulceration is a symptom of the patient s underlying pathophysiology (Ritchie and Warwick, 2018). Therefore, undertaking a full clinical history is vital to developing a diagnosis of the causative problem and ruling out any differential diagnoses (Neighbour, 2005). Gathering information about potential comorbidities, such as diabetes mellitus, rheumatoid arthritis, and peripheral arterial disease (PAD) is important in making an assessment of the patient s overall health and suitability for compression therapy (SIGN, 2010). Mobility, nutrition, hydration, smoking status and body mass index (BMI) are also important and can contribute to the development of a leg ulcer. These factors may also affect how quickly the patient heals and their susceptibility to infection, both of which will affect the choice of treatment options open to them (Wounds UK, 2013). Taking an ABPI measurement forms part of comprehensive holistic assessment and assists the nurse in identifying or excluding the presence of arterial disease by assessing if the limb has sufficient arterial blood supply. This contributes to the overall clinical picture, which assists in making a safe decision about the underlying pathophysiology (Vowden and Vowden, 2001). ABPI does not test for venous disease; however, if significant arterial disease is excluded by ABPI, it is assumed that the presenting complications are due to either venous disease or a mixed aetiology (a combination of venous and arterial disease). ABPI provides a comparison between the highest ankle systolic pressure in each leg and the central systolic pressure as indicated by the higher of the two brachial (upper arm) pressures. It is calculated using the equation below: highest ankle systolic pressure ABPI = highest brachial systolic pressure This calculation is then used to assist the nurse in identifying the underlying aetiology and preparing a treatment plan, as seen in Table 1. Timely ABPI measurement is crucial in diagnosis of the underlying pathophysiology of the leg ulcer. A delay in ascertaining ABPI may lead to a delay in implementing optimal treatment. If the nurse can accurately diagnose and begin treatment as soon as possible, they can prevent Table 1: Interventions based on the patient s ankle brachial pressure index (ABPI) score (adapted from Ritchie, 2017) Severe ischaemia. Consider urgent referral to vascular specialist. Patient not Reading of 0.5 suitable for compression therapy Presence of moderate-to-severe arterial insufficiency. Often termed mixed Reading of aetiology. Reduced compression may be appropriate under specialist direction only Some arterial disease may be present, but currently there is enough arterial Reading of blood flow for safe compression therapy often termed venous leg ulceration False high reading or abnormal vessel hardening. Consider factors affecting the Reading 1.3 and above accuracy of the ABPI assessment and consider undertaking a further reading or toe brachial index (TBI) 24 JCN 2018, Vol 32, No 3

4 For the 730,000 leg ulcer patients in the U.K. Every Moment Matters Atkin and Critchley (2017) reported service improvements through implementing the Best Practice Statement leg ulcer treatment pathway. Optimisation of resources, including utilisation of healthcare assistant s skills Signifi cantly improved outcomes, including improved healing A 43% reduction in appointments for leg ulcer patients To fi nd out how L&R can support your organisation to achieve these results customercare@uk.lrmed.com quoting every moment matters ADV292 V1.1

5 Practice point Holistic assessment is crucial in making a sound clinical diagnosis and treatment plan. SIGN (2010) advocates assessing the patient, leg and ulcer. ABPI assessment is a tool to screen for arterial disease and forms part of holistic assessment of the person. Certain patients can be considered for immediate light compression of up to 17mmHg without an ABPI reading, but must have a diagnosis, intact sensation, no sign of critical ischaemia and a normal limb shape (Wounds UK, 2015; 2016). leg ulcers becoming chronic, thus reducing the quantity of wound care products used and nursing time spent managing the ulcer, as well as minimising the human cost associated with leg ulcers (European Wound Management Association [EWMA], 2017a). In the presence of venous disease or a mixed aetiology, the patient is suitable for compression therapy; the level of which will be indicated by the ABPI score (Table 1) and holistic assessment (Vowden and Vowden, 2001). Normally in the UK, clinical practice guidelines state that patients diagnosed with a mixed aetiology ulcer can receive reduced compression therapy. However, this must be applied under the direction of a specialist and the patient may need more investigations before further compression can safely be instigated (Harding et al, 2015). For those identified as having a venous leg ulcer, compression therapy is usually a suitable option (EWMA, 2017b). Since the 1990s, when it was agreed that palpation of the ankle pulses alone was not sufficient to exclude arterial disease (Moffatt and