Download Management of Leg Ulceration for Adults Policy

Management of Leg Ulceration
for Adults Policy
Policy Date: September 2014
Policy Version: (V6.1)
September 2014
TARGET AUDIENCE (including temporary staff)
People who need to know this
document in detail
All clinical staff involved in caring for patients
with leg ulceration
People who need to have a broad
understanding of this document
All clinical staff caring for patients with leg
ulceration
People who need to know that this
document exists
All staff caring for patients with leg ulceration
Policy Author: Tissue Viability Nurse
Approved by:
Trust-wide Clinical Governance Group
Date:
25/11/2014
Ratified by:
Trust-wide Clinical Governance Group
Date:
25/11/2014
Date of next review:
November 2016
Management of Leg Ulceration for Adults Policy
CONTENTS
Page
1.
INTRODUCTION
5
1.1
Purpose
5
1.2
Scope
5
1.3
Definitions
5
2.
MANAGEMENT OF LEG ULCERATION
5
2.1
Training
5
2.2
Assessment
6
2.3
Aetiology
2.3.1 Venous Ulceration
2.3.2 Arterial Ulceration
2.3.3 Mixed Venous / Arterial Ulceration
6
6
6
6
2.4
Doppler Ultrasound
6
2.5
Use of Bandages
2.5.1 Arterial Disease
2.5.2 Venous Disease
2.5.3 Mixed venous/arterial disease
2.5.4 Measuring the Limb
6
7
7
7
7
2.6
Wound Management
2.6.1 Arterial Ulceration
2.6.2 Venous Ulceration
2.6.3 Mixed Venous / Arterial Ulceration
2.6.4 Wound Cleansing and Skin Care
8
8
8
8
8
2.7
Management of Varicose Eczema
2.7.1 Dry Varicose Eczema
2.7.2 Wet or Weeping Varicose Eczema
8
9
9
2.8
Management of Infection and Infection Control
2.8.1 Diagnosis and Treatment of Wound Infection
2.8.2 Use of Equipment and dressing materials
9
9
10
2.9
Elevation and Exercise
2.9.1 Venous Disease
2.9.2 Arterial Disease
2.9.3 Mixed venous/arterial disease
10
10
10
10
2.10
Referral for Further Advice
11
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Management of Leg Ulceration for Adults Policy
2.10.1 Tissue Viability Service
2.10.2 Vascular Surgical Departments
2.10.3 Dermatology Department
11
11
11
2.11
Prevention of Ulcer Recurrence
11
2.12
Smoking
12
3.
RESPONSIBILITIES
12
4.
ASSOCIATED DOCUMENTS AND REFERENCES
13
5.
MONITORING COMPLIANCE
14
6
DISSEMINATION AND IMPLEMENTATION
14
7.
CONSULTATION, APPROVAL, RATIFICATION & REVIEW
14
8.
VERSION CONTROL
15
APPENDIX A Leg Ulceration Differential Diagnosis Assessment Form
16
APPENDIX B DOPPLER ULTRASOUND PROCEDURE
19
APPENDIX C EXAMPLES OF BANDAGE AND COMPRESSION SYSTEMS
ON
23
APPENDIX D FINGER TIP UNITS
24
APPENDIX E ANKLE EXERCISES TO AID LOWER LIMB CIRCULATION
25
9
Equality Analysis
27
10
Ratification Checklist
33
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Management of Leg Ulceration for Adults Policy
1.
INTRODUCTION
1.1
Purpose
This document will outline the Trust’s expectations of staff involved in treating
patients with leg ulceration and will offer guidelines on how to approach the
patient’s treatment plan.
1.2
Scope
This document covers management of venous ulceration, arterial ulceration and
mixed venous/arterial ulceration. Guidance on management of diabetic foot
ulceration is available in a separate document.
1.3
Definitions
Aetiology
the cause of the disease
Venous leg ulceration
disease of the veins resulting in ulceration caused by poor
venous return of blood from the lower leg to the heart
Arterial leg ulceration
disease of the arteries resulting in ulceration from poor arterial
flow from the heart to the lower leg
Mixed Venous/Arterial
leg ulceration
disease of both veins and arteries resulting in ulceration which
can complicate diagnosis and treatment plan
2.
MANAGEMENT OF LEG ULCERATION
Clinical staff are required to follow the guidance below in order to provide the optimum
treatment for patients with leg ulceration.
