Download - Leg Ulcer Forum

Clinical Guidance on the treatment of Lower Limb Ulceration
Doc. Ref. No.
Title of Document
Lower Limb Ulceration Guidelines
Author’s Name
Gail Powell see page 38.
Author’s job title
CNS/Leg Ulcer Specialist
Dept / Service
Wound Care Service Provider Unit
Doc. Status
Version 5
Based on
Updated Guidelines from Version 4
Published Evidence and Good Practice
Signed off by
BCH CIC
Publication Date
August 2016
Next review date
August 2019
Distribution
All Clinical staff who are involved in
Wound care and leg ulcer management.
Version
Date
Consultation
1 of no 3
March 2016
LU Guidelines group
2 of no 3
May 2016
LU Guidelines group
3 of no 3
August 2016
Clinical Cabinet
Contents
1
Introduction .......................................................................................................... 4
2
Guideline Standards ............................................................................................ 4
2.1
Aims of the Guidelines .................................................................................. 4
2.2
General Standards ........................................................................................ 5
2.3
GP Practices ................................................................................................. 5
3
Assessment and Diagnosis ................................................................................. 5
3.1
Doppler Assessment ..................................................................................... 6
3.2
Diagnosis ...................................................................................................... 7
4
Flow Chart for Venous Ulcers .............................................................................. 8
5
Flow Chart for Mixed Venous and Arterial Ulcers ................................................ 9
6
Flow Chart for Arterial Ulcers ............................................................................. 10
7
General Management of Leg Ulcers .................................................................. 11
7.1
Treatment of infection ................................................................................. 12
7.2
Initial treatment should be with high dose oral antibiotics ........................... 13
8
Compression for Venous Ulceration .................................................................. 14
9
The Multi-layer Elastic Compression Bandaging System .................................. 16
10
The Short Stretch Bandage System ............................................................... 19
11
Other Bandage Systems ................................................................................ 20
12
Juxta ............................................................................................................... 21
13
Prevention of Recurrence in Venous Ulceration ............................................. 25
13.1
14
Compression Hosiery (appendix 6 & 7c) .................................................. 25
Recurrence of Ulceration ................................................................................ 26
14.1
Patient Education ..................................................................................... 27
14.2
Care of patients presenting with reoccurrence of ulceration .................... 28
15
Invasive Treatments for Venous Insufficiency ................................................ 28
15.1
Surgery .......................................................Error! Bookmark not defined.
15.2
Other treatments for venous disease ....................................................... 30
15.3
Summary ................................................................................................. 31
16
Trouble shooting Tips ..................................................................................... 31
16.1
Concordance ........................................................................................... 31
16.2
Pain.......................................................................................................... 32
16.3
Difficulty tolerating compression .............................................................. 33
16.4
Managing Exudate ................................................................................... 34
16.5
Footwear Problems .................................................................................. 34
Leg Ulcer Care Guidelines
Page 2 | 116
16.6
Managing Varicose Eczema .................................................................... 34
16.7
Contact Sensitivities................................................................................. 35
16.8
Cellulitis ................................................................................................... 35
16.9
Deep Vein Thrombosis (DVT) .................................................................. 36
16.10
Hosiery..................................................................................................... 36
16.11
Bandage slippage .................................................................................... 36
16.12
Patients unable to attend clinic ................................................................ 36
17
Flow Chart for non-healing Venous Ulcers (No Progression in Healing) ........ 38
18
Education, Training and Competencies .......................................................... 39
18.1
Aims of Education and Training ............................................................... 39
18.2
Training should cover:.............................................................................. 39
18.3
Competence in Application of Compression Bandages/hosiery ............... 39
18.4
Competence in Assessing patients and initiating compression therapy ... 40
19
Development, Consultation and Ratification Processes ................................. 40
19.1
20
Development of Guidelines ...................................................................... 40
Appendix 1 ..................................................................................................... 41
21
Appendix 1a - A Quick assessment guide for managing Venous Leg Ulcers
short term ................................................................................................................. 49
22
Appendix 1b - Flow Chart for Guide to Fitting Compression Hosiery ............. 51
23
Appendix 2 - Doppler assessment .................................................................. 53
24
Appendix 3 - Pain ........................................................................................... 57
25
Appendix 4 - Emollients .................................................................................. 59
26
Appendix 5 - Steroid Ladder ........................................................................... 61
27
Appendix 6a Compression Hosiery ................................................................ 62
28
APPENDIX 6b - Requirements for obtaining the accurate garment from your
prescription............................................................................................................... 70
29
Appendix 6c - Aids available to aid application, removal or wearing .............. 74
30
Appendix 7 - Competencies ........................................................................... 76
31
Appendix 8 ..................................................................................................... 91
32
Appendix 9 – Inclusion Criteria ....................................................................... 93
33
References ..................................................................................................... 97
34
Bibliography.................................................................................................. 102
35
Other Useful Sources ................................................................................... 103
Leg Ulcer Care Guidelines
Page 3 | 116
1
Introduction
Definition of a Venous Leg Ulcer
An open lesion between the knee and the ankle joint that remains unhealed
for at least four weeks in the presence of venous disease (SIGN 2010).
Leg ulcers are a chronic and recurring condition that affect between 1.5-3.0
people in every 1000 at any one time. (Graham et al 2003) The prevalence of
leg ulceration increases with age and can be as many as 20 in every 100
people over the age of 80, (Moffatt et al 2004)
There is no single aetiology; however it is thought that approximately 70% of
people with a leg ulcer are as result of venous hypertension (Moffatt and
Franks, 1994, Chen & Rogers 2007) Arterial or mixed arterial/venous disease
is responsible for a further 20% and the remaining are from other conditions
such as diabetes, rheumatoid disease, malignancy and vasculitic conditions
(Chen & Rogers 2007).
Inadequate assessment and ineffective treatment may result in the
persistence of ulcers for many years, some never healing (Harding K et al
2015).
The annual cost to the NHS for chronic wounds is estimated at £300-600
million per annum with a large proportion of this coming from nursing time
(NHS Centre for Reviews and Dissemination, 1997; Bosanquet, 1992; Baker
et al.1991 McCollum 2004). Some individual health authorities are spending
£0.9m to £2.1 million (Carr et al 1999).The cost to the NHS for treating
venous ulceration, alone, mostly in primary care and through community
nursing services, are at least £168-198 per year. (Posnett 2008 & Augustin et
al 2014).
Not only is it time consuming and costly to treat, but there are psychological
implications to the patient in that the ulcer increases social isolation through
limited mobility, uncontrolled exudate and odour, together with pain (Lindholm
et al.1993; Charles,1995).
Careful evaluation of causative and contributory factors is of great importance
in the management of patients with leg ulcers (Sarker and Ballantyne, 2000).
Research has shown that it is possible to heal up to 83% of venous ulcers
with compression bandaging. (Franks et al 1995)
2
Guideline Standards
2.1
Aims of the Guidelines

To ensure that all patients presenting with a leg ulcer receive a
comprehensive assessment and subsequent diagnosis from a
registered nurse who have additional competencies in leg ulcer
management.
Leg Ulcer Care Guidelines
Page 4 | 116

To ensure that all patients diagnosed with a leg ulcer receive
treatment according to agreed guidelines.

To ensure that leg ulcer management guidelines are monitored
and evaluated. It is intended that these guidelines undergo a
review every three years.
The Guidelines will facilitate each practitioner to utilise and update
skills, knowledge and competencies.
2.2
2.3
3
General Standards

A guideline conforming to current best practice has been agreed
by BCH CIC Clinical Cabinet.

Doppler machines must be available for each nurse undertaking
leg ulcer assessment.

An annual Audit of the use of the leg ulcer management
guidelines should be carried out by the Wound Care Service.

BCH CIC has at least one lead nurse to act as a source of expert
advice in leg ulcer management.

BCH CIC will work within these guidelines.

BCH CIC has a responsibility to provide a nursing workforce who
can offer assessment and compression therapy as a skill and
ensure their competency is maintained.
GP Practices

Each GP practice is aware of the management of leg ulcers
based on these guidelines and knows of a named individual who
can act as a point of contact and expertise.

Each GP practice ensures that all those patients presenting with a
leg ulcer are appropriately assessed and treated.
Assessment and Diagnosis
The first step in successfully managing a patient with a leg ulcer is
recognising the wound as a leg ulcer. Wounds that commonly fall into not
being recognised as an ulcer are pre-tibial lacerations (or other trauma
wounds) and surgical incisions where veins have been harvested for coronary
bypass grafts. (Moffatt et al 2007).
A detailed assessment of the patient’s general health and past medical history
is essential when diagnosing and determining treatment of the ulcer and
should be carried out using the assessment tool incorporated within these
guidelines (See Section 2 Lower Limb Care-Pathway / Appendix 1
Leg Ulcer Care Guidelines
Page 5 | 116
Assessment & 1a Quick Assessment). Assessment is not a one off procedure
but an ongoing one.
It is paramount that underlying disease processes are addressed and
stabilised to ensure maximum potential to heal.
Many textbooks state that compression therapy should not be used in patients
with diabetes. This is because of the concern that sensory neuropathy will
prevent a patient detecting whether the compression is causing trauma and
the risk of concurrent Peripheral arterial disease(PAD). However, patients with
diabetes are just as likely to suffer from a venous ulcer as patients without
diabetes. Healing may take longer but generally does occur. So if
compression is the treatment of choice it should be used. (Moffatt et al 2007)
It is intended that the assessment should be carried out by a Nurse holding
competencies in the theory and practice of the management of leg
ulcers.(SIGN 2010) Leg ulcer assessment is a highly complex skill,
practitioners who lack the skill can tend to focus on the wound rather than the
patient, not recognising the under- lying causes that need to be addressed.
3.1
Doppler Assessment
Doppler Ultrasound / ABPI is an integral part of the assessment of leg
ulceration. It enables an objective measurement of the blood flow to the
limbs to be made, supporting the clinical findings and so aiding the
planning and implementing of a management regime. Doppler
assessment is two fold, comprising of interpretation of both signals and
pressure index (Warboys 2006).This diagnostic test compares the
Ankle systolic pressure to the brachial systolic pressure. Patients who
have a normal arterial circulation will have an Ankle systolic pressure
that is the same as, or higher than, their Brachial pressure. Ankle
pressures lower than the brachial pressures are indicative of arterial
disease. (See Appendix 2 & Appendix 7)
These measurements need to be interpreted with caution in the
diabetic patient. Full Compression should not be applied until
Assessment and Doppler ultrasound have been performed and
the blood flow to the limb is confirmed as being sufficient. Neither
should be used in isolation. A study day is available to learn
about recording Doppler ultra sound. A period of practice with
assessment by a mentor should follow.
PAD occurs at an early age and progresses more rapidly in patients
with diabetes, compared with patients without diabetes. There is a
difference in the distribution of disease in the patients with diabetes.
Distal vessels, particularly the tibial and peroneal, are more frequently
involved in patients with diabetes. In patients without diabetes, the
femoral iliac and aorta are more commonly affected. Changes do occur
in the micro circulation, particularly thickening of the capillary basement
membrane that influences blood flow. Other regulatory mechanisms
Leg Ulcer Care Guidelines
Page 6 | 116
controlling local blood flow are effected, therefore influencing perfusion
of the tissues.
A Doppler assessment can be carried out as soon as possible after the
initial presentation but must be carried out within 4-6 weeks, as this is
sufficient time to ascertain that there is delayed healing that requires
investigation.
3.2
Diagnosis
Having made an assessment of the patient, the ulcer and the foot
circulation, a working diagnosis should be formulated. Treat patients
according to the underlying pathology of their diagnosis using the
following flowcharts. A patient should be given one of the three
treatment pathways available.
Patients where diagnosis is unclear should be referred to the Wound
Care Service, a referral form will need to be completed. If needed a
vascular Consultant opinion can be sought by direct referral to the
vascular dept, a referral form needs to be completed.
Leg Ulcer Care Guidelines
Page 7 | 116
4
Flow Chart for Venous Ulcers
Assessment including Ankle Brachial Pressure
ABPI 0.8 and above
Normal Doppler Index with
Triphasic and Biphasic sounds –
and no other significant arterial
factors
Normal Doppler Index with
Monophasic and Biphasic signals
with difficult or muffled sounds and
significant arterial factors indicating
possible arterial component.
Dress wound according to local
wound formulary – where
possible this should be a simple
non adherent dressing
Dress Wound according to local
wound formulary – where possible
this should be a simple non adherent
dressing.
Apply Full Compression
(40mmHg) at the ankle
Reduced compression (20 mmHg)
or short stretch initially) Increase to
Full Compression (40 mmHg) if
tolerated. ? Complex venous
pathway (Appendix 9)
Treatment pathway standard
venous (Appendix 9)
Address pain control
Address underlying disease e.g. Diabetes, Rheumatoid Arthritis –
refer if unstable
Address Dermatology issues – refer to Specialist Nurse for advice
Patient Education
Ulcer Healed
Prevent reoccurrence
Fit with compression hosiery class 2 or 3 German RAL
mod/high oedema British Standard
BS if minimal oedema
Ulcer not improving consider
complex treatment pathway
Or
Deteriorating
Reassessment and Re-Doppler
Refer to Vascular surgeon for
assessment of veins for treatment
if ulcers reoccurring despite
hosiery.
Leg Ulcer Care Guidelines
Refer to WCS for further assessment
Page 8 | 116
5
Flow Chart for Mixed Venous and Arterial Ulcers
Assessment including Ankle Brachial Pressure
ABPI 0.5 – 0.8
Monophasic and Biphasic
signals with difficult or muffled
sounds significant arterial
factors – Mixed venous /
arterial ulcer
All Monophasic signals and
significant arterial
components – Predominantly
Arterial Ulcer
Appropriate dressing
Appropriate dressing
Compression 20 mmHg
No Compression Refer to
WCS for Advice may need
urgent vascular opinion
Treatment pathway mixed
aetiology (Appendix 9)
Address pain control
Address underlying disease e.g. Diabetes, Rheumatoid Arthritis –
refer if unstable
Address Dermatology issues – refer to WCS for advice.
Patient Education
Healed
Not healed
0.5/0.6
0.7/0.8
0.5/06
0.7/08
Class 1
compression
hosiery
Class 2
compression
hosiery
Refer to WCS for
advice
German RAL for
Mod/high level’s
oedema BS for
minimal oedema
German RAL for
Mod/high level’s
oedema BS for
minimal oedema
Refer to
Vascular
Surgeon for
assessment of
arteries and
possible
surgical
treatment
Refer to WCS if ulcers reoccurring
Leg Ulcer Care Guidelines
Page 9 | 116
6
Flow Chart for Arterial Ulcers
Assessment indicating Arterial Components including Ankle
Brachial Pressure
ABPI < 0.5
Urgent referral to Vascular Surgeon
Appropriate dressing selection according to Wound Formulary
Address underlying disease e.g. Diabetes, Rheumatoid Arthritis –
refer if unstable
Address pain control
No Compression but layer one and layer 2 of the compression
system applied with a spiral technique will offer some support.
Leg Ulcer Care Guidelines
Page 10 | 116
7
General Management of Leg Ulcers
Essential skin hygiene and cleansing of the ulcer at each dressing or bandage
change. Soak the leg for 10 minutes in a clean (plastic-lined) bucket of warm
water, with an emollient to promote a healthy skin.

Dealey (1999) suggests that the aims of cleansing leg ulcers/legs are:

To remove dry and flaky skin, especially when a bandaging system is in
place.

To remove the build-up of emollients/topical steroids.

For patients well-being and comfort.
Hyperkeratosis is thickening of the outer layer of the skin- the stratum
Corneum. It is associated with an over-proliferation of the keratin producing
cells over the service of the skin (ILF 2012). Daily Skin care/Hygiene regime is
important for patients with hyperkeratosis. Patients should be encouraged to
carry out this care and perform regular care. Promoting self-care where
possible, is important in promoting and maintaining skin health (Whitlaker
2012, Pidlock and Jones 2013)
RCN (2006) Clinical Practice Guidelines suggest cleansing of the affected leg
should be kept simple using warm tap water and a non-lanolin based
emollient. (Tap water on exposed bone or tendon is not recommended) (See
Appendix 4)
Dry scales should be removed from the legs particularly around the ulcer
edge to allow new growth of epithelium. (Sterile single use forceps should be
used).Removal of the scales must be safe and atraumatic (Whitlaker 2012).
Recent NICE guidelines (NICE 2014) support the use of a monofilament
debridement pad in the management of hyperkeratosis. Emollients should be
removed before using the monofilament debridement pad. The instructions
should be read before using.
UCS cloth is another device that can be used to promote good skin hygiene
and debridement of skin scales.
A bland non lanolin moisturiser should be applied to the legs after cleansing
and drying. The emollient will help to form a waterproof barrier over the skin
surface, which helps to prevent the water within the skin evaporating and
keeps the underlying skin hydrated. (Coley 2009)
For additional information on skin care see Trouble Shooting Tips. (Page 22)
Standard Infection Control Procedures should be adhered to. See local
policies re: ANTT and hand hygiene. See also Appendix 8 for safe systems of
work within patients own home.
Leg Ulcer Care Guidelines
Page 11 | 116
Local Wound care
Dressings do not heal leg ulcers but can be used to control symptoms such as
odour or pain. They should be simple and cost effective; usually an atrauman
or similar is the initial dressing of choice. Refer to Wound Formulary/
Guidelines 2016.
7.1
Treatment of infection
When clinically assessing wounds, the practitioner should always be
mindful of the presence of infection (White et al 2011)
Bacteria can usually be grown from a leg ulcer but in most
circumstances they can be ignored as they don’t interfere with healing.
All broken areas of skin will rapidly become colonised with bacteria in
any normal environment.
Routine bacteriological swabbing is unnecessary (Harding et al 2015)
unless there is evidence of clinical infection such as:
Inflammation/redness/cellulitis

Increased pain, redness, swelling and exudate volume and
viscosity, temperature to skin.