O Hare, 1995), hand-held portable ABPI machines have been regarded as best practice. However, measuring ABPI using a hand-held machine can be hindered by the time required to undertake the procedure and the skill levels and experience of the operator. The Five Year Forward View (NHS England, 2014) acknowledged that technological advances are important in improving patient care, and that healthcare services should take this into account. In terms of leg ulcer management, this can be interpreted in practice to mean that clinicians and service providers should keep abreast of developments in technology and ensure that staff are educated to use new equipment so that current and high quality care is offered. To provide high-quality interventions and to maintain patient safety, it is imperative that all investigations are undertaken using equipment that is effective and safe. Recent clinical practice has seen the emergence of automated systems, which calculate ABPI as well as pulse volume waveform, which is useful as a second-level assessment for suspected peripheral arterial disease (Huntleigh, 2015). As well as improving patient s access to care by reducing the time it takes to acquire their ABPI (Beldon, 2011), this technology potentially reduces nurses workload as taking ABPI can be delegated to non-registered staff as the training required is minimal. However, this technology is still new to the market and due to budgetary constraints portable ABPI measurement systems are still the main product used in the NHS. Assess the leg A visual assessment of both lower limbs is important in identifying the cause of any ulceration as well as informing clinical decisions about which type of compression therapy is suitable. In addition, assessing the mobility of the limb and the general condition of skin are important factors, which will be discussed in more detail later in this series. The shape and size of the patient s limb, and the presence or absence of oedema, are important factors in assessing the lower limb and require a thorough review by the nurse. Compression therapy should aim to reduce oedema and restore normal limb shape as far as possible (Brown, 2017). Patients with longterm oedema which has not been managed can be challenging to treat due to changes in the subcutaneous tissue of the leg, such as lipodermatosclerosis a hardening and thickening of the tissue (Brown, 2017). In addition, nurses should consider any abnormal limb shapes when planning treatment, as this may affect the patient s suitability for certain compression therapy systems, such as two-layer hosiery. Patients with very large limbs which have been distorted by oedema or who have deep skin folds on their legs should be initially excluded from hosiery until the oedema is reduced and a more normal limb shape has been regained (Wounds UK, 2016). Limb size is important when considering the use of compression bandages (Stephen-Haynes, 2009). The patient s ankle circumference should be measured to ensure the correct bandaging technique and size and quantity of bandages are used. In addition, with both inelastic (Stephen-Haynes, 2009) and elastic bandages (Moffatt, 2005), a woollen bandage layer should be used to protect and shape the leg before compression bandages are applied. Further pathophysiological indicators of venous disease that are important for the nurse to be aware of include varicose veins, itching at the site of varices (dilated blood vessels), hyperpigmentation or venous staining of the skin, atrophie blanche, lipodermatosclerosis, and ankle flare. Patients may also report a sensation of heavy and/or aching legs, which can be relieved with elevation and compression therapy (Hopkinson, 2005), although it is important for nurses to understand that there are always exceptions to these rules. In the presence of arterial disease, the limb may feel cold to the touch and palpation of the pedal pulses will be difficult. Frequently, there will be hair loss on the leg and the skin will appear shiny. Muscle wasting in the calf or thigh is often present and nurses may observe changes to the toenails, such as thickening. The foot and toes may also be poorly perfused, which may cause the limb to appear dusky in colour. Arterial ulcers are widely reported as painful, particularly when the 26 JCN 2018, Vol 32, No 3

6 Ankle Brachial Index Why it is essential to measure both arms Example a) One Arm Right Arm 110 Right Ankle Ankle Brachial : 110 = 0.96 Left Ankle You would INCORRECTLY compress Example b) Both Arms Right Arm 110 Right Ankle Current guidelines specify you should measure both arm pressures and take the highest. (NICE, ESC, ACC/AHA, TASC2 and Aboyans et al*) Otherwise: You could misdiagnose PAD (Vowden & Vowden; 2018)** You could apply compression to a patient with PAD which could lead to an adverse incident (Vowden & Vowden; 2018)** You should always follow evidence based practice Automatic systems which measure the pressure in only one arm contradict the guidelines and may miss or incorrectly classify cases of PAD. Join the #correctabi #2arms Ankle Brachial : 