2.1
Training
All clinical staff involved in assessment and treatment of patients with leg ulceration must
attend training and maintain their skills by regular practice. Details of current training
programmes are available on the Pulse. An appropriate mentor should assess skills in use
of Doppler and compression bandaging before the clinician is involved in patient care and
re-assessed every three years.
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Management of Leg Ulceration for Adults Policy
2.2
Assessment
It is essential that all patients presenting with leg ulceration receive a thorough holistic
assessment. A Leg Ulcer Assessment form is provided as an aide memoir (see Appendix
A). This is to determine a differential diagnosis of either venous or arterial ulceration, or to
identify those patients whose treatment is complicated by a mixed aetiology of both
venous and arterial disease. Referral for further investigation may be required to determine
the exact diagnosis and therefore the most appropriate treatment. Please consider if it is
appropriate for the patient to be educated and supported to perform some care of the leg
ulcer themselves. This may involve education in cleansing and dressing of the ulcer and
the use of compression hosiery garments.
2.3
Aetiology
2.3.1 Venous ulceration
Venous ulceration occurs as a result of chronic venous hypertension, which leads to
backflow of blood and congestion in the venous system.
2.3.2 Arterial Ulceration
Arterial ulcers are the result of occlusion or reduction of blood flow in the arteries.
2.3.3 Mixed Venous/Arterial Ulceration
Patients with venous disease may also have concurrent arterial disease and vice versa,
giving rise to a mixed venous/arterial aetiology. When patients have mixed aetiology leg
ulceration, the advice contained in these guidelines needs to be considered and
appropriately applied depending on the primary problems encountered. Determining
treatment for patients with mixed venous/arterial disease can be complex and advice can
be sought from the Tissue Viability Service if required. See appendix B for referral form.
2.4
Doppler Ultrasound
For clinical assessment of patients with leg ulceration, Doppler ultrasound compares the
brachial systolic pressure with the ankle systolic pressure, thereby determining the severity
of any impairment of arterial blood flow to the feet. This results in a ratio number known as
the Ankle Brachial Pressure Index (ABPI). The use of Doppler is an important part of the
assessment process and must be performed on all patients presenting with leg ulceration
following appropriate informed consent guidance. Doppler assessment must be carried out
by a practitioner who has undertaken appropriate training. See appendix C for procedure
of obtaining and interpreting ABPI measurements.
2.5
Use of Bandages
Selection of bandages should be from the current Brighton & Hove (ONPOS) or West
Sussex Wound Care Formulary, unless clinical reasoning for variance can be justified in
the patient record. When any degree of compression is used, the patient’s ankle
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Management of Leg Ulceration for Adults Policy
circumference must be measured first and then the correct kit or size of bandage chosen,
depending on the ankle measurement. Under-bandage padding must always be used to
avoid pressure damage to bony prominences. The under bandage padding can also be
used to reshape a limb where the calf is either too narrow or too wide. In bedded units, if
compression therapy is required and staff are not trained to do this, please contact the
patient’s community nursing team or the TVN service for advice. See appendix D for
examples of bandage systems.
2.5.1 Arterial Disease
Patients with arterial disease should have dressings secured by light, cotton or crepe
bandages applied without tension to avoid the risk of further arterial occlusion.
2.5.2 Venous Disease
Patients with venous disease must be offered full compression as the mainstay of
treatment for venous hypertension. This is usually in the form of bandaging systems in the
active phase of ulceration, although hosiery may also be utilised.
It has been demonstrated by extensive research that sustained compression of 35-40
mmHg at the ankle, graduated to 17-20mmHg just below the knee enhances healing of
venous leg ulcers by reversing venous hypertension. This level of compression is achieved
by using one of the high compression bandaging systems in the Brighton and Hove or
West Sussex Wound Formularies. High compression must only be applied to a patient with
an ABPI of between 0.8 and 1.3, as determined by Doppler assessment.
It is imperative that the bandages that achieve these high rates of compression are
correctly applied. It is the responsibility of the practitioner applying the bandages to ensure
their competence in bandaging techniques through appropriate training, regular practice
and updating of skills. Inappropriate or inexpert bandaging can lead to limb loss. Any
delegation of bandage application to non-registered practitioners remains the responsibility
of the registered practitioner, therefore competencies must be reviewed on a regular basis.