Enlargement of the ulcer. (RCN,2006)

Delayed healing despite appropriate compression therapy

Newly formed ulcers within inflamed margins, or extension of the
wound margins (EWMA 2005)

Discolouration ( for example dull, dark brick red)

Friable tissue that easily bleeds

Increase in malodour

New onset dusky wound hue

Sudden appearance of slough or increase
Sudden appearance of necrotic black spots (EWMA 2005)
However some of the above signs are indicative of clinical inflammation
resulting from high protease activity. (White et al 2011).
There may also be fever, malaise, neutrophil leucocytosis and high
white cell count (raised CRP)
In most immunologically normal patients the infection is caused by
Streptococcus pyogenes group A and/or Staphylococcus aureus.
Leg Ulcer Care Guidelines
Page 12 | 116
Pseudomonas aeruginosa is commonly grown but very rarely of
pathological significance.
7.2
Initial treatment should be with high dose oral antibiotics
Cellulitis
Cellulitis is responsible for over 400,000 bed days per year in the
English NHS at a cost of £96 million. (Levell et al 2011). It is often
misdiagnosed by General physicians and can be a lower limb
dermatosis, commonly eczema, fungal infection, lymphoedema or
chronic odema (Levell et al 2011)
This is a bacterial infection of the skin and the tissues below the skin
surface. It is an acute spreading infection of the subcutaneous tissue.
Cellulitis is mostly caused by group A beta-heamalytic streptocci, but
can be caused by other bacteria such as Staphyloccus aureus. (see
RCN 2006) (Nazarako 2016)
Symptoms of cellulitis (Cutting and Harding 1994)

Hot, Red, Tender, painful, and swollen
Cellulitis often accompanies skin trauma and is usually unilateral
(Levell et al 2011). It occurs where bacteria gain access through
fissures and damage to the skin surface (Gabillot-Carre and Roujeau
2007)
The Patient may feel generally unwell, shivery or feverish.
Investigations may include bloods- Full blood count, erthrocyte
sedimentation rate, liver function tests, urea and electrolytes to identify
any contributory underlying pathology and wound swab if clinically
indicated for culture and sensitivity.
Antibiotics are the main treatment for cellulitis, oral for a mild infection
but intravenous antibiotics can be needed if:

There is a more severe infection

The infection has not responded to oral antibiotics

The patient has other health problems.
Other treatment is aimed at:

Treating any breaks in the skin that allowed the infection in E.G.
dressing the ulcer or the fungal infection.

Treating pain or swelling, with analgesia and elevation

Gentle cleansing with a soap substitute
Leg Ulcer Care Guidelines
Page 13 | 116

Elevation and resting the limb
In patients with recurrent cellulitis, prophylactic penicillin is sometimes
used; refer to nurse specialist re skin care management and advice.
Local microbiological advice should be sought if the clinical condition is
not improving.
For further advice on infection issues see ‘Troubleshooting’.
Bacterial swabs should only be carried out where there is clinical
evidence of infection. A swab will only tell you what bacteria is
present; it will not tell you if there is an infection.
MRSA: see local Guidelines re wound care & MRSA.
8
Compression for Venous Ulceration
The key to the successful healing of chronic venous ulcers will be to correct
the underlying venous hypertension using graduated compression therapy
(EWMA, 2003, Moffatt 2007, Harding et al 2015).
The application of high compression therapy exerts pressure on the
underlying skin and tissues reducing distension and pressure to the
underlying superficial veins. This reduces oedema and increases the blood
velocity in the deep veins, aiding venous return, thereby counteracting venous
hypertension. 40mmHg pressure at the ankle is considered the optimum
pressure required to reverse venous hypertension, graduating the pressure to
17mmHg just below the knee (Moffatt, 2000).
Compression may also be appropriate for the treatment of some other
aetiologies; however caution should be taken where patients have evidence of
the following conditions. Arterial disease, Diabetic ulceration, rheumatoid
ulceration, Peripheral neuropathy or loss of sensation to the lower limb. Full
compression systems should only be applied after a full assessment and
Doppler studies have been carried out. The above patients who have these
aetiologies may not be suitable for the mini assessment.
It is important that the science of bandaging is considered if safe and effective
compression is to be delivered.
Laplace’s Law
This Law of Physics states that there are a number of important factors which
determine the pressure achieved under any given bandage.
P = TN x 4630
CW
Leg Ulcer Care Guidelines
Page 14 | 116
Laplace relationship
The level of pressure exerted by a compression garment on the leg is
dependent on:

The Tension (T) of the bandage / hosiery material.

The Number (N) of layers of the compression applied.

The Width (W) of the bandages used.

The Circumference (C) of the limb.
Tension (T): is determined by the amount of elasticity of a bandage and the
degree to which it is stretched.
Number of Layers (N): the more the layers applied to a leg, the higher the
sub-bandage pressure obtained.
Width of bandage (W): higher pressures are achieved from narrow bandages
and lower pressures with wider ones. A 10cm bandage is appropriate in most
cases.
Circumference of the Limb (C): The thinner the leg, the higher the pressure
that will be achieved from a given bandage. Dangerously high pressures
can be obtained with compression bandages on thin legs. The larger the
leg/ankle, the lower the pressure achieved from a given bandage.
It is vital that this principle is taken into account when instituting a regime of
compression if therapeutic pressures are to be achieved in large limbs or
pressure necrosis is to be prevented in those patients with small ankles.
Using Laplace’s law graduated compression is achieved because of the
natural shape of the limb. Most legs are narrower at the ankle than the knee
so graduated compression is achieved automatically if a bandage is applied at
the same tension and overlaps all the way up the leg.
Where limbs are wider at the ankle than the calf due to oedema etc, padding
needs to be applied to the calf to ensure it is approximately 10 -14cm larger
than the ankle.
Always adhere to bandage manufactures recommendations regarding limb
circumference.
First line treatment for a leg wound.
A simple dressing applied to a leg wound on fist contact is expected, with
layer 1 k-soft, k-lite toe to knee. In some cases two layer 2, k-lite could be
applied all toe to knee. This gives good support, reduced oedema and
promotes venous return. This should then be reassessed as soon as possible
for a full compression system.
Leg Ulcer Care Guidelines
Page 15 | 116
9
The Multi-layer Elastic Compression Bandaging System
The most validated means of achieving sustained compression is by a multilayer technique, such as that pioneered at the Charing Cross Hospital venous
ulcer clinic. This comprises of multi layers of elastic bandaging over a nonadherent dressing. These layers build up to give pressures of 40mmhg at the
ankle. Multi-layer systems vary in the levels of compression in layers 3 and 4.
The current system in use, the K system from Urgo, produces 20mmhg in
both compression layers. K-2 –two layer bandage system has mainly replaced
the multi-layer bandage system.
Iglesias et al (2005) found that multi-layer elastic bandages were more cost
effective than multi-layer inelastic bandages for healing venous leg ulcers.
The healing rates using the system were reported at 74% at 12 weeks
compared with 30% healing with no compression and 45% with other
elasticated bandages.
Elastic bandages follow the shape of the limb maintaining a constant
pressure. The bandages move with the muscle contractions therefore only
minor variations in pressure occur as the limb moves. The elasticity of the
bandages mean that as the limbs oedema reduces as a result of the
compression, the bandages will follow the limb in as it reduces in size thus
maintaining a constant pressure on the limb. This means that the bandages
have a fairly constant working pressure with smaller variation between when
the patient is moving and when they are resting than occurs with inelastic
systems.
The aim is to leave the bandages in place for a week; initially they may have
to be changed more frequently if the exudate strikes through the bandage.
Layer 1, Orthopaedic wool: K-soft
This layer is applied directly over the primary dressing. It is laid on and no
stretch applied during application. Its main functions are to protect bony
prominences, act as an absorbent layer, and to reshape the limb. This layer
applies no compression. Padding should be applied from the base of the toes
to below the knee in a spiral.
Layer 2, conforming bandage: K-lite
This layer provides a second absorbent layer and smoothes the first layer in
preparation for the 3rd and 4th layers. This layer should be applied in a spiral
from the base of the toes to below the knee.
This layer can be used in conjunction with layer one to provide support
bandaging to limbs that are not suitable for compression.
Layer 3, Light Compression bandage: This bandage is available on the
specialist formulary only K-plus
This is the first compression layer, giving 120mmHg at the ankle when applied
in a figure of eight pattern at 50% stretch with a 50% overlap, to a leg with an
Leg Ulcer Care Guidelines
Page 16 | 116
ankle circumference between 18 and 25 cm. Apply with a 30-50% stretch on
the foot depending on the level of oedema.
Layer 4, Elastic cohesive bandage: This bandage is available on the
specialist formulary only K-flex
This layer gives a moderate compression of 20mmHg at the ankle when
applied toe to knee in a spiral technique at 50% stretch with a 50% overlap to
a leg with an ankle circumference between 18 and 25 cm. The bandage is
cohesive and helps to secure the bandage system in place and to maintain
the compression for at least a week
Table 1: Bandage Combinations for multi-layer elastic compression systems
Ankle circumference & first line compression
Bandage combination
Less than 18cm
2 or more layer 1
1 x layer 2
1 x layer 3
1 x layer 4
1 x layer 1
1 x layer 2
1 x layer 3
1 x layer 4
1 x layer 1
2 x layer 3 (or 1 x high
compression layer)
1 x layer 4
1 x layer 1
1 x layer 3
1 x high compression layer
1 x layer 4
Layer 1 is used to bring the circumference of the ankle up to
a minimum of 18cm
18-25 cm ( Juxta cures, k2, hosiery kits)
25-30 cm K-2, (Juxta cures, hosiery kits, k2)
Greater than 30 cm (K-2, Juxta cures, hosiery kits)
NB: The ankle circumference must be checked after the wool padding
has been applied and the bandage regimen determined by that
measurement.
Large limbs or limbs with ankle oedema and an ankle circumference greater
than 25cm require a high compression stronger elastic bandage as part of
their multi layer system to ensure adequate pressure is applied.
The ankle circumference should be measured every time the bandages are
reapplied as it may alter with reduction of oedema.
Reduced compression levels can be used on limbs with ABPI’s below 0.8 with
advice from experienced practitioners. (See table 2)
Leg Ulcer Care Guidelines
Page 17 | 116
Table 2: Bandage Combination for reduced compression using K system.
ABPI
Bandage combination
Ankle Circumference
2 x layer 1
1 x Layer 2
1 x Layer 4
Under 18cm
Approx 20mmHg
Layer 1 is used to bring the
circumference of the ankle
up to a minimum of 18cm.
K-2 reduced, or Juxta cures
set on 30mmHg
Class 2 Ral Hoisery
1 x Layer 1
1 x Layer2
1 x Layer 4
18– 25cm
0.7
0.7
0.7
0.6 – 0.5
Approx 20mmHg
K-2 Juxta set on 30mmHg
Class 2 Ral Hoisery
1 x Layer 1
1 x Layer 2
1 x Layer 3
1 x layer 4
Approx 20mmHg
Class 2 RAL hosiery.
Juxta Cures set on 30mmHg
2 x Layer 1
1 x Layer 2
1 x layer 3
Approx 20mmHg
K-2 reduced
Class 1 Ral hoisery
1 x Layer 1
1 x Layer 2
1 x layer 3
0.6 – 0.5
0.6 – 0.5
Leg Ulcer Care Guidelines
Approx 17mmHg
K-2 reduced
Class 1 RAL hoisery
1 x Layer 1
1 x Layer 2
1 x layer 4
25 – 30cm
Under 18cm
Layer 1 is used to bring the
circumference of the ankle
up to a minimum of 18cm.
18 – 25cm
25 – 30 cm
Approx 15-20mmHg
Depending on ankle size
Hoisery RAl class 1
Page 18 | 116
10
The Short Stretch Bandage System
The short stretch bandaging system is a two-layer bandage system
comprising of padding / reshaping layer and a compression layer.
The short stretch bandages extend and recoil very little, so when applied at
full tension they maintain a semi-rigid cylinder around the leg that does not
give when the muscle beneath expands. Contraction and expansion of the
calf muscle against this cylinder re-directs the energy, forcing it back into the
leg to squeeze the veins, thereby promoting venous return. This creates a
high ‘working pressure’.
When the leg is inactive ‘low resting pressures’ are exerted on the leg.
Because the bandages do not exert constant pressure on the limb, it may be
useful for patients who do not tolerate compression well. It also may be
considered for patients with arterial or sensory impairment and cardiac failure.
As the bandage is unable to follow the limb as it reduces in oedema it may
slip initially and require reapplying more frequently. The aim is to leave the
bandages in place for a week when there is no strikethrough or slippage.
There are two types of short stretch bandage available, cohesive and noncohesive.
Layer 1 – Orthopaedic wool
This layer is applied directly over the primary dressing. The padding layer
gives no compression. Its main functions are to protect bony prominences and
other vulnerable areas, to act as an absorbent layer and reshape the limb.
Layer 2 – Short stretch bandage
The bandage is applied with even tension at full-stretch overlapping the
bandage by 50% from the ankle to knee. If applying a second bandage
(where the ankle circumference is greater than 25cm) apply ankle to knee in
the opposite direction to the first bandage.
Table 3: Bandage Combinations for short stretch bandage systems
Ankle Circumference
Bandage Regimen
Under 18cms
2 or more layer 1
Layer 1 is used to bring the circumference of the ankle
up to a minimum of 18cm
1 x Layer 2
18 cms to 25 cms
Greater then 25 cms
1 x Layer 1
1 x Layer 2
1 x Layer 1
2 x Layer 2
NB: The ankle circumference must be checked after the wool padding has
been applied and the bandage regimen determined by that measurement.
Leg Ulcer Care Guidelines
Page 19 | 116
11
Other Bandage Systems
KTWO® Calibrated 2-layer compression system- High compression.
This is the first line compression bandage used within the SE.
KTWO® is a multilayer multi-component compression system, designed to
ensure even distribution of pressure between two dynamic bandages. The
system applies the effective therapeutic pressure required to treat venous leg
ulcers and associated symptoms along with severe oedema in chronic venous
insufficiency. Irrespective of leg shape the bandage system provides the
correct level of pressure from the very first application thanks to its specific
etalonnage system (pressure indicator). The system consists of two separate
dynamic bandages:

K Tech (1st layer) which is a composite layer formed of wading and a
moderately elastic compression fabric.

K Press (2nd layer) which is applied over the first layer, is a cohesive
bandage.
KTWO is not recommended when an ABPI is below 0.8, K TWO reduced is
advocated for these patients.
Both the KTWO and the KTWO reduced come in two ankle sizes 18-25cm
and 25-32cm. 10CM bandage width for leg ulcer management.
3M™ Coban™ 2 layer Compression System. This system is on the
specialist formulary
The system is latex free and has been specifically developed to overcome
some of the challenges associated with other compression systems, such as
foot wear problems. The system is 2 layer bandage system consisting of an
inner comfort layer and an outer compression layer. The unique foam comfort
first layer replaces the orthopaedic wool layer and is latex free. The cohesive
compression layer provides effective sustained compression and is also latex
free. Once applied the two layers bind together to form a slim, single layer
bandage that is designed to resist slippage and enables the patient to wear
normal foot wear.
One size kit fits all ankle circumferences
Suitable for patients with an ABPI of 0.8. For patients with an ABPI there is
the coban 2 lite kit. The system is a kit that contains two rolls and is designed
to be used together and not in conjunction with any other compression
bandages or orthopaedic wool. Each layer of the coban 2 layer system has a
purple core to allow easy differentiation form the original coban self-adherent
bandage.
Leg Ulcer Care Guidelines
Page 20 | 116
12
Juxta
Juxtacure Equipment required:

The ‘Body’ of the garment

A Velcro detachable ‘spine’ clearly marked ‘ankle’ at one edge and
‘calf’ at the other edge.

Four cotton liners and four compression anklets

A ‘BPS’ card

Velcro tabs to secure the spine if concerns regarding accidental
removal of spine by patient.

One pack of Juxtacures contains 1 body, 1 spine, 1 pair of liners, 1 pair
of compression anklets, 1 BPS card and spare Velcro tabs.

Also available on prescription are pairs of liners and standard or large
pairs of compression anklets.
Measurements required to ascertain correct size;

Length of Limb- to order short, standard or long Juxtacures pack
Once Pack has been received

Measure ankle circumference and Calf measurement.
To ascertain the correct size of the Juxtacures take the length (L) of the limb
from above the lateral malleolus to two finger width below the knee flexure.
Leg Ulcer Care Guidelines
Page 21 | 116
The excess is then cut off.
Applying the juxtacures
Pull the Comfort™ Leg Liner over the leg and any dressings (if the length is
past the knee, leave until the Juxtacures™ has been positioned and
anchored, and then fold the Comfort™ Leg Liner back down over it).
Smooth out any creases.
The Comfort™ Anklet can be applied after the main body of the Juxtacures™
has been fitted.
Once the spine has been adjusted, apply the garment to the leg with the black
material toward the skin.
When you are happy where it is positioned – tighten the straps, starting from
the bottom and finishing at the top.
Leg Ulcer Care Guidelines
Page 22 | 116
Adjusting of the juxtacures™ and setting the mmHg
Identify the correct scale on the BPS relating to the ankle circumference and
check the pressure applied.
Repeat for the remaining three straps keeping the measure on the BPS
consistent (e.g. if the ankle is set at 40mmHg, all other straps must read
40mmHg).
The patient should be reviewed within 24 hours to ensure that the device is
comfortable; not compromising the skin / limb in any way and that it is not
causing any discomfort.
It is expected that the limb will reduce in size as there will be a reduction in
the oedema due to the improved venous return. Therefore on each visit for
the first 2 weeks, the ankle and the calf circumference should be measured
and documented.
If there is a reduction in the volume of the leg the spine will need to be
adjusted, to match the new ankle and calf circumferences. This adjustment
may need to be daily initially.
Infection Control
The juxtacures is not a sterile system therefore the infection risk can be
mitigated but not eliminated. The following measures will reduce the risk of
infection:

Prescribed for use on one named patient only; no part of the system
can be used on another patient.