140 = 0.75 For more information contact or visit Huntleigh Healthcare Ltd. 35 Portmanmoor Rd. Cardiff. CF24 5HN Left Arm 140 Left Ankle You would NOT compress Dopplex Ability is an automatic ABI system that correctly measures systolic pressures in all four limbs. * NICE, CG147 (Peripheral arterial disease: diagnosis and management 2018); ESC - European Society of Cardiology (Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery, European Heart Journal, 2017); ACC/AHA - American College of Cardiology/American Heart Association (Guideline on the management of Patients with Lower Extremity Peripheral Artery Disease, Circulation, 2017); Measurement and Interpretation of the Ankle-Brachial Index (Aboyans et al, Circulation, 2012); TASC2 - Inter-Society Consensus for the Management of Peripheral Arterial Disease (Journal Of Vascular Surgery, 2007) ** Vowden P & Vowden K (The importance of accurate methodology in ABPI calculation when assessing lower limb wounds, BJCN, 2018)

7 leg is positioned at the same level as the rest of the body or above, for example, when sitting with the leg elevated or resting in bed (Grey et al, 2006). This kind of pain can be relieved through dependency, which involves the patient arranging the leg so that it sits lower than the rest of the body, for example, the leg can be supported so that it rests out of the bed at night. Assess the wound The final step in the holistic assessment is to assess the ulcer itself, including the wound bed (SIGN, 2010). In recent years, the TIMES acronym has re-emerged as an effective framework for holistic wound assessment (Wounds UK, 2016). TIMES stands for (Stephen Haynes, 2007): Tissue viability Infection or inflammation Moisture imbalance Edge of wound Surrounding skin. A full exploration of the TIMES principle is beyond the scope of this article, however, further reading is recommended to enhance nurses clinical practice and understanding of wound assessment. Hopkinson (2005) outlined that in venous disease, ulcers frequently develop in the gaiter area of the lower leg and often cover a large surface area while being superficial in terms of depth. They may be sloughy and frequently have an exuding wound bed. Venous ulcers do not frequently present as necrotic and the damage does not normally involve underlying structures such as tendons. Wounds UK (2016) provide guidance on the classification of venous leg ulcers and whether they should be termed complex or Red Flag Patients with an ABPI of 0.5 should be referred immediately for specialist assessment and are not suitable candidates for compression therapy (Vowden and Vowden, 2001). simple. A simple leg ulcer is defined as: Having an ABPI of Having a wound surface area of 100cm 2 or less Being present on the leg for a period of less than six months. Complex venous leg ulcers may be classified by: An ABPI outside the range of A wound surface area of 100 cm 2 or more Having been present on the limb for longer than six months Unmanaged pain Foot deformity Fixed or reduced range of motion in the ankle. Venous leg ulcers can also be classified as complex if the patient s history indicates any of the following: The wound has not reduced in size by 20 30% at 4 6 weeks despite optimum clinical practice interventions A history of non-concordance with treatment A history of infection/ recurrent infection A history of controlled/ uncontrolled cardiac failure (Wounds UK, 2016). In contrast, Grey at al (2006) discussed the clinical manifestations of arterial ulceration and explained that arterial ulcers frequently occur on the foot or lateral aspect of the leg, although they can develop outside these classic areas. An arterial wound will appear punched-out and the wound edges normally have a regular shape. Arterial ulcers frequently have a dark, dry base with little signs of healing (Grey et al, 2006). CONCLUSION This article has proposed holistic assessment based on a three-step approach to the management of ulcers on the lower limb: assess the person, assess the leg and assess the ulcer. The authors have outlined the importance of early intervention in leg ulcer management and emerging new technology that supports ABPI assessment. In addition, the article revisits the existing principles of ABPI assessment as an integral aspect of the clinical decision-making process. It has been established that once a patient s suitability for compression therapy has been confirmed, a treatment plan can be developed in partnership with them. Shared decision-making is an integral part of the process and an important factor in encouraging concordance with compression therapy. JCN REFERENCES Atkin L, Tickle J (2016) A new pathway for lower limb ulceration. Wounds UK 12(2): 32 6 Beldon P (2011) How to. Ten top tips for Doppler ABPI. Wounds Int 2(4): Brown A (2017) Dealing with common lower limb problems in primary care: part two. J Comm Nurs 31(4): 24 9 European Wound Management Association (2017a) Meeting report: No compromise on quality: Is good enough really good enough? Wounds International. Available online: journal-content/view/meeting-report-nocompromise-on-quality-is-good-enoughreally-good-enoughmeeting-report-nocompromise-on-quality-is-good-enoughreally-good-enough (accessed 1 May, 2018) European Wound Management Association (2017b) Management of Patients with Venous Leg Ulcers. Challenges and current best practice. Available online: ewma.org/what-we-do/ewma-projects/ we-are-currently-working-on/leg-ulcerguidance-document/ (accessed 1 May, 2018) Green J, Jester R, McKinley R, et al (2017) Chronic venous leg ulcer care are we missing a vital piece of the jigsaw? Wounds UK 13(1): Grey JE Harding KE, Enoch S (2006) Venous and arterial leg ulcers. 