key slides leg ulcer (2)

8/11/2019 Key Slides Leg Ulcer (2)

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Wounds: Leg ulcers

Key slides


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Wound care: leg ulcersNHS CRD (1997) Effective Healthcare 3 (4), 1-12

SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer

Clinical Knowledge Summaries_Venous Leg Ulcer_Feb 08

Wound care is a high cost area for patients and NHS in terms of

prescribing costs, patient QoL and NHS workforce time

The evidence base for therapeutics in much of this area is

limited Value for money for the NHS is an important factor when

choosing treatments

Leg ulcers are a common, chronic, recurring condition

Prevalence of active leg ulcers is between 1.5 to 3 per 1000 and

increases with age. Its estimated that up to 20 per 1000people over 80 yrs will suffer from a leg ulcer

Following healing, re-ulceration rates at one year range from

26% - 69%

Available treatments can reduce recurrence rates


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Leg ulcer aetiologyClinical Knowledge Summary Venous Leg Ulcers_February 2008

Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50

Venous insufficiency 80 - 85%

Other causes:

Arterial disease

Mixed arterial and venous disease Diabetes

Rheumatoid arthritis

Systemic vasculitis

Lymphoedema Trauma

Others including malignancy


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Assessment of the patient - historyClinical Knowledge Summary Venous Leg Ulcers_February 2008

Royal College of Nursing Clinical Practice Guidelines 2006

History suggesting venous

disease

History suggesting arterial

disease (c.10-20% patients)

Varicose veins, immobility, obesity Ankle Brachial Pressure Index less

than 0.8

Proven deep vein thrombosis in the

affected leg

Ischaemic heart disease, stroke or

transient ischaemic attack

Phlebitis in the affected leg Rheumatoid arthritis

Previous fracture, trauma, or

surgery

Diabetes mellitus

Family history of venous disease Peripheral arterial

disease/intermittent claudication

Symptoms of venous insufficiency:

leg pain, heavy legs, aching,

itching, swelling, skin breakdown,

pigmentation, and eczema

Smoking


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Assessment of the leg - examinationClinical Knowledge Summary Venous Leg Ulcers_February 2008

CREST Guidelines for the Assessment and Management of Leg Ulcers 1998

Measurement of Ankle Brachial Pressure Index (ABPI) is the most

reliable way to detect arterial insufficiency


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Assessment of the ulcerClinical Knowledge Summary Venous Leg Ulcers_February 2008


RECORD RATIONALE

Size, depth, edges and site of ulcer Serial measures useful for progress

Ulcer base:

Epithelialisation/granulation/slough/

eschar/necrosis

Aid choice of dressing and indicate

progress of healing

Level of exudate:

Minimal/ moderate/ high

Will influence dressing choice and

frequency of dressing change

Signs of infection:

Enlarging ulcer, increased exudate,

pyrexia, foul odour, cellulitis

May indicate infection

Pain:

Assess level, frequency and duration

Treat to relieve distress and aid

compliance with treatment


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Referral to a specialist clinic before treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008

Uncertain diagnosis

Suspected alternative causes of ulceration:

- Arterial or mixed venous/arterial ulcer. Refer people with

ABPI


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Lifestyle adviceClinical Knowledge Summary Venous Leg Ulcers_February 2008

Self - care strategies include:

Keep mobile with regular walking if possible

Elevate legs when immobile Use emollient and examine legs regularly for broken skin,

blisters, swelling or redness

Lose weight if appropriate

Stop smoking


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Venous leg Ulcer - treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008

Irrigate the wound with warm tap water or saline, then dry. Strictaseptic technique not required

Remove slough or necrotic tissue by gentle washing

If debridement is needed, it should be carried out by a trainedhealthcare professional

Consider using potassium permanganate 0.01% soak if theulcer is malodorous

For uncomplicated, non-infected ulcers apply a low-adherentdressing & replace weekly. (If heavy exudate - more frequentchange)

Other dressings may be used if needed - pain (hydrocolloid),heavy exudate (alginate) or slough (hydrogel)

For uncomplicated, non infected ulcers and where indicated byABPI, apply compression bandaging - 4 or 3 layer if immobile,or 2-layer if mobile


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Uncomplicated venous leg ulcer

Follow up during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008

Assess weekly for the first 2 weeks. If healing underway, assess

fortnightly or monthly, then 3 monthly

Change dressings at least once a week. Check for healing

and compliance with compression therapy and ask aboutproblems e.g. mobility, sleep, mood

If delayed or no healing, identify problems which may need

further treatment or referral

Check for complications

Check lifestyle advice is followed If ulcer not healing or deteriorating at 12 weeks, look for signs of

arterial disease and repeat ABPI


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Venous leg ulcer - treating infectionClinical Knowledge Summary Venous Leg Ulcers_February 2008