2.5.3 Mixed Venous/Arterial Disease
For patients with mixed aetiology leg ulceration and ABPI readings of between 0.7 – 0.8, it
may be helpful to apply reduced compression of 15-25 mmHg to control oedema and
leakage of fluid from the tissues. For readings between 0.5 – 0.7 there needs to be a clear
discussion with the Tissue Viability Service or the Vascular Services before a decision to
apply reduced compression is started. Reduced compression can be achieved by varying
the approach to bandaging systems, e.g. by omitting either the 3rd or 4th layer of the multilayer bandaging systems, or by utilising a bandage designed for this purpose. Shortstretch bandages cannot be used to achieve reduced compression.
2.5.4 Measuring the Limb
Before commencing compression therapy, refer to the manufacturer’s instructions of the
chosen bandage system. The patient’s ankle circumferences must then be measured with
a disposable single use measuring tape.
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Management of Leg Ulceration for Adults Policy
•
If the ankle circumference is <18cm, apply extra padding.
•
If the ankle circumference measures >25cm, a different bandage system or additional
bandages may be required.
•
Seek advice from the Tissue Viability Service if required.
2.6
Wound Management
The approach to wound management can vary depending on the aetiology of the leg
ulceration.
2.6.1 Arterial Ulceration
Arterial ulcers may need to be dressed as frequently as daily to facilitate the regular
viewing of the limb because of the high risk of wound infection and/or rapid deterioration.
In this group of wounds, the usual approaches to maintaining a moist wound healing do
not always apply as this can increase the risk of infection by making the surrounding tissue
too moist. The care plan should aim to achieve a wound bed that is dry rather than wet.
Allow dry necrotic tissue to auto-debride rather than adding Hydrogel to moisten.
2.6.2 Venous ulceration
It is more important to provide appropriate compression than to be concerned about the
primary wound contact layer; therefore, usually a non or low adherent primary dressing will
suffice. Dressing changes can be once weekly or more frequently if exudate level is high.
2.6.3 Mixed Venous/Arterial Ulceration
The choice of wound management will vary depending on the degree of arterial
involvement. Refer to the Tissue Viability Service if advice required.
2.6.4 Wound Cleansing and Skin Care
•
Wash hands with liquid soap and water/use alcohol gel prior to undertaking any wound
care and wear disposable latex-free gloves and disposable plastic apron.
•
Cleanse the lower limb by immersion in warm tap water in an appropriate clean bucket
or bowl with a plastic liner. Run the tap for 15 seconds before filling the bucket or bowl
to avoid contamination from the tap. Emollient can be added to the water if required.
Refer to the Brighton and Hove or West Sussex Wound Formularies for product details.
•
Pat dry with a clean paper towel. Do not rub or traumatise the wound.
•
If immersion is not possible, irrigate the wound with warmed normal saline.
•
Gently remove any plaques of skin that may otherwise act as pressure points below
compression bandaging.
•
Apply emollient to lower leg and foot to moisturise skin, e.g. 50% white soft
paraffin/50% liquid paraffin (50:50 ointment), or Cetraben cream.
•
Refer to section 2.8.1 on Infection for decontamination of equipment details.
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Management of Leg Ulceration for Adults Policy
2.7
Management of Varicose Eczema
Avoid use of soap when washing the limb and apply emollients regularly to moisturise the
skin. Apply emollients in the direction of hair growth to avoid folliculitis. Refer to the Tissue
Viability Team for advice if the following strategies are not successful.
2.7.1 Dry Varicose Eczema
This can usually be resolved by appropriate wound cleansing, regular application of
ointments and regular removal of dry skin plaques.
2.7.2 Wet or Weeping Varicose Eczema
The objective is to return skin to normal through excellent skin care, using bath oil, topical
emollients and steroids. Refer to the Brighton and Hove and West Sussex Wound
Formularies for further information on products available for skin care.