Compression including the juxtacures is contraindicated where there is
infection in the leg.

Use of the most appropriate, potentially high absorbency, primary
dressing to contain the exudate.EG: Eclypse
Leg Ulcer Care Guidelines
Page 23 | 116

If there is gross strike-through of exudate then compression anklet and
liner will be disposed. Washing and drying instructions:
The liner material is treated with a polymeric antimicrobial that prevents
bacterial growth in the fabric and it must be laundered and thoroughly dried
after each use. The breathe-o-prene fabric for the juxtacures is a laminated
fabric with a silver content on the black (skin facing) layer.
The juxtacures, Comfort Leg Liner and Comfort Compression Anklet should
be washed in the washing machine and tumble dried on a cool setting or air
dried on a flat surface.
The socks and liners are designed to be laundered at up to from 30 to 65
degrees and should be changed for a clean one at each dressing change.
The juxtacures itself can also be machine washed at the same temperature
range, this will be dependent on whether there has been any strike through
and should not be necessary at every dressing change.
Patient Information:
E-book of patient information booklet
http://epaper.ims.medi.de/en_GB/Phlebo/97C28_201302_EV_Broschuere_Ju
xta_CURES_UK/blaetterkatalog/index.html?lang=en_GB
Training Requirements
Nursing staff (bands 4 - 7) who have attended the Trust’s 2 day leg ulcer
assessment and management course will have a one hour training session on
the use of Juxta CURES. This will be given by the Specialist team and / or
medi uk staff
The juxtacures training will be included in the 2 day leg ulcer course for all
new staff and the one day update day for nursing staff who are attending an
update day, which is required once every three years.
Training will cover all aspects of the measuring and fitting of the device
together with advice on subsequent adjustments to chase oedema where
required.
The nursing staff will have on-going support from the Wound care service
team and Medi employees. This will be in the form of follow up visit with the
patient until the nurse is safe and competent to assess, adjust and readjust
the device.
When a patient has chronic oedema or lymphoedema, juxtafit would be more
appropriate.
Leg Ulcer Care Guidelines
Page 24 | 116
13
Prevention of Recurrence in Venous Ulceration
While research relating to recurrence of ulceration remains sparse, studies
suggest that the rate of recurrence is high (McDaniel et al 2002). Compliance
with wearing compression hosiery has shown to affect the rate of recurrence
(Erickson et al 1995).
Education for patients regarding the need for life long support of the veins in
their legs is paramount and should be emphasised from the beginning of
treatment. It should also be stressed to the patient that healed ulcers will
remain susceptible to breakdown following even minor trauma.
Once venous ulceration has healed, it is essential that all patients are
measured and fitted with compression hosiery. It is important to ensure that
they are managing the hosiery and subsequent advice and support are given
to ensure concordance. Patients are more likely to comply with compression
therapy that is easier to use and reduces pain and discomfort (Dowsett 2011).
Suitability for compression hosiery assessment tool at the end of appendix 6
will help to guide in hosiery selection.
13.1
Compression Hosiery (appendix 6 & 7c)
Patients should not be prescribed compression hosiery until their skin
is sufficiently robust to enable the stocking to be drawn over the ulcer
site.
There are various classification standards. Currently available on
prescription are the British Standard (BS) or German/ European
Standard (RAL). It is important to be aware that the compression rates
and the stiffness of the fabric are different for each classification
Standard.
Hosiery is graded into three classes:Class 1 BS – Light support that gives 14 – 17 mmHg pressure at the
ankle
Class 1 RAL 18-21.1mmHg

Indicated for superficial or early varicose veins.

Used as a treatment of reduced compression and in prevention of
reulceration for people who can not tolerate class II
Class 2 BS – Moderate support that gives 18 – 25 mmHg pressure at
the ankle
Class 2 RAL 23-32mmHg

Indicated for varicose veins of medium severity,

DVT Treatment
Leg Ulcer Care Guidelines
Page 25 | 116

Prevention of recurrence of venous ulceration for those who have
healed in reduced compression or cannot tolerate class III.
Class 3 BS – Strong support that gives 25 – 35 mmHg pressure at the
ankle
Class 3 RAL .34-46.mmHg

Indicated for severe varicose veins,

Treatment of venous ulceration when bandages cannot be
tolerated and prevention of recurrence.

DVT treatment recurrent and when flying
There are hosiery kits that give up to 40mmHg pressure at the ankle
which may be useful for those patients whose ulcers reoccur when they
finished their treatment with bandages. They can also be use as
prophylaxis on patients with healed ulcers who need to be maintained
at 40mmHg.
Selection of the correct size of stocking is very important. The patient’s
legs must be carefully measured and ideally a class selected that will
give the level of compression required preventing further venous
ulceration. Made to measure stockings are available for those whose
measurements fall more than 1cm outside the ranges catered for.
Ideally legs should be measured for stockings whilst still in
compression bandages or first thing in the morning where bandaging
has not been necessary, so that the legs are less swollen. (Hosiery
assessment tool appendix 6 will help with hosiery selection).
N.B: The restrictions with regard to arterial disease and
compression bandages also apply to the use of compression
hosiery.
14
Recurrence of Ulceration
Once a leg ulcer patient always a leg ulcer patient - Compression therapy “for
life” is essential to reduce the risk of recurrence (Harding et al 2015).
Once a Leg ulcer has healed the patient needs lifetime compression therapy
due to the underlying venous pathology. (See appendix 6 for hosiery
selection)
Despite the availability of compression hosiery ulcer recurrence rates varies
from 33% to 67%.
67% will experience 2 or more episodes of re-ulceration.
21% will experience more than 6 episodes of reulceration.
Leg Ulcer Care Guidelines
Page 26 | 116
Ulcers which are greater than 10cm in size, the chronicity of an ulcer, a
history of deep vein thrombosis, clotting disorders, arterial disease along with
the unsuitability or non concordance with hosiery are all risk factors that
increase the chance of recurrence.
Consider referral for vascular surgical opinion for recurrence of unknown
cause.
Practitioners fitting hosiery should have undertaken training in the
measurement, selection and application of hosiery. This is essential to ensure
maximum comfort and subsequent concordance from patients (Coull and
Clark, 2005). (Appendix 7c)
14.1
Patient Education
Managing the transition from high compression bandaging to hosiery
may be difficult. Oedema may occur if the pressure applied by the
stocking is considerably less than that applied by the bandage. (Moffatt
2007)
It is essential to ensure that patients understand the risk of their ulcers
recurring and the importance of caring for their legs in order to reduce
this risk.
Key points to enforce include:

The importance of complying with their hosiery

Avoiding trauma to the delicate tissues in the healed ulcer.

Regular exercise to improve circulation and improve the function
of their foot and calf pump.

Careful attention to foot hygiene, particularly in diabetics.

The avoidance of ill-fitting footwear.

Elevation of legs when sitting for long periods of time

To seek treatment as early as possible if they notice any damage
to skin on their legs

Essential maintenance of skin.

Renewal of Hosiery every 6 months if RAL or 3 months if British
per pair.

Educate patient re care of hosiery and aids for application
Written information should be given to patients relevant to their needs,
as this has been found to be a factor in improving compliance.
Leg Ulcer Care Guidelines
Page 27 | 116
14.2
Care of patients presenting with reoccurrence of ulceration
It is important to re-assess the patient including a repeat Doppler
assessment. (As soon as possible)
Remember that new processes may have developed, such as
deterioration in arterial competence in a patient who previously had a
venous ulcer.
Patients whose ulcers recur may require additional psychological
support as depression is a common factor in ulcer reoccurrence.
For some patients particularly susceptible to recurrence it will be
necessary to increase the level of compression hosiery once healed. It
might require a higher compression hose or a stiffer fabric hose e.g.
RAL (see appendix 6).
15
Invasive Treatments for Venous Insufficiency
The treatment of venous leg ulcers – the role of the vascular surgeon
Vascular surgeons manage patients with disease of the arteries, veins and
lymphatics. For patients with leg ulcers, they have two principal roles.
The ischemic leg
The first is to guide revascularisation for patients with occlusive disease of
their arteries. It is not safe to compress patients with ischemic legs (see
guidelines above). Referral to vascular surgery will allow both assessment
and treatment planning. It is always important to include any Doppler
pressure measurements and details of treatments (current and historical) in
your referral.
The vascular surgeon will confirm your findings and, if there is sever ischemia,
will assess the arteries for intervention by duplex ultrasound, CT or MR
angiography. This will give a clear map of the arterial tree and guide
treatment.
For patients with short segment stenosis or occlusion of the arteries, the first
modality is usually angioplasty with or without the addition of an intra-arterial
stent. The aim is to return the circulation to as near normal as possible, to
permit full compression and aid ulcer healing.
In some circumstances, the anatomical location of the narrowing/occlusion or
the extent of it may require open surgery, such as endarterectomy (removing
obstructing atheroma) or bypass. This will usually significantly improve the
circulation.
If you are looking after a patient who has undergone angioplasty/stenting or
bypass, it is important to remember that these procedures can fail over time.
Always re-check the ABPI before recommencing a course of compression. If
you find that it has fallen then consider re-referral to the vascular service. It is
Leg Ulcer Care Guidelines
Page 28 | 116
much easier to angioplasty a narrowing in a stent or bypass, than to try and
re-open it once occluded.
Vascular surgery to incompetent veins
Patients with normal arterial circulation who fail to heal their ulcers after a
reasonable period (3-6 months) should be considered for referral, especially if
their ABPI is borderline. Patients with healed ulcers following a period of
compression should be referred for assessment for interventions to their
veins, as indicated in the NICE guideline 168. The rationale for this is the
ESCHAR trial which demonstrated a significant reduction in recurrence of
ulcers in patients who had their superficial venous reflux successfully treated.
In younger, normally mobile patients such treatments may permit cessation of
compression hosiery.
Some patients have significant reflux, or obstruction to flow, in their deep
venous system. If this is identified, then vascular surgery may be contraindicated and the patient will require lifelong compression. The vascular
service will advise what treatments are required and why.
Modern treatment for varicose veins are largely day-case outpatient
procedures and nearly all patients can be treated with either ultrasound
guided sclerotherapy (liquid or foam based treatments), or catheter based
ablation techniques (radiofrequency or LASER). These have largely replaced
the traditional surgical technique of ligation and stripping of incompetent
truncal veins. Studies of effectiveness suggest that catheter base vein
ablation offers a similar level of effectiveness to surgery with fewer
complications, less pain and a quicker return to full activity [1,2,3]. Foam
sclerotherapy is a little less effective, but much cheaper and provides an
acceptable outcome to catheter-based interventions. It may require more
frequent repeat treatment to achieve the same outcome. Not all patients can
have catheter based treatments. NICE recommends that catheter based
treatment or foam sclerotherapy should be the preferred treatment modalities
[4].
Compression bandaging and stockings form the main stay of treatment
directed at healing venous ulcers. Despite these treatments, ulcer
recurrence rates run at over 1/3 of patients within one year. The
reasons for this are not well understood but probably include noncompliance and ill fitting i.e. inadequate compression hose as well as
more severe pathology (total deep vein incompetence, arterial disease)
and trauma.
A recent trial has shown that the addition of surgery to compression
therapy both normalises venous physiology (Gohel et al, 2005) and
reduces ulcer recurrence rates at one year (Barwell et al. 2004). This
trial and a previous smaller trial suggested that surgery produced better
healing and recurrence rates when compared to compression over a 3year period (Zambori et al. 2003; Barwell et al. 2000). How ever recent
long term results of the ESCHAR trial (Gohel et al 2007) surgical
correction of superficial venous reflux in addition to compression
Leg Ulcer Care Guidelines
Page 29 | 116
bandages does not improve ulcer healing but reduces recurrence of
ulcers at four years and results in greater proportion of ulcer free time.
The ESCHAR trial (Barwell et al 2004, Gohel et al 2007) used
sapheno-femoral ligation with stripping as standard therapy but also
undertook sapheno-femoral ligation under local anaesthesia for those
unfit for general anaesthesia. The results of this trial can be
generalised to a population with venous ulceration and superficial
venous incompetence.
The message from these trials is that all patients with venous ulcers
and venous disease should be considered for surgery after healing if
there are problems of recurrence. Patients should be assessed by a
trained vascular specialist. Venous ultrasound assessment may be
required to supplement the examination findings if the diagnosis is in
doubt.
The trials described have looked at venous physiology and shown that
changes produced by surgery change abnormal reflux patterns back to
normal. Healing and recurrence rates can also be related to changes
in venous reflux and to the efficacy of the calf muscle pump. The
difference between individuals goes someway to explaining the
variation in healing rates with compression and following surgery.
Problems of surgery include, nerve injury, wound infection, DVT and
recurrence of varicosities, rates of which vary from 10-25% at 10 years
15.1
Other treatments for venous disease
To date the main trials have focussed on the role of open surgery, in
the healing or prevention of recurrence of venous ulcers. There are
now a number of newer “minimally invasive” treatments being offered
to patients and this section attempts to provide an overview of less
invasive alternatives to surgery.
a) VNUS closure
This technique involves passing a probe up the saphenous vein, using
ultrasound to accurately guide placement. Once correctly located near
the junction with the deep veins, the vein is then surround by a cuff of
injected saline containing local anaesthetic for pain relief. The probe is
then heated up and withdrawn slowly. The probe heats the vein to a
high temperature and denatures the vein wall causing fibrosis. The
technique has a good success rate of over 80% (Nicolini,2005). Further
injections or phlebectomies may be required to remove residual
varicosities.
Problems with this technique include cost (may be cost effective if time
off work considered), Tero-Rautio et al. (2002), saphenous nerve
injury, skin burns and DVT. Long-term durability is not known. NICE
guidance September 2003
Leg Ulcer Care Guidelines
Page 30 | 116
b) Endovenous laser therapy
This technique is very similar to VNUS closure but uses a laser fibre
passed into the vein under ultrasound guidance. Once correctly
located, the leg is injected with saline and local anaesthetic to prevent
heating of surrounding tissues and to minimise pain. The laser is then
activated as the fibre is withdrawn, causing thermal injury to the vein
wall. Subsequently, residual varicosities may need treatment. Again
the technique has a good success rate of over 80% (Min Robert et al.
2003).
Problems include, recurrence (related to laser energy used (Proebstle
et al. 2004) phlebitis, pain and bruising. Long-term durability is not
known. (NICE, 2004)
c) Ultrasound guided foam sclerotherapy
Injection sclerotherapy has been promoted for the treatment of venous
disease in mainland Europe for some years. The technique of creating
foam by forcing air through sclerosing agents allows the injected foam
to displace blood and come into contact with a significant proportion of
the vessel wall. This makes it more effective than standard liquid
sclerotherapy techniques (Hamel et al.2003). A needle is located in
the saphenous vein under ultrasound guidance and then the foam
injected. The ultrasound probe is used to compress the vein and limit
the flow of foam into deep veins once it reaches the junction with the
deep system. The technique may obliterate all varicosities or
subsequent injection or phlebectomy may be needed to remove
residual varicosities as in a) and b).
Problems include chemical phlebitis, skin staining, transient
neurological disturbance (micro-bubbles may traverse cranial vessels)
and DVT. Long-term durability is not known, (NICE, 2003).
15.2
Summary
There are a variety of treatments, suggesting that no one treatment is
significantly superior to another. Practitioners looking after patients
with venous ulceration are advised to consult the NICE website
(www.nice.org.uk) for further updates on currently available treatments.
16
Trouble shooting Tips
16.1
Concordance
Compression therapy is the cornerstone of treatment for venous leg
ulceration and furthermore there is increasing evidence that patients
quality of life is improved while receiving this treatment (Moffatt, 2000,
Harding et al 2015). These benefits are not always seen immediately
and it is vitally important that nurses spend time explaining the
importance of compression to heal patient’s legs and discuss
expectations so that they understand the process.
Leg Ulcer Care Guidelines
Page 31 | 116
Often the first few weeks can be difficult for patients and they will need
a lot of encouragement and support. Pain should be addressed
immediately and reassessed at every bandage change. Building a
rapport and getting the patient working with you is essential. Consider
developing a contract between the patient and yourself. Tracings,
measurements and photos are an essential tool to monitor progress
and are useful to demonstrate improvement to patients. Patient
education leaflets should be used to reinforce advice.
Contact telephone numbers should be given to patients for both regular
and out of hour’s services so that they can contact a practitioner for
advice.
16.2
Pain
Health care professionals often overlook pain although 80% of patients
do experience pain from leg ulceration (Hollingworth, 2001). It is
important to remember that pain is individual and that venous and
arterial ulcers can be equally painful.
Knowing and understanding a patient’s level of pain and type of pain is
a vital element of leg ulcer assessment on two counts. One, it will help
the practitioner in making a diagnosis; and two, even moderate levels
of continuous uncontrolled pain can significantly impact on a person’s
normal day–to-day activities, (QOL) work, rest, relationships and
mental state – which in turn can delay leg ulcer healing.
Compression will improve pain over time for venous ulcers but
sometimes pain levels can raise in the first few weeks, due to
physiological changes in the central nervous system (Moffatt et al
2007). Analgesia should be addressed at the start of treatment,
(Appendix 3).The following factors should be considered:

Be aware of triggers that increase pain

Remember that careful explanation is required for all procedures

Handle the wound as little as possible and with great care

Recognise that pain may extend some distance from the ulcer

Recognise that cleaning, soaking and the temperature of the
water may exacerbate pain

Avoid wound exposure, which may cause pain

Review dressing choice

Cover the wound with cling film if waiting for the wound to be seen
by a colleague
Leg Ulcer Care Guidelines
Page 32 | 116
16.3

Avoid draughts from windows or fans as these may also
exacerbate pain.

