Promoting best practice in leg ulcer management Sylvie Hampton MA BSc (Hons) DpSN RGN Independent Tissue Viability Consultant Nurse
Leg Ulcers - What are the causes? Chronic leg ulcers are defined as those that show no tendency to heal after 3 months of appropriate treatment What is appropriate treatment?
70% Rule! 70% of District Nurse workload is wound care 70% of wounds are leg ulcers 70% of leg ulcers are venous in origin 70% can be healed in 12 weeks* 70% of patients with leg ulcers are over 70
Leg Ulcers - What are the causes? 70,000 190,000 individuals in the UK with venous leg ulcers at any time Painful Malodorous Leaks fluid everywhere Has never registered on any Government s need for improvement (until now) Some patients have had their wounds for decades Given the 70% rule this is now thought unnecessary Socially isolating
Leg Ulcers - What are the causes? Causes of leg ulcers are varied: Venous Arterial Diabetic Rheumatoid arthritis Hypertension Cancer
Leg Ulcers - What are the causes? The cause of chronicity of a wound is poor blood supply to the area Arterial blood does not successfully reach the leg Venous the blood does not return from the feet Diabetic the blood cannot reach the tissues Rheumatoid arthritis blood is restricted due to vasculitis
Leg Ulcers - What are the causes? Therefore, treatment should be simplistic return the blood supply to the wound and it will heal However, there may be other problems that prevent healing dermatitis; eczema; infection; allergies; cancer; oedema
15/01/16
20 th July 11 th September
Review The treatment for each of these causes would also be varied
Conclusion Treatment relies mainly on restoring the blood supply or removing the irritation (infection / dermatitis / allergy etc) Careful assessment is absolutely required in order to determine the cause
Management techniques for leg ulcers
Management techniques for leg ulcers With arterial wounds, the blood does not successfully reach the feet Venous blood cannot successfully not return to the heart Diabetic wounds blood cannot successfully reach the tissues etc.
Management techniques for leg ulcers Leg ulcers should always receive a Doppler assessment to rule out arterial disease
Doppler Sounds There are 3 different sounds to the arteries Triphasic: Biphasic: Monophasic: 3 sounds 2 sounds 1 sounds
Doppler Sounds Triphasic: Blood accelerates quickly with the beat of the heart It stops very briefly It then flows backwards as a pressure wave traveling faster than the blood itself reflects back from the smaller arterioles near the end of the blood pathway This gives 3 sounds
Doppler Sounds Biphasic: The elasticity of the artery is reduced due to some atherosclerosis forward flow in systole reverse flow in diastole This gives 2 sounds
Doppler Sounds Monophasic: This is a single phase with slow acceleration and deceleration (dampened flow) The artery is so blocked by atherosclerosis that there is no elasticity to the vein the sound heard is the blood rushing through the artery under high pressure Sound of a dog barking or a steam train
Intermittent Claudication Pain on exercises that reduces at rest Atherosclerosis partially blocking the artery Blood normally can pass through On exercise, the greater demand for blood in the lower limb will lead to pain as the blockage will not permit an increase in blood to the lower limb
Arterial Ulcers Arterial ulcers appear anywhere on foot or leg Generally stamped out cliff sides Often will have tendon exposed Can be associated with neuropathic pain where the patient tends to lower their feet to the floor at night Gravity helps return the blood to the feet reducing pain
Treatment Refer to the vascular team for surgical consideration May be prescribed Pentoxifylline (Trental) which has demonstrated benefit to patients with intermittent claudication
Venous Ulceration Venous ulceration of the lower limb is end-stage disease It is a sign of underlying pathology If the pathology is corrected the ulcer will heal This pathology exists prior to the development of ulcers and tissue breakdown is the end result of the problems that already exist One of the aims for healing an ulcer would be to correct the pathology (blood return to the heart) to enable the wound to heal
Venous Ulceration The veins have sounds similar to the wind in the trees On exercise there is a pumping sound On breathing out there is a pause in the sound On breathing in, the suction sound can be heard These are the two methods of returning blood to the heart
Venous Ulceration Lack of exercise or poor air intake will reduce the potential for return of blood to the heart
Venous Ulceration Venous ulcers are more commonly found above the medial or lateral malleoli in the area referred to as the gaiter area The wounds are usually shallow with sloping sides
Venous Ulceration Both superficial & deep systems of veins are found within the lower limbs The unprotected superficial veins are outside the calfmuscle pump The deep veins are supported & protected by the calf muscle (Keachie, 1992)
Venous Ulceration Valves become ineffective due to: Deep vein thrombosis (often undiagnosed) Standing for long periods Familial tendency Resulting in varicosities
Perforators Check for a suspected incompetent perforator by checking skin temperature, which will be warmer at the perforator level due to the faster blood flow from the deep veins where the blood is warmer, to the superficial vein 33
Venous Ulceration Leakage of red blood cells causes pigmentation of the skin which is a permanent brown stain called haemosiderin Leakage of fat through the walls leads to lipodermatosclerosis a woody feel to the tissue
Oximeter 35
Management Techniques Compression Bandages Compression Hosiery Compression Wraps Intermittent Compression Therapy Leg Elevation
Compression Bandaging This shape leg requires padding on boney prominence Requires padding with wool bandage Requires padding with wool bandage to increase size of calf Would require reshaping with wool padding
Compression Hosiery Vital to measure correctly, particularly with made to measure hosiery If the leg is abnormal shape, then made to measure would be acceptable Ensure oedema is reduced prior to measuring for hosiery Assess dexterity for applying own hosiery
Compression Wraps
Conclusion An ulcer is a problem waiting to happen It can be prevented All ulcers are treatable Not all ulcers are healable A venous ulcer can be healed with compression
Intermittent Compression Therapy Intermittent compression therapy is not a new conception It is a proven method of compression Proven useful in arterial disease Exceptional in lymphoedema Useful adjunct to compression or used on its own
Ensuring patients the best possible chance of healing and preventing recurrence
Healing There are several options that will lead to healing Unless the blood supply is not restored, healing will either be very slow or will not occur
Restoring the blood Arterial refer to the vascular consultant Dermatitis / vasculitis refer to the dermatologist Venous Doppler and compress Diabetic wound refer to diabetic team but assist and advise on diet Infection? Be certain it is an infection
Recognising Infection
Recognising Infection These DO NOT require antibiotics They DO NOT require swabbing for bacteria If a true infection is identified then antibiotics would be required
Psychosocial assessment The psychosocial side of healing should not be dismissed does the leg ulcer offer social links (with carers or nurse) does the leg ulcer create isolation (malodour, exudate, pain etc) What can be done to correct social isolation? What can be done to correct pain, odour and exudate?
Dressings Dressings can only help of the underlying cause is addressed Once addressed, treatment is simpler Dry dressing for a wet wound Wet dressing for a dry wound Antibacterial dressing for one that has an odour Superabsorbent for a very wet wound Foam dressing as secondary dressing in the above or primary in a healing wound
Healing in Reality Holistic assessment is essential to identify the underlying cause and identify factors that affect healing Dressings do not heal wounds they help to provide the ideal environment for healing The optimum wound environment has yet to be developed There is no one product that does it all!
Thank you for listening