•
If Potassium Permanganate is to be used:
Soak the affected area daily for a maximum of 10-15 minutes in a solution of potassium
permanganate, for up to 2 weeks. Tablet should be diluted 1:10,000 (i.e. 1 tablet in 4
litres of warm water). As the tablet takes a long time to dissolve it is helpful to dilute this
first in a small quantity of hot water before adding the remaining water. The final
solution should be pale pink in colour. If no improvement has occurred in the first week
of treatment, or if deterioration occurs, discontinue treatment. See Waste Management
policy at http://thepulse/downloads/trustwide-policies-procedures/estatesfacilities/waste-management.pdf or flow chart at http://thepulse/downloads/trustwidepolicies-procedures/estates-facilities/waste-management.pdf
Topical Steroids can be helpful to calm irritation and should be used as a treatment over
several weeks with a care plan to reduce the frequency of application to avoid a rebound
effect. Apply emollient to the limb and allow this to absorb for a while. Apply three fingertip
units (FTU) over the lower leg (add 1 fingertip unit if the foot also affected). Use a
moderate potency ointment (e.g. Eumovate™ or Betnovate RD™) daily for 1 week,
alternate days for 1 week, twice weekly for 1 week then once the following week before
discontinuing. See appendix E for details of FTU dosage measurement.
2.8
Management of Infection and Infection Control
Refer to the current Infection Prevention & Control Policy and associated procedures on
the Pulse for advice on prevention of spread of infection. Ensure Standard Infection
Control principles are used. See the procedure at
http://thepulse/downloads/trustwide_policies_procedures/infection_prevention_control/ipc1
_standardinfectioncontrol.pdf
2.8.1 Diagnosis and Treatment of Wound Infection
The majority of bacteria found in venous ulcers are simply commensal organisms that do
not cause clinical infection. Patients can be inappropriately prescribed antibiotics if clinical
infection is not present leading to less effective use of antibiotics when needed or
Clostridium difficile infection (Cdiff). Only if clinical signs of infection of the wound or leg
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Management of Leg Ulceration for Adults Policy
are observed (redness, increased pain, increased exudate, pyrexia and/or inflammation)
would a wound swab be required, unless there are any other good reasons for suspecting
a hidden clinical infection, e.g. wound deterioration or failure to progress despite
appropriate holistic management. N.B. All bedded units undertake routine MRSA
screening of patients on admission. Prescribed systemic antibiotics should be used to treat
diagnosed infection. Short courses are sometimes inadequate due to the poor perfusion of
the drug into infected tissue. Topical antibiotics can lead to contact sensitivity and
resistance.
It may be appropriate to use topical antimicrobial dressings (e.g. iodine, silver or honey) in
conjunction with systemic antibiotics. These dressings must be reviewed at regular
intervals. Refer to the Brighton and Hove or West Sussex Wound Formularies for further
details.
2.8.2 Use of Equipment and dressing materials
Scissors
•
Cutting primary dressings – must be sterile single use and dispose of into
sharps container.
•
Cutting outer bandaging – non-sterile single patient use – cleanse with detergent
wipe followed by alcohol wipe. Store dry.
Leg ulcer buckets - must be lined with a plastic bag and cleaned with detergent and
water/detergent wipe after every use.
•
In leg ulcer clinics, decontaminate buckets with 1000 ppm available chlorine i.e. Chlorclean wipes. Discard bucket if surface becomes scratched and difficult to clean.
•
Water must be disposed of down a designated sink or toilet, taking care to avoid
splashing. Never dispose of down a hand washing sink.
•
Clean dry buckets need to be stored upside down in accordance with infection control
guidelines.
2.9
Elevation and Exercise
All patients should be advised to improve their calf muscle pump (see appendix F for
details).
2.9.1 Venous Disease
To reduce oedema and improve the venous circulation, patients should be advised to
elevate their limbs to above the height of their hip when sitting or lying. Wherever possible,
patients should have the foot of the bed elevated on blocks for night use and be
encouraged to rest on the bed during the day. The prescription of riser recliner chairs is
not deemed an appropriate solution to achieve the recommended level of elevation.
Consideration needs to be given to the impact on raising the foot of the bed on functional
abilities to transfer in and out.For iCES Brighton and Hove follow this link
http://thepulse/downloads/patient-care/clinical-services/ices/ices/catalogue/criteria-riserreclinerchairprovision.pdf
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Management of Leg Ulceration for Adults Policy
Walking with normal heel/toe gait and regular exercises to improve the calf muscle pump
function are also helpful and the patient should be encouraged to practice these several
times daily.See Appendix E.
2.9.2 Arterial Disease
Patients with arterial disease will find it more comfortable to have their legs dependent and
it may be helpful to consider raising the head of the bed. If the patient experiences pain
that wakes them during the night, then hanging the limb(s) from the side of the bed will
help to alleviate this pain.