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8 online: consensus-documents/view/simplifyingvenous-leg-ulcer-management (accessed 1 May, 2018). Hopkinson A (2005) Leg ulcers. Assessment and management plan. Available online: Huntleigh (2015) Dopplex Ability: the business case. Available online: www. huntleigh-diagnostics.com/_assets/ img/2016%20pdf/dopplex%20ability%20 Business%20Case%20A4%208pp% UK-1%20.pdf (accessed 1 May, 2018) Jin J, Sklar GE, Oh VMS, et al (2008) Factors affecting therapeutic compliance: a review from the patient s perspective. Ther Clin Risk Manag 4(1): Moffatt C, O Hare (1995) Ankle pulses are not sufficient to detect impaired arterial circulation in patients with leg ulcers. J Wound Care 4(3): Moffatt C (2005) Four-layer bandaging: from concept to practice. Part 2 application of a four-layer system. Available online: www. worldwidewounds.com/2005/may/ Moffatt/Four-Layer-Bandage-System- Part2.html Revalidation Alert Having read this article, Why it is important to assess the patient, their leg and wound How you would involve patients in the decisionmaking process The benefits of taking timely ABPI measurements When light compression might be suitable without an ABPI reading. Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: National Institute for Health and Care Excellence (2015) Clinical knowledge Summaries: Leg Ulcer Venous. NICE, London. Available online: org.uk/cellulitis-acute#!topicsummary Neighbour R (2005) The Inner Consultation. How to Develop an Effective and Intuitive Consultation Style. CRC Press, Padstow National Institute for Health and Care Excellence (2018) Shared decisionmaking. NICE, London. Available online: our-programmes/nice-guidance/niceguidelines/shared-decision-making NHS England (2014) NHS Five Year Forward View. Available online: uk/wp-content/uploads/2014/10/5yfvweb.pdf NHS England (2016) Leading Change, Adding Value. A framework for nursing, midwifery and care staff. Available online: uploads/2016/05/nursing-framework.pdf NHS England (2018) Leading Change, Adding Value. A framework for nursing, midwifery and care staff e-lfh Framework E learning. Available online: programmes/leading-change-addingvalue/ (accessed 10 April, 2018) Ritchie G (2017) Chronic leg ulcers. Nurse Prescribing. Available online: www. magonlinelibrary.com/doi/abs/ / npre Ritchie G, Warwick G (2018) Understanding how compression works: part 1. J Community Nurs 32(2): Scottish Intercollegiate Guidelines Network (2010) Management of chronic venous leg ulcers. A national clinical guideline. SIGN, Edinburgh. Available online: pdf Stanton J, Hickman A, Rouncivell D, et al (2016) Promoting patient concordance to support rapid leg ulcer healing. J Community Nurs 30(6): Stephen-Haynes J (2007) Leg ulceration and wound bed preparation towards a more holistic framework. Available online: www. worldwidewounds.com/2007/october/ Jackie-Stephen-Hayes/test.html (accessed 1 May, 2018) Stephen-Haynes J (2009) Compression: applying short stretch bandages. Wound KEY POINTS Holistic assessment and accurate diagnosis are the first steps in clinical decision-making in leg ulcer management. Adopting a what matters to you approach is recommended as an important method of ensuring that patients remain at the centre of care. The relationship between nurse and patient may extend over a long period of time and so mutual respect and trust is vital. Timely ABPI measurement plays a crucial part in diagnosing the underlying pathophysiology of leg ulcers. Without ABPI assessment and the provision of appropriate compresstion therapy, lower limb ulcers will not heal and may even deteriorate. Essentials 4: Available online: www. wounds-uk.com/wound-essentials/ wound-essentials-4-compressionapplying-short-stretch-bandages Vowden P, Vowden K (2001) Doppler assessment and ABPI: Interpretation in the management of leg ulceration. Available online: com/2001/may/vowden/dopplerassessment-and-abpi.html (accessed 1 May, 2018) Wounds UK (2013) Best Practice Statement: the use of topical antimicrobial agents in wound management. Available online: (accessed 1 May, 2018) Wounds UK (2015) Best Practice Statement: Compression Hosiery. Second edition. Available online: pdf/content_11547.pdf (accessed 1 May, 2018) Wounds UK (2016) Best Practice Statement: the holistic management of venous leg ulceration. Available online: www. wounds-uk.com/best-practicestatements/best-practice-statementholistic-management-of-venous-legulceration JCN 2018, Vol 32, No 3 29