Involve the patient in the procedure-this gives them a greater
sense of control and will help to reduce pain and anxiety.

Allow patients to remove their own dressings if they wish

Allow patients to halt or slow down procedures.

Some patients have stated distraction through music and deep
breathing helps pain reduction.

Reassess pain and analgesia often. Regular analgesia is better
than ad hoc administration.
Difficulty tolerating compression
If a patient expresses concern over tolerating compression, it is worth
applying the compression as a reduced compression regime. It is
essential to try and engage patients with compression by
compromising. A reduced regime is better than none and often the
level of compression can be increased gradually. Short stretch
bandages produce low resting pressures and so may be better
tolerated in some patients. Using Liners and hose kit components are
also a good way of playing with the compression levels to aid
concordance. Juxta cures aids mobility and ankle movement.
Practitioners frequently report that patients do not adhere to
compression therapy because of pain, despite them having adequate
arterial circulation (Moffatt 2004b). The main factors causing pain in
these circumstances are due to;

Inappropriate choice of compression system

Lack of adequate padding over bony and tendinous areas with
bandaging

Failure to adapt the compression bandage system to the limb
size and shape

Over stretching bandages at calf level causing a tourniquet effect

Over stretching bandages below knee

Too many or too few layers of bandage causing a lack of
graduation

Pressure damage to the skin

Bandage slippage causing trauma
Leg Ulcer Care Guidelines
Page 33 | 116
16.4

Over stretching of bandage causing joint or muscle or joint pain

Inability to wear shoes

Trauma from foot wear over bandaging
Managing Exudate
Patients who have heavily exuding legs may well experience exudate
striking through the bandages daily or on alternate days initially, due to
the compression. Patients should be reassured that the compression is
working and that the leakage should reduce. Try using multilayer
elastic bandages rather than short stretch as the layers provide more
absorbency. Leave the bandages for as long as possible and supply
the patients with large 20 x 40 cm dressing pads that can easily be
wrapped around the outside of the bandage until the Nurse comes the
following day. Good skin care regime is important to ensure the
exudate is removed as it can act as an irritant to surrounding skin. A
superabsorbent dressing could also be added short term to allow
compression to stay in place longer and protect the surrounding skin.
These dressing usually go directly on the ulcer and do not needed to
be used once exudate is reduced. They should not be used as
surgipads and never layered
NB: Strikethrough of exudate should not be left uncovered as this
provides a port of entry for bacteria
You should also check that you have achieved full compression where
appropriate as this will improve reduction of exudate. Remember to
measure ankle after the padding to maximise the effect. If strike
through continues exclude varicose eczema as the cause before
referring to the WCS. The treatment of varicose eczema is a daily
treatment for 7-10 days with emollient therapy depending on severity
with a topical cortico-steroid.
16.5
Footwear Problems
Hosiery kits that provide 40mmHg pressure at the ankle are available.
It is important to find an alternative rather than taking the compression
off. Keraped boots are now available on drug tariff and can last over 3
months, which are ideal for bulky dressings and bandages on the foot.
However they do not facilitate normal ankle movement, and patients do
tend to shuffle their feet which could delay ulcer progression. Juxta
garments will promote good ankle and calf movement.
16.6
Managing Varicose Eczema
It is essential to provide a good skin care regime for patients with
eczematous change, due to their reduced skin barrier function.
Clinically this will appear as a dry, scaly and inflamed skin, which could
be broken. The regime should comprise of emollients for skin
cleansing i.e. soap substitutes. Avoid using potential irritants such as
Leg Ulcer Care Guidelines
Page 34 | 116
soaps. The choice of emollient is dependent on the clinical appearance
of the skin. For example, a thick, dry and scaly skin would benefit from
a grease based emollient where as a wet and weepy eczema would
require a lighter cream based emollient, (Appendix 4 for recommended
emollients).
When inflammation is present a topical steroid would be necessary.
When deciding on a cream or ointment base for topical steroids, the
same rationale as for emollient choice should be used. Usually a
moderate potency topical steroid should be used on eczema of the
lower leg. This may be increased to a potent topical steroid if short
term if severe inflammation is present. Wet and weepy eczema with a
lot of excoriation may benefit from a steroid with an antibacterial
component short term (Appendix 5).
If the topical regime is only being applied once weekly due to
compression bandaging, it may be necessary to increase frequency of
dressings to daily for one or two weeks to obtain full benefit from
topical therapy. Compression bandages should be maintained but
change to a more appropriate cost effective system. It is not acceptable
to apply daily multilayer. Tensopress can be washed and is more cost
effective bandage for a daily skin care regime.
Occlusion may be used in the form of dry elasticated viscose
stockinette or paste bandages to enhance the effects of the topical
agents applied. Bandaging also acts as a mechanical barrier to
prevent excoriation.
If response is poor after the above treatment regime has been
instigated, contact dermatology specialist nurses for further advice.
16.7
Contact Sensitivities
When the lower limb is being treated for ulceration 60% have the
potential to develop contact sensitivity. If persistent inflammation is
confined to a well-demarcated area and does not respond to topical
steroid therapy, contact sensitivity should be suspected and a cotton
liner can be added.
16.8
Cellulitis
Where cellulitis is present, individual assessment is required. Generally
the oedema and pain associated with cellulitis can be eased with some
compression. However if the cellulitis is extensive, consider reducing
compression until the patient is able to tolerate existing compression
regime. Close monitoring is required to ensure the cellulitis is resolving
which will mean changing bandages more frequently. Advice should be
sought from a Specialist Nurse or Medical Practitioner.
In those patients that suffer recurrent cellulitis, compression hosiery
can often prevent recurrence. Essential skin care should be
Leg Ulcer Care Guidelines
Page 35 | 116
maintained. For recurrent cellulitis it would be helpful to seek specialist
nurse advice. Refer to local guidelines for antibiotic treatment.
In uncomplicated cases of cellulitis with no ulceration consider class 2
below knee compression hose for 4-6 months, with emollients (Linsay
& Stephens 2007).
16.9
Deep Vein Thrombosis (DVT)
If a new episode of DVT is identified leave compression off until anticoagulant therapy treatment has commenced and medical advice
sought. There is no consensus of when compression can be reapplied
but usually 2-4 days after anti-coagulant therapy commences.
16.10 Hosiery
It is essential that hosiery is fitted well and the patients can manage
either independently or with aid from relatives or carers. Fitting aids are
available to help with application. It is important to follow patients up to
ensure they are wearing their hosiery, as time and effort taken with this
can make the difference between staying healed and a new episode of
ulceration. Remember that for those patients who have difficulty either
fitting or tolerating their hosiery a reduced compression is better than
none. (See appendix 6 & 6c)
If difficulties arise consider these options:

Longer lengths of hosiery are available from some companies.

Open toe hosiery may be more comfortable for some patients.

Large arthritic knees, measure to mid-thigh as this will be far more
comfortable or Made to measure hosiery (MTM).
16.11 Bandage slippage
The rigid nature of short stretch bandages means that reduction in
oedema sometimes allows bandages to slip down the leg initially and
so they may need re-application.
When applying any bandage regime ensure the gradient from ankle to
calf is not too steep, the calf measurement should be 10-14cm larger
than the ankle. Use the orthopaedic wool to pad out the ankle and
improve the gradient. Coban Layer 2 has shown good results with
slippage reduction. Try to ensure the limb has a good leg shape, use
as many layers 1 as needed to achieve this good shape.
16.12 Patients unable to attend clinic
If patients want to go on holiday or if they are unable to attend clinic for
other reasons consider using hosiery instead of bandages if the
exudate is manageable.
Leg Ulcer Care Guidelines
Page 36 | 116
Leg Ulcer Care Guidelines
Page 37 | 116
17
Flow Chart for non-healing Venous Ulcers (No Progression in Healing)
Perform a full reassessment
Correct if possible any detected abnormality.



Doppler ABPI. To rule out the advancement of Arterial Disease.
Blood screening. To rule out new organic causes, such as anaemia,
diabetes, hypothyroidism and low albumen levels.
Wound bed assessment. To rule out wound infection, critical
colonisation with bacteria and possible other aetiology of ulcer.
Refer to WCS if unsure.
No Abnormality detected on reassessment
Re measure ankle circumference
Has the correct bandage regime been applied for the ankle
circumference and Doppler ABPI result?
.
Yes
No
Is the gradient of the
lower leg normal?
Apply correct compression
regime -Pages 13 and 14
No
Yes
Have you padded the lower
leg with the wool layer to
achieve a normal gradient?
Refer to WCS
Yes
No
Shape the leg with the wool
layer to mimic the shape of the
normal lower leg. P11
Page 11
Leg Ulcer Care Guidelines
Page 38 | 116
18
Education, Training and Competencies
18.1
Aims of Education and Training
The aim is to ensure Nurses receive up-to-date evidence based
training in order that: Nurses need to attend 2.5 day in house courses
as minimum standard, this course includes;
18.2
18.3

Appropriate assessment of patients with ulceration.

Correct management of patients occurs that is proven and
effective

Resources are appropriately used

Variation in practice is minimised

Optimum health of the patient/client is maintained

The cost of intervention is a proven effective resource
Training should cover:

The Leg Ulcer Care Guidelines (This document)

Pathophysiology of leg ulceration

Leg ulcer assessment using a lower limb care-pathway

Introduction to the use of Doppler ultrasound for ABPI

What is normal and abnormal wound healing

Compression Therapy – theory, management and application

Dressing selection- keeping it simple

Essential skin care and emollient therapy

Health Education

Prevention of recurrence

Criteria for referral for specialist assessment

Hosiery – measuring, fitting, application
Competence in Application of Compression Bandages/hosiery
To be competent to apply compression unsupervised, candidates must
have attended BCH Leg Ulcer management course covering the above
and be assessed on core competencies of the course by a Mentor,
(Appendix 8).
Leg Ulcer Care Guidelines
Page 39 | 116
A mentor will be a registered Nurse who has undertaken the study
days and who is currently practicing and experienced in Leg Ulcer
Management.
If this is difficult in the candidates own work area, alternative mentoring
must be found i.e. another work area.
18.4
Competence in Assessing patients and initiating compression
therapy
To be competent in assessing patients and initiating compression
therapy the candidate must first have achieved the core competencies
for application of compression, hosiery application and management of
leg ulceration, (Appendix 7 a b c).
They should then undertake a further training course in Doppler
Assessment.
The candidate will need to identify a mentor who will supervise those
assessing patients until competence has been gained and they can be
assessed on the core competencies for assessment of patients with leg
ulceration (Appendix 7a b c).
19
Development, Consultation and Ratification Processes
19.1
Development of Guidelines
These guidelines were based in part on the Avon Leg Ulcer Care
Programme, issued in September 1995, version 2 Leg ulcer Guidelines
(2005), version 3 (2008) & version 4 (2013)
The Leg Ulcer Guidelines were reviewed by Bristol Community Health
wound care service;
Gail Powell CNS & Lead Nurse Leg ulcer management WCS
Val Helliar Wound care specialist Nurse WCS
Acknowledgements to
Mr David Mitchell Vascular Consultant Bristol North
Medi UK. Ltd Dominique Phippen, administration Manager
Nina Linnitt Clinical Manager Vascular & Lymphology division Medi UK
Ltd.
Leg Ulcer Care Guidelines
Page 40 | 116
20
Appendix 1
It is intended that the assessment of leg ulceration is carried out by a
Registered Nurse trained in the theory and practice of the management of leg
ulceration. A detailed assessment of the patient’s general health is paramount
in order to determine cause and maximise the patients’ potential to heal. (See
part 2 lower limb pathway which should be used to document patient’s
assessment).
1. General Assessment
Age. Leg ulcers are more prevalent in the elderly and the ability to heal is
decreased due to a delayed immune response to initiate healing, thinning of
skin and delayed epithelialisation. There is also an increased risk of arterial
involvement in the elderly.

Weight and Height. - Malnutrition both in anorexia and obesity will
affect healing

BP / Pulse. - To detect hypertension and cardiac arrhythmias

Capillary Blood Glucose. – To detect raised blood glucose levels.

FBC , TFTs , U&E. - Anaemia, hypothyroidism and low albumin can
delay healing

Rheumatoid factor does not exclude vasculitis, as there will be many
false positives.
2. Medical History
Arterial Related
Venous Related
Peripheral Vascular disease
Varicose Veins / surgery
Arterial surgery
Pregnancies.(More than 3)
Diabetes
Phlebitis
Myocardial Infarction/Angina
Previous DVT
Stroke / Transient Ischaemic Attacks
Period of prolonged bed rest
Rheumatoid Arthritis
Trauma or orthopaedic surgery
Ulcerative Colitis
Smoking
Leg Ulcer Care Guidelines
Page 41 | 116
Varicose Veins
The normal venous system has non-return valves which prevent the pooling
of blood in the lower limb veins. Blood is pumped up the venous system by
the pumping effect of the foot and the calf muscles. If the valves are faulty, a
back flow of the blood results in high blood pressure in the veins (chronic
venous hypertension CVH). This results in the walls of the vessels becoming
stretched and weak. This could be likened to a traffic jam on a motorway and
the resulting congestion in the connecting side roads, CVH is the underlying
condition that may eventually lead to ulceration, and evidence of varicose
veins is the first sign of this condition.
Deep Vein Thrombosis
Approximately 4% of venous leg ulcers are caused by a DVT as a result of
post thrombotic syndrome (Muldoon 2013). The location of the clot may
damage a valve or cause an obstruction in the flow of blood back to the heart.
Lifestyle factors
Obesity and pregnancy are risk factors in the development of venous disease
as the blood flow will be reduced when it reaches the pelvis. The result in
obstruction and back flow to the lower limbs.
Intermittent claudication and rest pain
This indicates that the arteries are narrowed due to atherosclerosis and the
arteries are less elastic and unable to respond to the pumping action of the
heart. These patients should not be treated with compression without input
from a vascular specialist.
CVA or PVD or Cardiac events
As above- presence of these conditions indicate that the patients’ arterial
system compromised and may be indicative of arterial ulceration.
Associated conditions such as diabetes or rheumatoid arthritis.
Rheumatoid arthritis may result in venous disease due to poor mobility,
reduced calf muscle pump and ankle function (Muldoon 2013). There may
also be evidence of arterial insufficiency. Patients with diabetes may have
similar underlying problems. These patients may have a combination of both
venous and arterial disease (mixed disease).
Lifestyle factors
Smoking is a known contributory factor in arterial disease. Ascertaining the
patients’ smoking status may aid diagnosis in order to differentiate between
arterial and venous leg ulceration.
Leg Ulcer Care Guidelines
Page 42 | 116
3. Medication
For example:

Warfarin Therapy.

Steroids - Can thin skin, delay healing (topical and oral) and can induce
diabetes (oral).

Anti inflammatory drugs - Can affect inflammatory phase of healing.

Immunosuppressant drugs - Increased risk of infection
4. Allergies

Medication

Dressings

Latex

It is important to know of any interactions to previous treatments.
5. Mobility

Ability to mobilise / Distance

Use of aids

Abnormal walking gait

Ability to use foot and calf pump.

Since the foot and calf muscles pump the venous blood back towards
the heart, if they are not activated regularly, there will be increased
blood pressure in the lower limbs. Oedema will also develop, increasing
the congestion. If muscle wasting is also present, such as in wheelchair
users, this further increases the risk of venous ulceration.

Sitting for long periods of time with legs dependant induces oedema
and inability to use foot and calf pump contributes to venous
hypertension.
6. Clinical Examination & Investigation
Both legs should be examined at the initial assessment.
Examination should note:

Colour – staining / erythema / cellulitis
Leg Ulcer Care Guidelines
Page 43 | 116

Temperature of legs

Condition of surrounding skin – eczema / maceration from exudate

Oedema? Cardiac failure / Immobility

Rash vasculitic
Venous Disease
Arterial Disease
Varicose veins
Shiny taut skin
Ankle flare
Dependent rubor
Staining
Pale or blue feet
Usually shallow
Gangrenous toes
Usually gaiter area
Cold legs / feet
Punched out ulcers
Eczema
Poorly perfused wound
bed
Oedema
Lipodermatosclerosis
Atrophie blanche
Leg Ulcer Care Guidelines
Page 44 | 116
Varicose .Veins
Leg Ulcer Care Guidelines
Atrophe Blanche
Staining
Page 45 | 116
Ankle Flare
Lipodermatosclerosis
It should be noted how the ulcer occurred and its site and duration. Venous ulcers
tend to deteriorate slowly. The longer an ulcer is present, the harder it is to heal due
to chronic changes that occur in the wound bed and the exudate.
Site – It is important to record the site accurately. Venous ulcers are common in the
gaiter area, whereas arterial and diabetic ulcers are more commonly present on the
foot. Small patchy painful ulcers are often indicative of vasculitis. Atypical distribution
of ulcers or ulcers with abnormal appearance should be referred to either a General
Practitioner or Dermatologist. A biopsy may be indicated.
Condition of ulcer bed – this should be assessed for the presence of slough,
necrosis or granulation and wound care products used appropriately to prepare the
ulcer bed to heal using the local Trusts Formulary. A simple non-adherent dressing is
recommended under compression bandaging for venous ulcers.
Exudate – note the colour, consistency and amount of exudate produced. This may
give an indication of bacterial burden if purulent, malodorous or excessive.
Measurement – The ulcer should be traced or measured and photographed using
acetate, grid camera or camera using a tape measure in the photo. Digital photos
can be printed and stored in the patients EMIS notes but they should not be taken or
stored on nurse’s phones.
7. Nutritional Status; a MUST tool is available to aid assessment.

Appetite.

