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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. 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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