All chronic wounds are colonised with bacteria Antibiotics should be used only if there is evidence of

cellulitis or active infection (e.g. pyrexia, increasing pain,

enlarging ulcer)

If there are clinical signs of infection present, clean ulcer with

warm tap water or saline before taking a swab Start immediate empiric treatment with an anti-staphylococcal

antibiotic i.e. flucloxacillin or erythromycin 500mg qds for seven

days

Change dressing daily or alternate days to assess if infection is

improving Do not use antimicrobial dressings

Do not start compression therapy if ulcer is infected


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Infected venous leg ulcer- follow up

during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008

SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer

Reassessment and follow up frequency is different

for uncomplicated and infected ulcers

Review the patient within 3 days to assess response

to treatment, ideally followed by re-assessment every

two or three days until clinical improvement is seen

Reassess the ulcer as at initial assessment:

dimensions, site, base, odour and exudate

If infection is not responding, consider change of

antibiotic based on swab results

If signs of worsening infection, refer

After infection has settled, follow up as for

uncomplicated venous ulcers


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Venous leg ulcer - dressing choiceSIGN 26 (1998) The Care of patients with Chronic Leg UlcerClinical Knowledge

Summary Venous Leg Ulcers_February 2008

There is good evidence that the type of dressing used has

no effect on ulcer healing

Uncomplicated ulcer-use simple low-adherent dressing

Sloughy ulcer-hydrogel provides moisture that may help liquefyslough

Moderate to heavily exuding ulcer-alginate or foam dressing

may help absorb exudate

Painful ulcer-occlusive hydrocolloid or foam dressing may

reduce pain

Simple non-adherent dressings are recommended in the

treatment of venous ulcers as no specific dressing has

been shown to improve healing rates


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Venous leg ulcer - compression bandagingClinical Knowledge Summary Venous Leg Ulcers

Below-knee graduated compression is the mainstay of

treatment to improve venous return, and to reduce venous

stasis and hypertension in uncomplicated venous leg

ulcers

Graduated compression delivers the highest pressure at theankle and gaiter area (40 mmHg), and pressure progressively

reduces towards the knee and thigh where less external

pressure is needed (18 mmHg)

High compression multilayer(four layer, three layer)

bandaging has improved healing rates over single layerbandaging

An appropriately trained personshould apply high

compression multi-layer bandaging, to avoid the risk of pressure

ulceration over bony points


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Venous leg ulcer - preventing recurrenceClinical Knowledge Summary Venous Leg Ulcers_February 2008


Graduated compression stockings should be used for at

least 5 years after ulcer healing

Educate and explain to the patient the importance of preventing

recurrence through lifestyle changes and use of hosiery

Accurate measurement of limbs for compression hosiery is

essential

Follow up with 6-monthly Doppler ABPI checks

Class III (high) compression stockings are associated with lessrecurrence than Class II (medium) compression stockings, but

may be less acceptable to the patient


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Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50

Caused by reduced blood supply to the lower limbs either by a

blockin the artery or narrowing of the arteriesresulting in hypoxic

damage, ulcer formation and necrosis

Arterial ulcers account for 10% - 15% of leg ulcers

Typically occur over toes, heels and bony prominences of foot Can take months or years to heal, are painful and often become

infected

Men over 45 years and women over 55 years are more likely to have

PVD, (peripheral vascular disease) and so are prone to arterial leg

ulcers

Modifiable risk factors: smoking, hyperlipidaemia, hypertension,

obesity, diabetes, decreased activity


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Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50Nelson EA et al.

Dressings and topical agents for arterial leg ulcers. Cochrane Database of

Systematic Reviews 2007, Issue 1.

Infection can cause rapid deterioration of an arterial

ulcer

It is not appropriate to debride arterial ulcers as this

may produce further ischaemia and formation of a

larger ulcer (specialist only)

Compression bandaging should not be applied

as severe damage to the leg can result

Choice of dressing is dictated by the nature of the

wound Treatment options include reconstructive surgery or

angioplasty


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Summary: leg ulcer therapeutics

For both venous and arterial leg ulcers Systematic assessmentof the wound is essential for baseline dataand to evaluate healing and treatment efficacy

Regular wound reassessmentis good clinical practice

There is insufficient evidence that one type of dressing is superior toanother in leg ulcer wound healing

Treat infection with systemic antibiotics not topical antimicrobials

Management of venous vs. arterial leg ulcers

Compression therapyis the mainstay of venous leg ulcermanagement, but should not be used for arterial ulceration or infected

wounds Increasing peripheral blood flowis the intervention most likely to

affect healing in arterial ulceration

key slides leg ulcer (2)

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