Dietary intake

Special dietary requirements
Leg Ulcer Care Guidelines
Page 46 | 116

Malnourishment

Obesity

A person with a wound needs 10 – 20% more energy than a healthy
person at rest. A balanced diet including carbohydrate, protein,
vitamins A and C, zinc and iron is essential.
8. Smoking Status
Arterial risk factor.
Smoking delays wound healing (McDaniel & Browning 2014). Cigarette smoking
impairs the function of several cell types such as neutrophils and macrophages
important to inflammatory and bacterial activity and compromises oxygen delivery to
tissues. Smoking cessation has been associated with a reduction in infection
(Sorensen et al (2003). Patients that smoke should be encouraged to reduce or quit
smoking and this should be part of the patients’ treatment plan and support given to
change behaviour.
9. Pain – appendix 3

Type of pain and when it occurs

Location

Use pain assessment tool in pathway

Current analgesia

Formulate individual management plan.
10. Psychological Status
The psychological effects of painful ulceration should not be underestimated.
Depression, even of a mild degree, may be exacerbated by pain and social
isolation. The patient’s quality of life (QOL) will be adversely affected by these
issues. This may make it difficult for the patient to comply with treatment.
Strategies to help to break the cycle of poor concordance in non-healing ulcers
may heal some that appear resistant to treatment. Kulik and Mahler (1993)
claim:
Well supported patients are more likely to comply with treatments…emotional
support reduces emotional distress which can itself impair treatment and
recovery.
11. Patients Understanding of the Ulcer

Patients’ understanding and involvement in their treatment is essential.

Education leaflets are useful to reinforce.
Leg Ulcer Care Guidelines
Page 47 | 116

Consider use of contract between nurses and patient to enhance
concordance.

How is it affecting their quality of life; what can be realistically
achieved?
12. Social Assessment

Personal hygiene

Family support

Employment; prolonged standing or sitting.

Accommodation, heating, living standards

Financial concerns regarding prescriptions
Leg Ulcer Care Guidelines
Page 48 | 116
21
Appendix 1a - A Quick assessment guide for managing Venous Leg
Ulcers short term
Quick Assessment must include
General Assessment from lower limb
care-pathway
 Family history (CHD / Diabetes may be
significant)
 Smoking history
 Past medical history
 Blood pressure
Age – Arterial risk increases with age
<50years unlikely to have significant arterial disease
> 80 years it is highly likely that there will be an element of arterial
disease
No arterial risk
factors or other
aetiology suspected
< 2 arterial risk factors
and no other
suspected aetiology
Check ankle circumference
Fit up to 20mmhg compression until
full assessment
Take blood ready for full
assessment
> 2 arterial risk
factors
Full Assessment before
applying any
compression
Date given for
Full
assessment
within 2 weeks
Alter compression
levels as appropriate
Leg Ulcer Care Guidelines
Page 49 | 116
This quick assessment guide has been designed to be used as a first line option,
when as a practitioner; you know that compression applied as soon as possible will
promote effective wound healing.
IT IS NOT DESIGNED TO TAKE THE PLACE OF THE FULL LEG ULCER
ASSESSMENT PATHWAY AND A FULL ASSESSMENT SHOULD BE
UNDERTAKEN WITHIN TWO WEEKS.
If a full assessment cannot be done within this time frame a quick assessment guide
should not be considered.
When using these guidelines if you are unsure of your findings or the safest way to
proceed please exercise caution and contact the leg ulcer specialist nurse or any of
the specialist nurses.
The quick assessment guide must include:

General patient assessment lower limb care-pathway – This must be
completed. These are actual arterial risk factors and must not be
ignored. The arterial signs and symptoms need careful consideration.

Age – It is generally considered that any person under the age of 50
years old it is unlikely to have developed significant arterial disease. It
is likely that someone over the age of 80 years will have developed
some element of arterial disease. Therefore you need to consider age
as a potential risk factor. The higher the age the greater the arterial
risk.

Family history – If someone has a strong family history of coronary
heart disease or diabetes again you need to consider this as a potential
risk factor.

Smoking – If they are a smoker this is a risk factor and with age the risk
of arterial disease is increased. If they have quit, being a past smoker
however long ago still needs to be considered.

Past medical history – anything of significance that might lead you the
practitioner to consider this ulcer may have other aetiology. If so do not
apply any compression.

Blood pressure – If this is raised it could be significant. Monitor further
and consider when assessing the risk factors.
If you have the resource, skill and opportunity it is worth using the Doppler machine
to listen to the foot pulses. If you consider they are monophasic, do not use these
guidelines but undertake a full assessment before applying compression. This does
not replace doing a full ABPI assessment but may be a helpful tool as part of your
quick assessment.
Leg Ulcer Care Guidelines
Page 50 | 116
22
Appendix 1b - Flow Chart for Guide to Fitting Compression Hosiery
When using these guidelines if you are unsure of your findings or the safest
way to proceed, please be cautious and contact the leg ulcer specialist nurse
or any of the named nurses with a specialist interest for advice and support.
These you will find named in the appendix.
The assessment guide must include:

General patient assessment – This must be completed. These are
actual arterial risk factors and must not be ignored. The arterial signs
and symptoms need careful consideration.

Age – It is generally considered that any person under the age of 50
years old is not likely to have developed significant arterial disease. It
is likely that someone over the age of 80 years will have developed
some element of arterial disease. Therefore age is an increasing
arterial risk factor and needs to be considered with other arterial risk
factors.

Family history – If someone has a strong family history of coronary
heart disease or diabetes again you need to consider this as a potential
risk factor.

Smoking – If they are a smoker this is a risk factor and with age the risk
of arterial disease is increased. If they have quit, being a past smoker
however long ago still needs to be considered.

Past medical history – anything of significance that might lead you the
practitioner to consider this ulcer may have other aetiology. If so do not
apply any compression.

Blood pressure – If this is raised it could be significant. Monitor further
and consider when assessing the risk factors.
If you have the resource, skill and opportunity it is worth using the Doppler
machine to listen to the foot pulses. If you consider they are monophasic, do
not use these guidelines but undertake a full assessment before applying
compression. This does not replace doing a full ABPI assessment but may be
a helpful tool to use as part of your assessment.
Leg Ulcer Care Guidelines
Page 51 | 116
Leg Ulcer Care Guidelines
Page 52 | 116
23
Appendix 2 - Doppler assessment
Procedure:
a.
The patient should lie as flat as possible and be allowed to relax for at least
15 minutes before any Doppler readings are taken to allow the blood
pressure to equalise throughout the body. Any deviation from the patient
lying flat should be recorded. The procedure can be explained and the
patient history can be taken during this time.
b.
Using the appropriate Doppler probe instead of a stethoscope, record the
brachial systolic pressure in both arms.
c.
Cover the ulcer with cling film and place the sphygmomanometer cuff
around the leg just above the ankle. The sphygmomanometer bladder must
circle two thirds of the leg. If it does not a larger / smaller cuff will be
needed.
d.
Identify the Dorsalis Pedis (DPA) Anterior Tibial (ATA) and Posterior Tibial
(PTA) pulses. Using plenty of ultrasound gel, locate the pulses with the
Doppler probe and record the pressures on two of the pulses on each limb,
even if only one limb is ulcerated.
e.
Note the quality of the pulses and what type of signal is heard; i.e. triphasic,
biphasic, monophasic or muffled sounds. If all pulses are equal sound &
strength, pump up on the PTA and one other pulse, otherwise choose the
best sounding pulse if not all the same.
f.
Calculate the Ankle Brachial Pressure Index (ABPI), by dividing the highest
ankle pressure for that limb by the higher of the two brachial pressures.
g.
For the patient with diabetes ABPI needs to be interpreted with caution due
to the risk of micro vascular and macro vascular circulation problems.
Table 4: Interpretation of ABPI
ABPI
Signal
Interpretation
>1
Triphasic
Normal
> 0.8
Triphasic/Biphasic
No significant arterial disease. Considered safe
to apply compression therapy
> 0.8
Monophasic
Incompressible arteries. In this instance ABPI
will not give an accurate indication of arterial flow
to the foot (false high reading).
0.6 – 0.8
Mono/biphasic (unlikely
to hear triphasic)
Mild to moderate arterial disease. Consider
reduced compression and monitor closely.
0.4 – 0.6
Mono/biphasic (unlikely
to hear triphasic)
Moderate to severe arterial disease. May
warrant a vascular referral. Community nurses
can refer direct using the vascular referral form,
Leg Ulcer Care Guidelines
Page 53 | 116
and inform the GP that a referral has been
made.
<0.4
Monophasic (unlikely to
hear bi/triphasic)
Severe arterial disease. Symptoms i.e. rest pain
will warrant urgent vascular referral
2) What to do about the ABPI?
The ABPI cannot be taken alone as an indicator of the safety of applying
compression. It is important to remember that other factors are involved as identified
in the holistic assessment. (Guttormsen & Smith 2016)
Oedema and/or induration in the leg can give a false high reading because greater
pressure is required to compress the artery under the accumulation of fluid in the
limb.
The ABPI may be within normal indices in some patients with a history of arterial
disease e.g. history of intermittent claudication pain. These patients should be
referred for a stress or exercise tolerance test to detect arterial insufficiency.
In patients with disease affecting their small blood vessels such as rheumatoid
arthritis and diabetes, the large vessels may be patent giving a good ABPI, but there
may be severely compromised blood flow in the micro-vessels.
Patients with calcified arteries, common in diabetes, the blood vessels will be very
difficult to compress with the sphygmomanometer cuff, and therefore, artificially high
ABPI’s will be obtained. TBPI (toe pressures) may be indicated, which will give a
more accurate result in some conditions.
If there is any doubt as to the significance of the Doppler readings consult the
WCS.
3) Frequency of Doppler Assessments
All patients with an open ulcer in compression should have their ABPI monitored;
the frequency of this should be individually assessed.
Patients who are healing well under compression and have no arterial risk factors
shouldn’t need reassessment of the ABPI.
Patients whose ulcers are static should be reassessed according to Lower limb carepathway.
Patients whose ulcers are deteriorating should have an urgent reassessment in
response to this.
Patients that have an elevated risk of their arterial circulation becoming
compromised should have a reassessment performed 3 – 6 monthly.
Leg Ulcer Care Guidelines
Page 54 | 116
Patients who develop a new ulceration or pain also need to be urgently have a
Doppler re-assessment.
The patients that may fall into this group include:

Patients with diabetes

Abnormal ABPI on initial assessment

Mixed Aetiology

Significant systolic difference between pedal pulses
Once patients have healed and are fitted with compression hosiery they should be
asked to return for reassessment if they have any discomfort or deterioration in the
general condition of their legs. Advice about signs and symptoms to look out for
should be given. If patients have significant risk factors, they should be monitored.
Leg Ulcer Care Guidelines
Page 55 | 116
Leg Ulcer Care Guidelines
Page 56 | 116
24
Appendix 3 - Pain
Pain can have a detrimental effect on a person’s health and quality of life as a
result of the physical, psychological and social consequences of suffering
pain.
The development of pain may indicate a number of possible causes including
a change in aetiology of the ulcer, as is the case in deteriorating peripheral
arterial occlusive disease. It may also indicate that an infection is developing
or that treatment is not suiting the patient. In some cases it may signal that the
treatment is being poorly or inappropriately applied, such as over tight
compression bandages.
Assessment of pain is an important aspect of nursing documentation (Nash et
al.1999), found pain management is the key function of health care
professionals and as nurses spend more time with patients than any other
healthcare professional group have a major role to play in its management.
A review of the literature asserts that despite pain being the main feature of
leg ulceration, venous and arterial, there is evidence to suggest, that it is an
aspect that is ignored by healthcare professionals. (Husband, 2001; Douglas,
2001).
Varying patterns of pain and discomfort and experienced by patients with
venous disease. Patients report aching heavy legs, particularly in the calf
region, which is often relieved when the patient can lie or sit with their limb
elevated and is worse during the summer. The symptoms are probably
directly linked to the development of venous hypertension (high pressure in
the superficial veins and micro circulation) which is relieved on high elevation.
Casey (1998) suggests that pain assessments should be carried out at every
treatment of the wound. A pain scale should be used when assessing
patients’ pain, (National Pain Society)
Hofman (1997) found that patients are usually pleased that their pain is
understood and is being taken more seriously. Concordance is encouraged
and patients more likely to tolerate treatments such as compression
bandaging.
Pain assessments can help to demonstrate effective treatment. Normally as
an ulcer heals, so the pain gets less, therefore pain charts alongside tracings
and wound documentation can show progress and deterioration.
Pharmacological therapy
The World Health Organisation has created guidelines to assist clinicians to
use a variety of drugs available for the pharmacological management of pain.
A stepwise method of symptomatic therapy, known as the ‘analgesic ladder’
WHO (1996).
For mild to moderate pain, regular oral Paracetamol are appropriate.
Leg Ulcer Care Guidelines
Page 57 | 116
If this fails to bring relief, they should be replaced by the regular administration
of a drug from the next ‘rung ‘a weak opioid, i.e. codeine, dihydrocodeine
(special care in elderly).
If pain relief is still not achieved with the maximum recommended dose, then
movement upwards towards the next ‘strong analgesic rung’ opioids.
Non-opioid analgesics (non-steroidal anti-inflammatory drugs) are effective in
treating mild to moderate pain when an inflammatory component is present,
i.e. Ibuprofen, Diclofenac Sodium, Naproxen.
Adjuvant analgesics may be effective without concurrent analgesics i.e.
anticonvulsants e.g. Carbamazepine, Gabapentin and Amitriptyline (Tricyclic
drug) are used for the treatment of burning, stabbing pains Gabapentin is a
class of drug called anticonvulsants and relieves the pain by changing the
way the body senses pain. Amitryptyline works by increasing the amounts of
natural substances in the brain and changes the way pain is felt. Amitriptyline
should be introduced in small doses and due to their sedative action, be taken
at night. Doses in excess of 30mgs may be required and it may take several
weeks before the correct dose is achieved.
Nurses and doctors should examine their goals for pain relief, and work with
the patients to achieve appropriate outcomes of pain management. Pain can
be multidimensional and analgesia is just one aspect of management.
Patients should be taught how to manage their pain effectively. Analgesia
should be used regularly rather than waiting until pain has developed.
Practical strategies such as written instructions and dosette boxes can
significantly improve pain therapies.
A comprehensive approach to pain control control advocated by the WHO
(1996) should be adhered to, working as a team is crucial for optimum care.
Leg Ulcer Care Guidelines
Page 58 | 116
25
Appendix 4 - Emollients
Emollients- this includes some of the commonly used emollients, however
there are others available on prescription and /or over the counter
Criteria for choice
Avoid soap, bubble bath and shower gels which strip
skin of natural oils
Emollients- listed from
bath oils and light
creams to greasy
ointments.
Emollients soothe, smooth and hydrate the skin and are
indicated for all dry or scaling skin conditions. The affects
are short lived and they need to be re-applied frequently.
Emollients should be applied in the direction of hair
growth to prevent folliculitis. Severity of condition, patient
preference, site of application and time available will
influence the choice of emollient.
Bath Additives: Hydration can be improved by soaking
in the bath for 10-20 minutes.
Oilatum
Balneum
If this time cannot be achieved then it may not be cost
effective to use a bath additive.
Hydromol bath and
shower emollient*
Dermol 600 **
Warning: They can make people and surfaces slippery
QV Bath Oil and wash
Dermol 200 shower*
emollient
Spray: useful for hard to reach areas, very light, care is
needed with application as this can be sprayed onto
surfaces as well as skin. Good to use if painful fragile
skin.
Emollin
Lotions: Useful for application to large hair bearing
areas or treatment of exudative areas.
Dermol 500**
E45
Have a cooling effect, can sting when used over broken
areas of skin if in alcohol basis preparation.
Gels: Have high water content particularly suitable for
application to scalp and face. Quick and easy to apply
and absorbs well. Does not have the tacky messy feeling
as with grease based products.
Leg Ulcer Care Guidelines
QV Lotion
Double base Gel
Page 59 | 116
Creams: Generally well absorbed into the skin more cosmetically Cetraban cream*
acceptable than ointments because less greasy and easier to
Hydromol cream
apply, may contain anti-bacterials or fungicides. Can cause
sensitivity reactions due to the preservatives
Epaderm cream*
Dermol cream**
QV cream
Zerocream
Zeroderm
ointment
Ointments: Greasy and more occlusive than creams, ideal for
chronic dry skin conditions. Encourages hydration often have
Hydromol
mild ant inflammatory effect and lock in the skins natural moisture Ointment *
and acts as a barrier to irritants.
Epaderm
Can mark clothing and fabrics.
Ointment*
Very effective but sometimes difficult for patients to use.
May be cosmetically unacceptable to some patients. Good under
bandaging when left for a week.
PATIENTS MUST BE WARNED THAT PARAFFIN CONTAINING
PRODUCTS THAT ARE FLAMMABLE THIS SHOULD BE DOCUMENTED IN
NOTES.
White soft
paraffin liquid
paraffin 50/50
Aqueous cream: Should only be used as a soap substitute not
as leave on emollient as can cause irritation (Cork et al 2003).
The * denotes emollients suitable for use as soap substitute. This can also be used
as a moisturiser unless a lighter or greasier moisturiser is preferred. As a general
rule the drier the skin the greasier the moisturiser
Emollients with specific properties
Antibacterial- **Dermol range useful for infected/excoriated eczema and MRSA.
Should not be used as long term emollient therapy.
Containing urea a hydrating agent, useful for scaly conditions. Hydromol intensive,
Calmurid or Eucerin. Urea enhances absorption of topical steroids.
Balneum Plus contains urea and lauramacrogols that have a local antipruritic action.
Looking after elderly skin-a simple guide (2006) Best Practice Statement (2007)
Leg Ulcer Care Guidelines
Page 60 | 116
26
Appendix 5 - Steroid Ladder
Very Potent
Specialist use
only
1
2
Moderate
Potent
Dermovate
Dermovate NN
Betnovate*
Betnovate C
Synalar Betnovate
N Diprosalic
Elocon*
Locoid
Locoid C
Cutivate
Diprosone
Fucibet
Betnovate RD*
Trimovate*
Calmurid HC
Haelan
Synalar 1:4
3
Mild
Not used in leg
ulcer management
Hydrocortisone
0.5%, 1% & 2.5%
Fucidin H
Nystaform HC
Canestan HC
Synalar 1:10
Alphosyl HC
Daktacort
Timodene
Leg Ulcer Care Guidelines
Page 61 | 116
27
Appendix 6a Compression Hosiery
Compression Hosiery
The use of hosiery in the management of leg ulceration has expanded in
recent years.
The three areas in which it is predominantly used are:

Healing

Secondary prevention - Maintaining a healed state

Primary prevention
Healing
There are now hosiery systems available that can be used instead of
compression bandages where concordance maybe an issue. These systems
with a liner and below-knee sock provide approximately 40mmHg pressure at
the ankle.
It is also possible to use ‘off-the-shelf’ or ‘made-to-measure’ hosiery to
achieve a healed state. It is important to be aware of the levels of
compression that are being applied if using hosiery. Using hosiery, while
effective, tends to have a slower healing rate. It is not always suitable for
heavily exudating and /or large leg ulcers.
Leg Ulcer Care Guidelines
Page 62 | 116
Leg Ulcer Care Guidelines
Page 63 | 116
Secondary prevention - Maintaining a healed state
Once a leg ulcer has healed, the patient needs lifetime compression therapy due to
the underlying venous pathology.
Recurrence rate varies from 33% to 67%.
67% will experience 2 or more episodes of reulceration
21% will experience more than 6 episodes of reulceration
Ulcers which are greater than 10cm in size, the chronicity of an ulcer, a history of
deep vein thrombosis and clotting disorders, along with the unsuitability or non
concordance with hosiery are all risk factors that increase the chance of recurrence.
The patients should be fitted hosiery with compression levels at 25 – 33mmhg at the
ankle. RAL / European standard class 2 (RCN 2006)
If this is not possible the patient needs to be fitted with the highest level of
compression they will tolerate but there will be an increased risk of reulceration.
(RCN 2006)
A lower compression level will need to be used if you have healed the patient in
reduced compression. Close monitoring and caution if fitting hose to mixed
aetiology/arterial ulcers.
Compression Standards / Hosiery Pressure Comparison Table
Mmhg at ankle
1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4
4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
Class 1
RAL/European Standard
British Standard
Class 1
Class 2
Class 2
Class 3
Class 3
IDEAL
Adapted from medi UK Ltd June 2016
Patients should not be fitted with compression hosiery until the skin is sufficiently
robust enough to enable the stocking to be drawn over the ulcer site.
The patient or carer will require a hosiery fitting aid that suits them, due to fabric
stiffness and level of compression in the hosiery. See appendix A.
Leg Ulcer Care Guidelines
Page 64 | 116
Education for patients regarding the need for life long support of the veins in their
legs is paramount and should be emphasised from the point of assessment.
Recommended hosiery
Manufacturer
Classification
Comments
RAL (European) standard – Mediven
range inc socks for men
7 sizes available for both
First choice when considering
using hosiery due to fabric
stiffness
regular and extra wide calf
circumference
Medi
Thigh circumference also in extra wide
Will need renewing 6 monthly
Petite and regular lengths
Foot length standard all sizes
More information
www.mediuk.co.uk/compression/low
er-limb
British standard – Duomed (stiffer
fabric than normal British std hose)
European standard – Actilymph
range
5 sizes available – size ranges overlap
for calf and thigh measurements
Activa is a finer knit hosiery that will
pull into creases and deformities
Actilymph is a stiffer knit fabric.
Petite and regular lengths
Foot length variable
Will need renewing at 100 washes or
approx 3 months
Activa
British standard – Activa range inc
unisex socks for men
More information:
5 sizes available
One length
www.activahealthcare.co.uk/compres
sion-hosiery
Foot length variable
Leg Ulcer Care Guidelines
Page 65 | 116
For standard shape and length legs
the above listed ready - made hose
will suit
Medi – Mondi
Made to Measure
BSN – Elvarex
Available as British or European
standard
Activa –
Actilymph
MTM
If you need to use made to measure
– use the correct form of the
manufacturer, they are not
interchangeable. Available from
company web sites
There can be a long manufacturing
time. Speak to the wound care
service or the rep for advice.
BSN -www.bsnmedical.co.uk - other
web addresses above
Fitting Hosiery
Hosiery should be fitted by a practitioner who can demonstrate a knowledge and
understanding of compression hosiery and is competently trained in hosiery
application.
It is essential that it fits well.
Ideally hosiery should be removed at night and reapplied first thing in the morning.
Advocating good skin care before reapplying is essential, along with checking the
feet and legs for any damage. If this is not possible an extended wear time of up to
7 days is possible.
Patient dexterity, their cognitive ability and agility need to be considered when fitting
hosiery. It may be that the patient needs supervision to apply their hosiery or it may
need to be fitted by a carer. The use of various aids can also be a valuable tool for
application, fitting and removal (see table in Aids section)
Measurement
Ideally measurements should be taken in the morning, following removal of
compression bandages or after keeping the limb suitably elevated to reduce
oedema.
Initial measurements need to be on bare legs and include:

Ankle – the narrowest point just above the malleolus (approx 5cm). If there
are ankle deformities the narrowest point may be too high up the leg to be
accurate
Leg Ulcer Care Guidelines
Page 66 | 116

Calf – the widest point
 Foot length
 Thigh – the widest part or 5 cm below the groin, if stockings are
required, rather than below the knee
 Below the knee width – 2 fingers below where the back of the knee
creases (required for some kits)
If the patient does not fit into an ‘off-the-shelf’ range then ‘made-to-measure’ needs
to be considered. It is important to use the correct measuring guide for the company
you have chosen to ensure the correct fit.
Fabric stiffness
A stiffer knit fabric is preferable as it is less likely to cut into or cause a tourniquet
effect to the limb (Lymphoedema framework 2006).
British Standard items tend to be knitted using thinner yarn that produces a finer
finish. Cosmetically may be more suitable but are more likely to cut in or tourniquet.
RAL / European standard items tend to be knitted with a thicker yarn that gives a
stiffer and thicker finish but are less likely to cut in or tourniquet.
Style
It is important to work with the patient to find what will suit their lifestyle, be
comfortable and aid concordance.
Open or closed toed - this can be the patients choice providing there is not a clinical
need for open toed.
Colour - again this should be the patients’ choice. It is important to remember that
the darker the colour of the hose the increased chance of skin sensitivities
developing due to the dyeing process.
Below knee hosiery is usually suitable.
Thigh length hosiery is required if the patient has varicosities or oedema around the
knee joint and / or the thigh area. Patients with arthritis may find thigh length more
comfortable.
Most manufacturers have a range of compression socks for men - these are
designed for the male foot, ankle and leg shape.
If the unaffected leg does not have significant arterial disease and the ABPI supports
this, it is best to fit hosiery to both legs. If the unaffected leg is fitted with hosiery at
the start of using compression bandages many of the problems can be overcome
prior to the affected leg being suitable for hosiery when it is healed.
Leg Ulcer Care Guidelines
Page 67 | 116
It is important that hosiery is renewed regularly to maintain the correct compression
rates. Skin care products and regular washing will cause the hosiery to deteriorate.
Generally one pair of hosiery will last between 3 - 6 months. The overall
performance of hosiery will be affected if they have tears, ladders or holes. RAL /
European lasts longer than British standard.
All wrinkles need to be removed and this can be done by smoothing upwards using a
pair of household rubber gloves.
Hosiery must never be folded over at the top band.
Hosiery should be washed in non-biological detergents and should not be dried over
direct heat.
Prescription information
Do not order hose generically on prescription. Ensure the prescription has.
Manufacturer and range, Class and Standard, Size, Length, Open or Closed toes,
Colour and any aid required. See appendix 6b for prescription instructions.
Education
This needs to start at the point of the assessment and should include:









The importance of skincare
Importance of a good fit
Care of hosiery
Renewal of hosiery
Importance of concordance with hosiery
Early referral with possible skin break downs
Avoidance of self-treatments from over the counter
Maintaining mobility and exercise
Footwear
Diet
Leg Ulcer Care Guidelines
Page 68 | 116
Leg Ulcer Care Guidelines
Page 69 | 116
28
APPENDIX 6b - Requirements for obtaining the accurate garment from
your prescription
Pharmacy
stamp
Age
Title, Forename, Surname & Address
………………………………………………………………………………………………
DoB
………………………………………………………………………………………………
Number of days treatment
NB Ensure dose is stated
………………………………………………………………………………………………
………………………………………………………………………………………………










MANUFACTURER + STYLE*
GARMENT TYPE (Below knee, thigh or tights)
STANDARD – BRITISH/GERMAN
CLASS – 1, 2, 3
SIZE
LENGTH / ANY EXTRA WIDTH
COLOUR
TOE TYPE
HOW MANY
APPLICATOR AID
Signature of Prescriber
Date
Name and NMC number of prescriber
Contact address and telephone number
GP Practice Number
NH
SH
S
*IF MADE TO MEASURE – ADD AT THIS POINT AND REMEMBER TO ATTACH
THE COMPLETED MADE TO MEASURE FORM
Leg Ulcer Care Guidelines
Page 70 | 116
Name:
Hosiery path:
Address:
Bristol Community Health Suitability for Hosiery Assessment Form
Prevention/Mild Venous Disease
This assessment tool is to assist you in your decision making when assessing for hosiery. It is primarily for
lymphovenous disease but can be used with limbs that have a mixed aetiology.
This tool is designed to be used in conjunction with BCH Lower Limb Pathway.
Document your decision .
Prevention/
Mild
Venous
Disease
More than 4
signs and
symptoms
choose the 2nd
option
Signs and
symptoms
No Oedema at
initial
assessment
Oedema
Tired achy
legs (s)
1.British Standard
hosiery Class 1
(14-17mmhg)
1.European/German
Standard Class 1
(18-21mmhg)
European/German
Standard
ABPI 0.5-0.6
Class 1
(18-21mmhg)
British Standard
Class 1
(14-17mmhg)
2.European/German
Standard Class 2
(23-32mmhg)
ABPI 0.6-0.8
European/German
Standard Class 2
(23-32mmhg)
2.British Standard
hosiery Class 2
(18-24mmhg)
Or
European/German
Class 1
(18-21mmhg)
Hosiery must be
removed at night
Leg ulcer kit –
British Standard
Leg Ulcer Care Guidelines
Mixed Aeitology
ABPI 0.5-0.8
Leg ulcer kit –
German/European
Standard
Ongoing
monitoring will be
essential
Page 71 | 116
Name:
Hosiery path:
Address:
Bristol Community Health Suitability for Hosiery Assessment Form
Moderate Venous Disease
This assessment tool is to assist you in your decision making when assessing for hosiery. It is primarily for
lymphovenous disease but can be used with limbs that have a mixed aetiology.
This tool is designed to be used in conjunction with BCH Lower Limb Pathway.
Document your decision i
Signs and
symptoms
No Oedema at
initial
assessment
Mixed Aeitology
ABPI 0.5-0.8
Oedema
Varicose
eczema (C4a)
Moderate
Venous
Disease
More than 4
signs and
symptoms
choose the
2nd option
Atrophie
Blanche (C4b)
Induration
(C4b)
European/German
Standard
1.British
Standard hosiery
class 2
(18-24mmhg)
Moderate to
severe varicose
veins (C2)
Moderate to
severe
hyperkeratosis
2.British
Standard class 3
(25-35mmhg)
ABPI 0.5-0.6 Class 1
(18-21mmhg)
2.European/German
Standard class 3
(34-46mmhg)
ABPI 0.6-0.8 Class 2
(23-32mmhg)
Hosiery must be
removed at night
Healed ulcer
(C5)
Open ulcer (C6)
1.European/German
Standard class 2
(23-32mmhg)
Leg ulcer kit –
British Standard
Leg ulcer kit –
German/European
Standard
Ongoing monitoring
will be essential
Cellulitis
Leg Ulcer Care Guidelines
Page 72 | 116
Name:
Hosiery path:
Address:
Bristol Community Health Suitability for Hosiery Assessment Form
Severe Venous/ Lymphovenous Disease
This assessment tool is to assist you in your decision making when assessing for hosiery. It is primarily for
lymphovenous disease but can be used with limbs that have a mixed aetiology.
This tool is designed to be used in conjunction with BCH Lower Limb Pathway.
Document your decision.
Signs and
symptoms
Severe
Venous/
Lymphovenous
Disease
If there is 1
symptom in this
section please
follow this pathway
More than 3 signs
and symptoms
choose the 2nd
option
Lipodermatosclerosis
(acute or chronic)
(C4b)
Chronic oedema /
Lymphoedema
(C4b)
Leg Ulcer Care Guidelines
1.European/German
Standard Class 2
(23-32mmhg) or 3
(34-46mmhg)
Severe
hyperkeratosis
Skin folds
Papillomatosis
Lymphangiomata
The use of
compression
bandages will be
required before
fitting hosiery
Mixed Aeitology
ABPI 0.5 – 0.8
Oedema
Lymphorrhoea
(wet or Leaky legs)
2.Made to measure
European/German
Standard Class 2
(23-32mmhg) or 3
(34-46mmhg)
Leg ulcer kit
German/European
1.European/German
Standard Class 1
(18-21mmhg) for
ABPI 0.5-0.6 or 2
(23-32mmhg) for
ABPI 0.6-0.8
2.Made to measure
European/German
Standard Class 1
(18-21mmhg) for
ABPI 0.5-0.6 or 2
(23-32mmhg) for
ABPI 0.6-0.8
Hosiery must be
removed at night
Ongoing monitoring
will be essential
Page 73 | 116
29
Appendix 6c - Aids available to aid application, removal or wearing
Patients who are having hosiery applied by home care services need to have
an applicator aid prescribed when hosiery are ordered on prescription.
Aid
Bath / Shower
Type / manufacturer
Comment
Limbo
FP10
Slim build
Short leg suits 5’2” – 5’4”
height
Slim build /short leg
normal leg 5’5” – 6’ height
Normal build
Normal build / short leg
Large build
Large build / short leg
Slim build 35 – 39cm leg
circumference, Normal build
39 – 54cm leg circumference.
Large 52cm – 6’ height.
Seal tight
FP10
Adult short leg
Heel to seal length 23” for
both
Adult short wide leg (leg
circumfrence >16”
Applicators
Open Toes
Chinese slippers
Available with some hose
Supermarket carrier bag
Easy slide - Credenhill
FP10
Actiglide
FP10
Medi 2 in 1
FP10
Venotrain glider
Non prescription
Closed toe
Easy slide Caran Credenhill
Non prescription
General
Household rubber gloves
Removal Aids
Easy off – Medi
Non prescription
Medi 2 in 1
FP10
Closed toes & Open
toes
Leg Ulcer Care Guidelines
Page 74 | 116
Frames
Avoid slippage
Sockade - urgo
FP10
Valet - Medi
Non-prescription – various
sizes
Suspenders
FP10
Silicone bands
Can be added to some hose
Waist Attachments
Available with some thigh
length hose
Primary prevention
This might present opportunistically and prevention is always a better option than
cure.
GP’s will sometimes request fitting hosiery rather than using diuretics for oedema.
It may be that this group of patients can be managed in class 1 British or RAL
standard, but it will depend on the level of oedema.
Use the ‘Guideline to fitting hosiery’ flow chart Appendix 1b when considering
fitting compression hosiery, especially as a preventative measure.
Leg Ulcer Care Guidelines
Page 75 | 116
30
Appendix 7 - Competencies
Roles and Responsibilities for Students undertaking practice competencies:
Compression Bandaging/Doppler assessment &Hose management.
Leg Ulcer Management
Core Competencies for Venous leg Ulcer Management
These core competencies should be used in conjunction with the BCH CIC Leg ulcer programme.
To be competent you must have attended the two and a Half day leg ulcer study day and fulfilled the
criteria for assessment with your mentor. It is expected that the competencies should be completed
within a six month frame work or earlier. During this period you are expected to practice with a mentor
and be supported until you are confident and competent in your practice ready for assessment.
A mentor is someone who has undertaken the study days and has been deemed competent to
practice normally in your own work area. This may prove difficult for some and so an alternative
mentor must be found i.e. another work area.
Students must carry out the adapted Dacum/AMOD Self Assessment scale at the beginning and end
of the competency programme.
Competence is achieved at level 3
Advanced practitioners you would expect to see at the higher levels 4 and above
Level
Associated Statement
0
Cannot perform this activity satisfactorily to participate in the clinical environment
1
Can perform this activity BUT not without constant supervision and some
assistance.
2
Can perform this activity satisfactorily but requires some supervision and / or
assistance
3
Can perform this activity without supervision and/or assistance (knows how to
access resources for support)
4
Can perform this activity satisfactorily without assistance and \ or supervision with
more than acceptable speed and quality of work
5
Can perform this activity satisfactorily with more than acceptable speed and
quality of work and with initiative and adaptability to special problem situations
6
Can perform this activity with more than acceptable speed and quality, with
initiative and adaptability and can lead others in performing this activity
Leg Ulcer Care Guidelines
Page 76 | 116
Core competencies and training in the management of
Venous leg Ulceration
Date candidate attended 2 day leg ulcer study days………………………..
The candidate has been assessed and has achieved the core competencies
Assessor signature…………………………………………………………………
Print Name………………………………………………………………………….
Candidate signature……………………………………………………………….
Print Name………………………………………………………………………….
Date of assessment……………………………………………………………….
Place of work………………………………………………………………………
Leg Ulcer Care Guidelines
Page 77 | 116
Assessment of Clinical Practice
Compression Bandaging
Meets KSF – HWB6/7
Name of Candidate: __________________________ Name of Assessor: ___________________________________
Knowledge Base
Date Trained
Date first
assessment
K 1 Demonstrates knowledge of comprehensive assessment
(I.C.P) and ABPI results
K 2 Demonstrates an awareness of Laplace’s law in clinical
practice
K 3 Discuss bandage system for all leg sizes
K 4 Demonstrates knowledge of purpose of each layer
K 5 Demonstrates knowledge of limb reshaping
K 6 Demonstrates a knowledge and purpose of each layer
K 7 Discuss patient information and health promotion that
should be considered when treating patients with leg
ulceration
Leg Ulcer Care Guidelines
Page 78 | 116
Date second assessment
Knowledge Base
Date Trained
Date first
assessment
Date second assessment
Date Trained
Date first
Date second assessment
assessment
K 8 Discuss the decision making pathways you would take to
decide if you need to refer on
Performance
P 1 Communicates with individuals and carers in a manner
which encourages an open exchange of views and
information whilst treating them with dignity and respect.
P 2 Demonstrate the individual understands the intended
assessment is fully informed and has capacity to give
consent and records this accurately.
P 3 Provides appropriate management to the ulcer site and
surrounding skin
P 4 Accurately measures the ankle circumference
P 5 Assemble correct bandage system pertaining to patient
circumstances and/or aetiology
P 6 Demonstrates correct padding of the leg
P 7 Demonstrates accurate application of compression with
each layer applied
P 8 Achieves appropriate and accurate graduated
compression therapy
Leg Ulcer Care Guidelines
Page 79 | 116
P 9 If appropriate offers appropriate health promotion and
educational advice to the patient and/or carer
P 10 Develops strategies for managing potential problems in
negotiation with the patient
P 11 Correctly documents management system used
P 12 Implements an appropriate management strategy for
the patient and healthcare teams
Assessment Criteria
Two service user demonstrations with two different service users.
Candidates Signature: _________________________________ Assessors Signature: ___________________Date_________
Leg Ulcer Care Guidelines
Page 80 | 116
Core competencies and training in Doppler Assessment in Leg
Ulcer Management
Date candidate attended workshop/Study Day………………………..
The candidate has been assessed and has achieved the core competencies
Assessor signature……………………..…………………………………………….……
Print Name…………………………………………………..……………………..……….
Candidate signature……………………..………………………………………..……….
Print Name……………………………..…………………………………………….…….
Date of assessment……………………………………………………………………….
Place of work…………………………………………………………………….…………
Leg Ulcer Care Guidelines
Page 81 | 116
Roles and Responsibilities
Mentors for practice competencies Doppler Ultrasound ABPI assessment
Mentors must carry out adapted Dacum / AMOD Self Assessment scale and achieve level 6.
Recommended period of student achieving competencies - 6 months
Mentors should:



Meet initially with their students to discuss the competency documentation.
Meet midway through the 6 month period in order to identify potential problems
Meet at the end of the period to discuss the final assessment and results
Dacum / AMOD rating scale
Rating Scales – Level of achievement
Level
Associated Statement
0
Cannot perform this activity satisfactorily to participate in the clinical environment
1
Can perform this activity BUT not without constant supervision and some
assistance.
2
Can perform this activity satisfactorily but requires some supervision and / or
assistance
3
Can perform this activity without supervision and/or assistance (knows how to
access resources for support)
4
Can perform this activity satisfactorily without assistance and \ or supervision with
more than acceptable speed and quality of work
5
Can perform this activity satisfactorily with more than acceptable speed and
quality of work and with initiative and adaptability to special problem situations
6
Can perform this activity with more than acceptable speed and quality, with
initiative and adaptability and can lead others in performing this activity
Competence is achieved at level 3
Advanced practitioners you would expect to see at the higher levels 4 and above
Leg Ulcer Care Guidelines
Page 82 | 116
Roles and Responsibilities
Students undertaking practice competencies: Doppler Ultrasound ABPI assessment
It is the students’ responsibility to work with their named mentors within 2 weeks of completing the
Doppler Workshop course.
Students must carry out adapted Dacum / AMOD Self Assessment scale at the beginning
and end of the competency programme.
It is expected that the competencies should be completed within a six month frame work.
You will need to complete at least two assessments prior to your final assessment.
The student may wish to negotiate time spent within the Vascular Studies department at the BRI.
This is not an essential component of the competencies but may enhance future practice. It may be
appropriate to arrange this once the 6 month period has passed and the student has experience of
dopplering routinely.
Dacum / AMOD rating scale
Rating Scales – Level of achievement
Level
Associated Statement
0
Cannot perform this activity satisfactorily to participate in the clinical environment
1
Can perform this activity BUT not without constant supervision and some assistance.
2
Can perform this activity satisfactorily but requires some supervision and / or assistance
3
Can perform this activity without supervision and/or assistance (knows how to access
resources for support)
4
Can perform this activity satisfactorily without assistance and \ or supervision with more than
acceptable speed and quality of work
5
Can perform this activity satisfactorily with more than acceptable speed and quality of work
and with initiative and adaptability to special problem situations
6
Can perform this activity with more than acceptable speed and quality, with initiative and
adaptability and can lead others in performing this activity
Competence is achieved at level 3
Advanced practitioners you would expect to see at the higher levels 4 and above
Leg Ulcer Care Guidelines
Page 83 | 116
Assessment of Clinical Practice
Doppler Ankle Brachial Pressure Index
Meets KSF – HWB6/7
Name of Candidate: __________________________ Name of Assessor: ___________________________________
Knowledge Base
Date Trained
Date first
assessment
K 1 Demonstrates knowledge of comprehensive assessment
(I.C.P)
K2 Knowledge of appropriate position and rest period
K 3 Demonstrate knowledge of effect of the immediate
environment on the procedure
K 4 Demonstrates an understanding of need to check and
maintain equipment
K 5 Demonstrates knowledge of all ABPI results and
associated pathways of care
Leg Ulcer Care Guidelines
Page 84 | 116
Date second assessment
Performance
Date Trained
Date first
assessment
P1 Communicates with individuals and carers in a manner
which encourages an open exchange of views and
information whilst treating them with dignity and respect.
P 2 Demonstrate the individual understands the intended
assessment is fully informed and has capacity to give
consent and records this accurately.
P3 Demonstrates an ability to take a comprehensive patient
assessment
P 4 Provides appropriate management to the ulcer site
P 5 Assemble correct equipment with appropriate probe
P 6 Selects correct gel for procedure and uses appropriately
P 7 Distinguish arterial and venous blood supply
P 8 Distinguish normal and abnormal sounds
P 9 Select correct readings to calculate ABPI
P 10 Perform calculation appropriately and reaches correct
answer
P 11 Interpret the results and explain the significance of the
findings
P 12 Correctly documents the results
P13 Implements an appropriate management strategy for the
patient and healthcare teams
Leg Ulcer Care Guidelines
Page 85 | 116
Date second assessment
Assessment Criteria
Two service user demonstrations with two different service users.
Candidates Signature: _________________________________ Assessors Signature: ___________________Date_________
Leg Ulcer Care Guidelines
Page 86 | 116
Core competencies and training in Compression Hosiery
Date candidate attended workshop/Study Day………………….………………..
The candidate has been assessed and has achieved the core competencies
Assessor signature………………………………………….……………………………
Print Name……………………………………………………………………………….
Candidate signature…………………………………………………………………….
Print Name……………………………………………………………………………….
Date of assessment…………………………………………………………………….
Place of work……………………………………………………………………………
Leg Ulcer Care Guidelines
Page 87 | 116
Roles and Responsibilities
Students undertaking practice competencies: Compression Hoisery
It is the students’ responsibility to work with their named mentors.
Students must carry out adapted Dacum / AMOD Self Assessment scale at the beginning
and end of the competency programme.
It is expected that the competencies should be completed within a six month frame work.
You will need to complete at least two assessments prior to your final assessment.
Dacum / AMOD rating scale
Rating Scales – Level of achievement
Level
Associated Statement
0
Cannot perform this activity satisfactorily to participate in the clinical environment
1
Can perform this activity BUT not without constant supervision and some assistance.
2
Can perform this activity satisfactorily but requires some supervision and / or assistance
3
Can perform this activity without supervision and/or assistance (knows how to access
resources for support)
4
Can perform this activity satisfactorily without assistance and \ or supervision with more than
acceptable speed and quality of work
5
Can perform this activity satisfactorily with more than acceptable speed and quality of work
and with initiative and adaptability to special problem situations
6
Can perform this activity with more than acceptable speed and quality, with initiative and
adaptability and can lead others in performing this activity
Competence is achieved at level 3
Advanced practitioners you would expect to see at the higher levels 4 and above
Leg Ulcer Care Guidelines
Page 88 | 116
Assessment of Clinical Practice
Compression Hosiery
Meets KSF – HWB6/7
Name of Candidate: _______________________ Name of Assessor: _____________________
Knowledge Base
Date
Trained
Date first
assessment
Date second assessment
K1 Demonstrates knowledge of
comprehensive assessment (I.C.P)
and ABPI results.
K2 Knowledge and awareness of
hosiery selected should be
appropriate to the presenting needs of
the patient
K3 Selection of styles available
K4Practitioners have the knowledge of
hosiery available on FP10/GP10.
K5 Demonstrate an awareness of the
difference between German RAL
classification and the British Standard
classification and understand when
each should be used.
K6 Demonstrates a knowledge of
hosiery application
Performance
Date
Trained
Date first
Date second
assessment assessment
P1 Communicates with individuals and
carers in a manner which encourages
an open exchange of views and
information whilst treating them with
Leg Ulcer Care Guidelines
Page 89 | 116
dignity and respect.
P2 Demonstrates the ability, knowledge
and understanding to explain the
principles of compression hosiery to the
patient and obtains consent
P3 Appropriate management of skin
P4 Accurately measures for stock sizes
of hosiery
P5 Accurately measures for custom
made hose using appropriate
documentation
P6 Selects appropriate hosiery
according to lower limb assessment size
and shape
P7 Demonstrates fitting of stock hosiery
P8 Demonstrates fitting of custom
hosiery
P9 Able to teach patients and carers in
the application of hosiery
P10 Patients and carers are aware of
the wear time
P11hCorrectly documents care planning
re aftercare and follow up for re ordering
and replacement.
P12 Implements an appropriate
management strategy for the patient
and healthcare teams
Assessment Criteria
Two service user demonstrations with two different service users.
Candidates Signature: _________________________________
Assessors Signature: ___________________Date_________
Leg Ulcer Care Guidelines
Page 90 | 116
31
Appendix 8
Managing Leg Ulcers in Patients’ Homes
Safe System of Work

At initial assessment risk assess the procedure, and make sure that any necessary
equipment is available, for all staff members who may have to undertake the task
(e.g. stool/kneeler).

Carry equipment, including kneeler if required, into the house (Refer to your SSOW
for carrying equipment).

Explain procedure and obtain verbal consent.

Choose the best available working environment in which to perform the procedure.
Consider the distance from the sink, (the nearer the better), as well as the amount of
clutter which may limit your ability to work comfortably.
Decontaminate hands.


Collect bowl (this should be a bowl or bucket only used for the soaking of the legs
during these treatments) line and fill from the sink nearest to the procedure area.

Only fill the bucket to the minimum level required to complete the task.

Consider the use of a jug to fill the bucket rather than lifting into high sinks.

Carry the bucket to the procedure room, using appropriate manual handling
technique for carrying loads safely.

Risk assess and consider your working position (try to avoid the need to twist), use a
kneeler/stool as required and use any equipment that the patient has that might help
(having got permission from the patient first).

Ask the patient to get in the best position for you to work in. If you need to help the
patients refer to safe handling techniques.

Gather equipment on a clean, clear surface (consider the use of a clean blue tray if
there is no suitable surface). Do not put open dressing packs on the floor


Decontaminate hands.
Open dressing pack to access bag and apron without touching inside of pack.
Leg Ulcer Care Guidelines
Page 91 | 116

Put on apron and non-sterile gloves.

Remove dirty bandages and dispose in bag.

Decontaminate hands.

Ask patient to put leg in bucket (If patient needs help, risk assess and use safe
manual handling techniques).

Put on a pair of non-sterile gloves.

Prepare emollient for washing and applying to clean leg.

Remove emollient from tub with disposable spatula and close lid of tub

Wash leg with gauze and emollient

Ask patient to remove leg from bucket (If patient needs help, risk assess and use
manual handling techniques).

Dry skin using towel from pack.

Using safe load handling techniques, carry the bucket to the Nearest toilet and throw
contents away. Use eye protection if splashing is anticipated (risk assess).

Clean the bucket and handle with a detergent or universal wipe, and dry with a
paper towel.

Remove gloves and decontaminate hands.

Go back to procedure room.

Don sterile gloves from pack, debride scales if required and apply dressings using
ANTT i.e. Protect key parts, touch only outer surfaces which will not touch key sites
i.e. the wound (See ANTT wound care guideline for further details).

Dispose of waste and decontaminate hands.

Clean kneeler and tray using wipes.
Leg Ulcer Care Guidelines
Page 92 | 116
32
Appendix 9 – Inclusion Criteria
Leg Ulcer Care Guidelines
Page 93 | 116
Leg Ulcer Care Guidelines
Page 94 | 116
Leg Ulcer Care Guidelines
Page 95 | 116
Leg Ulcer Care Guidelines
Page 96 | 116
33
References
1. Activa Compression hosiery training module (now out of print)
http://www.activahealthcare.co.uk/content/home/homepage.html
2. Augustin M, Brocatti I K, Rustenbach S J et al (2014) Cost of illness of Leg ulcers in
the community. Int Wound Journal 11 (3) 283- 92
3. Baker S.R, Stacey M.C, Jopp-McKay A.G, Hoskin S.E. and Thompson P.J. (1991)
Epidemiology of chronic venous ulcers. British Journal of Surgery. 78:864-7.
4. Barwell J.R, Davies C.E, Deacon J, Harvey K, Minor J , Sassano A, Taylor M,
Usher J, Wakely C, Earnshaw J.J , Heather B.P , Mitchell DC, Whyman M.R and
Poskitt K.R. (2004). Comparison of surgery and compression with compression
alone in chronic venous ulceration (ESCHAR study): randomised controlled trial.
Lancet. 363:1854-1859.
5. Barwell-J-R, Taylor-M, Deacon-J, Ghauri-A-S, Wakely-C, Phillips-L-K, Whyman-MR, Poskitt-K-R (2000) Surgical correction of isolated superficial venous reflux
reduces long-term recurrence rate in chronic venous leg ulcers. European journal of
vascular and endovascular surgery {Eur-J-Vasc-Endovasc-Surg}. 20. (4):363-368.
6. Best Practice in Emollient Therapy a Statement for Health care Professionals,
Dermatological Nursing 2007.
7. Bosanquet N. (1992) Costs of venous ulcers - from maintenance therapy to
investment programs. Phlebology. 7:44-46.
8. BMA and Royal Pharmaceutical Society of Great Britain (2009) (BNF ) 2016 BMA
and Royal Pharmaceutical Society of Great Britain London.
9. British Association of Dermatologists Patients information sheet, Prepared by the
senior skin group. Oct 2003
10. BSN medical http://www.bsnmedical.co.uk
11. Carr L, Phillips Z, & Posnett J (1999) Comparative cost – effectiveness of four- layer
Bandaging in the treatment of venous leg ulceration. Journal of Wound Care 8 (5):
243-248
12. Casey G. (1998) Overcoming the barriers to effective pain control. Nursing
Standard. 13. (12):49-54.
13. Charles H. and Lindsay E. (2004) Principles of Leg Ulcer Management and
Prevention: Educational Booklet. The Wound Care Society. 1.(4): 4-20.
14. Chen WY, Rogers AA (2007) recent insights into causes of chronic leg ulceration in
venous disease and implications on other types of chronic wounds. Wound Rep
Regen 15: 434-9.
Leg Ulcer Care Guidelines
Page 97 | 116
15. Coley C (2009) Skincare for leg ulcers. Journal of Community Nursing. March 2009,
23, 3, 26-30.
16. Cork MJ. Et al (2003): An Audit of adverse reactions to aqueous cream in children
with atopic eczema. Pharmaceutical Journal, vol 271 Nov.
17. Coull, A Clark M (2005) Best Practice Statement for Compression hosiery. Wounds
UK vol 1(1) May 70-78 http://www.wounds-uk.com/journal-articles/best-practicestatemenr-for-compression-hosiery (accessed April 2016)
18. Cutting KF, Harding KG (2004) Criteria for identifying wound infection. J Wound
Care 3 (4): 198-201
19. Dale J.J, Callam M.J, Ruckley C.V, Harper D.R. and Berry P.N. (1983) Chronic
ulcers of the leg: a study of prevalence in a Scottish community. Health
Bulletin.41:310-314.
20. Dealey C (1999) Wound Care: Cleaning rites and wrongs. Nursing times 95,43, 7175
21. Dowsett C, (2011) Treatment and prevention of recurrence of venous leg ulcers
using RAL hosiery. Wounds uk vol 7 no 1.
22. Douglas V. (2001) Living with a chronic leg ulcer: an insight into patients’ experience
and feelings. Journal of wound care. 10. (9):355.
23. Erickson C A, Lanza DJ, Karp DL, Edwards JW (1995) Healing of venous ulcers in
an ambulatory care programme: the roles of chronic insufficiency and patient
compliance. J Vasc Endovasc Surg 22: 629-36
24. European Wound Management Association (EWMA) (2003). Position Document:
Understanding compression therapy. http://www.ewma.org/
english/publications/position-documents/all-documents.html (accessed April 2016).
25. European Wound Management Association (EWMA) (2005) Position Document.
Identifying criteria for wound infection. MEP Ltd London. Available online at
http://ewma.org/english/publications/position-documents/all-documents.html
(accessed April 2016)
26. Franks P, Moffatt C, Connolly M, Bosanquet M, Oldroyd R, Greenhalgh R, McCullum
C. (1995) Factors associated with Healing Leg Ulceration with High Compression.
Age and Aging: 24; 407-410.
27. Gabillot-Carre M, Roujeau JC (2007) Acute bacterial skin infections and cellulitis.
Curr Opin Infec Dis 20 (2): 118-23
28. Gohel M.S, Barwell J.R, Earnshaw J.J, Heather B.P, Mitchell D.C, Whyman M.R
and Poskitt KE (2005). Randomized clinical trial of compression plus surgery versus
compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic
and anatomical changes. British journal of surgery {Br-J-Surg}. 92:291-297.
Leg Ulcer Care Guidelines
Page 98 | 116
29. Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ, Heather BP,
Mitchell DC, Whyman MR, & Poskitt KR.(2007) Long term results of compression
therapy alone versus compression plus surgery in chronic venous ulceration
(ESCHAR): randomised control trial. BMJ published online 1 June 2007; doi:
10.1136/bmj.39216.542442.BE
30. Graham I,D et al (2003) Prevalence of lower limb ulceration a systematic review of
prevalence studies. Advances in Skin and Wound Care, 16 6, 305-316.
31. Guttormsen K & Smith L (2016) What is an Ankle Brachial Pressure Index. Wounds
Essentials 11 no 1 22-26
32. Ham, S. Padmore, J. (2006) Two layer compression for patients with venous
ulceration. Nursing Standard vol 20(45) 19 July p68 – 76
33. Harding K.et al Simplifying venous leg ulcer management. Consensus
recommendations. Wounds International 2015. Available at
www.woundsinternational.com
34. Haynes-Stephen, J. (2006) An Overview of compression therapy in leg ulceration.
Nursing Standard vol 20(32) 19 April p68,70,72,74,76
35. Hamel-Desnos-Claudine, Desnos-Philippe, Wollmann-Jan-Christoph, Ouvry-Pierre,
Mako-Serge, Allaert-François-Andre. (2003) Evaluation of the efficacy of polidocanol
in the form of foam compared with liquid form in sclerotherapy of the greater
saphenous vein: initial results. Dermatologic surgery {Dermatol-Surg}. 29:11701175.
36. Hofman D. (1997) Assessing and managing pain in leg ulcers. Nurse
Prescriber/Community nurse. July. 40-43.
37. Hollingworth H. (2001) Pain relief: approaches that reduce pain and aid wound
healing. Nursing Times.97.(28):63-66.
38. Husband L.L. (2001) Venous ulceration: the pattern of pain and the paradox. Clinical
effectiveness in Nursing. 5:35-40.
39. Iglesias C, Nelson E.A and Cullum N.A. (2005) 4 Layer elastic bandages were more
cost effective than multilayer in elastic bandages for healing venous leg ulcers.
Evidence based nursing.
40. International Lymphoedema Framework (2012) Compression Therapy a position
Document on Compression bandaging. International Lymphoedema Framework in
association with The World Alliance for Wound and Lymphoedema Care. Available
online at
http://www.lympho.org/mod_turbolead/upload//file/Resources/Compression%20band
age%20-%20final.pdf (accessed March 2016)
41. Johnson, S (2002) Compression hosiery in the prevention and treatment of venous
leg ulcers. Journal of Tissue Viability vol 12 no 2 p 67 -74
Leg Ulcer Care Guidelines
Page 99 | 116
42. Kulik JA,Mahler HIM (1993) Emotional support as a moderator of adjustment and
compliance after coronary bypass surgery, a longitudinal study. J Behav Med 16: 4564
43. Levell N J, Wingfield CG, Garioch J J. (2011) Severe lower Limb Cellulitis is best
diagnosed by dermatologists and managed with shared care between primary and
secondary care: Epidemiology and Health Services Research. British Journal of
Dermatology 164, 1326-1328.
44. Lindholm C, Bjellerup M, Ole B. C. and Zederfeldt B (1993) Quality of life in chronic
leg ulcer patients: an assessment according to the Nottingham health profile. Acta
Derm Venereol (Stockh). 73:440-443.
45. Linsay E & Stephens F Effective skin care Chap14P 159-177 Leg ulcers and
Problems of the Lower Limb: An holistic approach. Ed E Linsay and R White (2007)
Wounds UK.
46. Lymphoedema Framework, (2006) Template for Practice: Compression hosiery in
lymphoedema. London: MEP Ltd
47. McDaniel HB, Marston WA, Farber MA, Mendes RR (2002) Recurrence of chronic
venous ulcers on the basis of clinical, etiologic, anatomic, and pathophyiologic
criteria and air plethysmography. J Vasc Surg 35: 723-8
48. McDaniel J C. & Browning K K. (2014) Journal Wound Ostomy Continence Nursing.
41 (5) 415-E2.
49. Medi formulary guide August 2015 www.medi-uk-formulary-guide-072015pdf
accessed March 2016)
50. Min-Robert-J, Khilnani-Neil, Zimmet-Steven-E. (2003). Endovenous laser treatment
of saphenous vein reflux: long-term results. Journal of vascular and interventional
radiology {J-Vasc-Interv-Radiol}. 14:991-996.
51. Muldoon J (2013) Chronic ulcers of the lower limb. In Flanagan M ed wound healing
and skin integrity. Wiley Blackwell Sussex
52. Moffatt, C. (2007) Compression Therapy in Practice. Aberdeen. Wounds UK
53. Moffatt C. (2000) Compression therapy. Journal of Community Nursing. 14.(12)
http://qjmed.oxfordjournals.org/content/97/7/431.full (accessed March 2016)
54. Moffatt C, J, Franks, PJ, Doherty, DC, Martin, R, Blewett, R & Ross, F. (2004a)
Prevalence of Leg ulceration in a London population. Quarterly Journal of medicine
97: 431-437.
55. Moffatt C. and Franks P. (1994) A prerequisite underlining the treatment programme;
risk factors associated with venous disease. Professional Nurse. 9. (9):637-642.
Nash R, Yates P, Edwards H, Fentiman B, Dewer A, McDowell J. and Clark R.
(1999) Pain and the administration of analgesia: what nurses say? Journal of clinical
nursing. 8: 180-189
Leg Ulcer Care Guidelines
Page 100 | 116
56. Nash R, Yates P, Edwards H, Fentiman B, Dewer A, McDowell J & Clark R (1999)
Pain and the administration of analgesia: what nurses say? Journal of Clinical
Nursing. 8: 180-189
57. National Institute for Health and Clinical Excellence (2004) Endovenous laser
therapy of long saphenous vein. https//www.nice.org.uk/guidance/ipg52 (accessed
March 2016)
58. National Institute for Health and Clinical Excellence (2013) Ultrasound Guided Foam
Sclerotherapy for Varicose Veins. http://www.nice.org.uk/guidance/ipg440 (accessed
March 2016)
59. National Institute for Health and Clinical Excellence: Medical Technologies
Guidance (MTG17) (2014) The Debrisoft monofilament debridement pad for use in
acute or chronic wounds, Available from www.nice.org.uk/guidance/MTGI17
60. Nazarako L (2016) Cellulitis: correct diagnosis and treatment of red legs.
Dermatology in practice vol 22 no 2 p50-53
61. Nicolini P.H. and the Closure Group. (2005).Treatment of primary varicose veins by
endovenous obliteration with the VNUS closure system: results of a prospective
multicentre study. European journal of vascular and endovascular surgery {Eur-JVasc-Endovasc-Surg}. 29. (4):433-439.
62. Pidlock L, Jones H. (2013) Use of a monofilament fibre debridement pad to treat
chronic oedema-relaterd hyperkeratosis. Wounds UK 9 (3): 89-92
63. Posnett,J,Franks,PJ (2008) The burden of chronic wounds in the UK. Nursing
Times; 104: 3, 44-45 http://www.nursingtimes.net/clinical-subjects/wound-care/theburdon-of-chronic-wounds-in-the-uk/527138.fullarticle (accessed March 2016)
64. Proebstle-Thomas-M, Krummenauer-Frank, Gül-Doendue, Knop-Juergen. (2004).
Nonocclusion and early reopening of the great saphenous vein after endovenous
laser treatment is influence dependent. Dermatologic surgery {Dermatol-Surg}.
30:174-178.
65. Royal College of Nursing Institute (1998) Clinical Practice Guidelines: the
management of patients with venous leg ulcers. (archived)
66. Royal College of nursing. (2006) Clinical practice guidelines: The nursing
management of patients with venous leg ulcers Recommendations. London. Royal
College of Nursing( archived)
67. Ruff, D. (2005) Conservative management of varicose veins Nursing Times vol
101(4) p51-54
68. Sarkar P.K. and Ballantyne S. (2000) Management of leg ulcers. Postgraduate
Medical Journal. 76:674-682.
Leg Ulcer Care Guidelines
Page 101 | 116
69. Sorensen L T, Karlsmark T, Gottrup F.(2003). Abstinence from smoking reduces
incisional wound healing infection: Randomised controlled trail. ANN Surgery 238 (1)
1-5
70. Tero-Rautio, Ohinmaa-Arto, Perälä-Jukka, Ohtonen-Pasi, Heikkinen-Timo, WiikHeikki, Karjalainen-Pasi, Haukipuro-Kari, Juvonen-Tatu. (2002). Endovenous
obliteration versus conventional stripping operation in the treatment of primary
varicose veins: a randomized controlled trial with comparison of the costs. Journal of
vascular surgery {J-Vasc-Surg}. 35. (5):958-965.
71. Tyler, P. Hollinworth, H. Osborne, R. (2005) The wearing of compression hosiery for
leg problems other than leg ulcers British Journal of nursing (Tissue Viability
supplement ) vol 14 (11) pS21 –S27
72. White R, Ali O, Mackie M, Dix F, Young T, Clark M, Chadwick P, Hutchcox S, King
B, Mangan M, Bateman D, Williams-Oliver R, (2011) Evidence in venous ulcer
management: a new consensus recommendation. Wounds Uk vol 7 4. 69-75.
73. Whitaker J (2012) SDelf management in combating chronic skin disorders. Journal
of Lymphoedema 7 (1): 46-50
74. World Health Organisation (1996) “Analgesic ladder “. WHO.
http://www.who.int/medicine:/areas/quality_safety/scoping_WHOGUIDE_malignant_
pain_adults.pdf
www.who.int/medicines/areas/quality_safety/scoping_WHOGUIDE_non_malignant_
pain_adults.pdf
75. World Health Organisation (1996) Cancer Pain Relief. WHO. 2nd ed. Geneva
http://www.whqlibdoc.who.int/publications/9241544821.pdf.
76. Zamboni-P, Cisno-C, Marchetti-F, Mazza-P, Fogato-L, Carandina-S, De-Palma-M,
Liboni-A. (2003). minimally invasive surgical management of primary venous ulcers
vs. compression treatment: a randomized clinical trial. European journal of vascular
and endovascular surgery {Eur-J-Vasc-Endovasc-Surg}. 25. (4):313-318
34
Bibliography

All Wales Tissue Viability Nurse Forum: Management of Hyperkeratosis of the
Lower Limb. (2014)

Charles H. (1995) the impact of leg ulcers on patients' quality of
life. Professional Nurse. 10:571-574.

Cullum N, Nelson E.A, Fletcher A.W. and Sheldon T.A. (2001) Compression
for venous leg ulcers. The Cochrane Database of Systematic Reviews, Issue
2. Art. No.: CD000265. DOI: 10.1002/14651858.CD000265.

Fowkes F.G.R. and Callam M.J. (1994) Is arterial disease a risk factor for
chronic leg ulceration? Phlebology. 9:87-90.
Leg Ulcer Care Guidelines
Page 102 | 116
35

Lees T. and Lambert D. (1992) Prevalence of lower limb ulceration in an
urban district. British Journal of Surgery. 79:1032-1034.

Logan R. (1997) Common skin conditions of shins and feet. Medicine
(International). 25: 26-27.

National Institute of Clinical Excellence Varicose Veins: diagnosis and
management CG168. Published July 2013.
http://www.nice.org.uk/guidance/cg168 (accessed March 2016)

Nelzen O, Bergqvist D. and Lindhagen A. (1996) Prevalence of lower limb
ulceration has been underestimated. British Journal of Surgery. 83.(2):255258.

Nelzén O. (2000) Leg Ulcers: Economic Aspects. Phlebology. 15:110-114

Pankhurst S. (2004) Should ABPI be measured in patients with healed
venous leg ulcers every three months. Journal of Wound Care. 13.(10):438440.

Scottish Intercollegiate Guidelines Network (2010) The care of patients with
chronic leg ulcer: a national guideline. SIGN publication number 26: 1-21.
(accessed Jan
2013)http://www.sign.ac.uk/guidelines/fulltext/120/recommendations.html

Simon D.A, Freak L, Williams I.M, McCollum C.N. (1994) Progression of
arterial disease in patients with healed venous ulcers. Journal of Wound Care.
3.(4):179-180.

Stevens J (2004) Diagnosis, assessment and management of mixed aetiology
ulcers using reduced compression. Journal of Wound Care. 13.(8):339-343.

Vowden K. and Vowden P. (2002) Hand-held doppler ultrasound: the
assessment of lower limb arterial and venous disease. Huntleigh Healthcare.

Vowden K.R, Goulding V. and Vowden P. (1996) Hand-held doppler
assessment for the peripheral arterial disease. Journal of Wound Care. 5.(3):
125-128.
Other Useful Sources
Books

Herbert L.M. (1997) Caring for the Vascular Patient. Churchill Livingstone.
London.

Leg Ulcers A Problem-Based Learning Approach (2007) Ed Morison M,Moffatt
C, & Franks P. Mosby Elsevier

Leg Ulcers and Problems of the Lower Limb (2007) An holistic approach. Ed
Lindsay E & White R. Wounds UK.
Leg Ulcer Care Guidelines
Page 103 | 116

Moffatt C (2007) Compression Therapy in Practice. Wounds Uk

Moffatt C. and Morrison M. (1995) A Colour Guide to the Assessment and
Management of Leg Ulcers (2nd ed) Mosby. London.

Moffatt C, Martin R, & Smithdale R (2007) Leg Ulcer Management; essential
skills for nurses. Blackwell Publishing

Murray S. (2001) Vascular Disease: Nursing Management. Whurr Publishers.
London.

England T & Akhator N (
Edition. Wiley Blackwell.

The Leg Ulcer Forum - www.legulcerforum.org/
Leg Ulcer Care Guidelines
) ABC of Arterial and venous Disease third
Page 104 | 116
Section 2
Lower Limb Care-Pathway
Assessment tool
Leg Ulcer Care Guidelines
Page 105 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
General Patient Assessment
Past Medical History:
Current medication & dose:
Known drug allergies:
Allergies to dressings / topical preparations including latex.
Evidence of
Neuropathy
BP:
Other bloods:
No
Yes:
P:
HB:
Glucose:
Venous Related Risk Factors
Left
Right
Left
Right
Deep vein thrombosis
Y
N
Y
N
Thrombophlebitis
Y
N
Y
N
Past surgery
Y
N
Y
N
Varicose veins
Y
N
Y
N
Past venous surgery
Y
N
Y
N
Prior venous ulceration
Y
N
Y
N
Lower leg fractures
Y
N
Y
N
Orthopaedic surgery
Y
N
Y
N
Any prolonged periods of
bed rest
Venous Related Signs / Symptoms
Multiple pregnancies (3+)
Varicose veins
Yes
No
Yes
No
Left
Right
Left
Right
Y
N
Y
N
Pigmentation (brown staining)
Y
N
Y
N
Y
N
Y
N
Varicose eczema ( wet or dry)
Y
N
Y
N
Y
N
Y
N
Ankle flare ( broken
capillaries)
Y
N
Y
N
Oedema
Y
N
Y
N
Itching over varices
Y
N
Y
N
Ulcer over malleolus
Y
N
Y
N
Ulcer with gaiter area
Y
N
Y
N
Aching or heaviness in legs
Y
N
Y
N
Induratation
(hard woody feeling in skin)
Atrophie blanche (white with red
dots)
Arterial Related Risk Factors
Peripheral vascular disease
Yes
No
Arterial surgery
Yes
No
Rheumatoid arthritis
Yes
No
Intermittent claudication
Yes
No
Diabetes mellitus
Yes
No
Angina
Yes
No
Ischaemic heart disease
Yes
No
Myocardial infarction
Yes
No
Trans ischaemic attack
Yes
No
CVA (Stroke)
Yes
No
Smoker
Yes
No
Leg Ulcer Care Guidelines
Amount & duration
Page 106 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 107 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 108 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 109 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 110 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Consent Form
Name of Patient:
Date of Birth:
Patient NHS Number:
Date:
Information recorded during your time with our team may be shared with others involved in your
care. This will help them to understand your needs and avoid them having to repeat some of the
assessments.
Do you consent to the information
gathered about you to be shared with
others involved in your care?
Is there anything you do not want to
share?
Photographic consent (this includes
video and digital images):
Yes / No
If ‘No’ give details below:
I confirm that I give my permission for Bristol
Community Health Community Interest
Company (CIC), Inspire Better Health and
Bristol City Council to take photographs that
will help with my care. I understand that
these will be stored in my confidential
patient records. I acknowledge that all
photographs are the property of Bristol
Community Health CIC, Inspire Better
Health or Bristol City Council. I understand
that these pictures may be used to train
other professional staff within the
organisation.
Patient’s Signature:
Date:
Practitioner’s signature:
Date:
If the patient has an inability to give informed consent, information will be shared in accordance
with the Mental Capacity Act Code of Practice (2007)
Leg Ulcer Care Guidelines
Page 111 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 112 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 113 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 114 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 115 | 116
Name:
Address:
Integrated Care Pathway
Lower limb Care Pathway Form
Leg Ulcer Care Guidelines
Page 116 | 116