2.9.3 Mixed Venous/Arterial Disease
When there is mixed venous/arterial disease present, positioning of the limb will be
determined by patient comfort and the degree of oedema present. It may be necessary to
advise a mixture of elevation and dependency determined by the patient’s pain levels.
2.10 Referral for Further Advice
2.10.1 Sussex Community NHS Trust Tissue Viability Service
•
North and Coastal localities – in the first instance refer via One Call
•
Brighton and Hove – Refer by faxing a referral form to 01273 242214 or by e-mail to
[email protected].
A patient should be referred to Tissue Viability if:
•
The aetiology is unclear.
•
The patient is not able to follow the best practice advice given in this document.
•
There is no improvement in the leg ulcer after 12 weeks of appropriate treatment.
•
Any support or advice about wound care is required.
Brighton & Hove Leg Ulcer Clinics – ambulant patients, suffering from venous leg ulcers
only, who are registered with a Brighton & Hove GP practice can be referred to the
Community Leg Ulcer Clinics in the city if their own practice does not provide a leg ulcer
service under the Local Enhanced Service agreement with the commissioners. Referral via
fax to 01273 265899.
Brighton Vascular Assessment Unit (VAU) – patients who are registered with a Brighton
& Hove GP practice can be referred to the VAU for investigations if:
•
Doppler readings are unobtainable in the home or clinic environment and/or the patient
requires further investigation in the Vascular Assessment Unit.
•
There is evidence of arterial calcification demonstrated by incompressible or falsely
high (>1.3) ABPI readings.
•
N.B. The VAU will only accept referrals from GPs, Tissue Viability Service and Leg
Ulcer Clinic Lead Nurses. The VAU will not accept a referral for ABPI’s if the patient
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Management of Leg Ulceration for Adults Policy
has been assessed by them in the previous 12 months and a normal ABPI was
reported.
•
SCT Venous Leg Ulcer Service (VLUS) – refer via One Call North. Clinics held in a
number of locations. Refer by GP/Practice Nurse/Podiatrist or any other health care
professional.
2.10.2 Vascular Surgical Departments
A patient can be referred for consultant vascular advice via the GP if:
•
Clinical assessment and Doppler readings of between 0.5 and 0.8 suggest arterial
disease – routine referral.
•
Clinical assessment and Doppler readings of <0.5 suggest severe arterial disease –
urgent referral.
•
Critical limb ischaemia is suspected – emergency referral via A&E.
•
Doppler readings show an ABPI above 1.3 and further advice is required.
•
There is marked or sudden deterioration in either the condition of the foot or leg, or the
ulcerated area.
•
There is uncontrolled pain where other causes of pain have been eliminated.
•
The patient has venous disease that may be improved by venous surgery i.e. with
competent deep veins and incompetent superficial veins. Determine whether the
patient wishes to be considered for surgery prior to making this referral.
2.10.3 Dermatology Department
It is recommended that a patient should be referred for consultant dermatology advice via
the GP if:
•
The patient has venous disease that is not improving after 6 months of appropriate
compression therapy and Tissue Viability advice has been sought.
•
The ulcer appears abnormal or is in an unusual site (i.e. other than the gaiter region). A
biopsy may be necessary to exclude skin cancer.
•
There is marked or sudden deterioration in the condition of the leg, or the ulcerated
area, and the ABPI does not indicate arterial disease.
•
The patient has associated varicose eczema, allergy, or other skin problems that are
complicating treatment – patch testing may be required.
2.11 Prevention of Ulcer Recurrence
•
Surgical correction or sclerotherapy of superficial venous reflux can prevent recurrence
– refer for Vascular opinion.
•
Measure the patient for prescription of compression hosiery. Ideally, class II should be
used, but if not tolerated by the patient, try class I or liners. If the measurements do not
fit into the normal range of ready-made stockings, prescribe made to measure hosiery.
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Management of Leg Ulceration for Adults Policy
•
Hosiery is available in British Standard and European classifications on prescription.
The level of compression differs between these classifications therefore consider this
when recommending a prescription.
•
Hosiery can be worn day and night, or be removed at night if preferred.
•
Stockings should be replaced every three - six months as they lose some of their
elasticity after this time. This is an ideal opportunity to reassess the limb, check the skin
and reinforce advice.
•
Continue to elevate the leg at night with bed blocks.
2.12 Smoking
Smoking can affect the wound healing process regardless of aetiology. Patients with
arterial disease are particularly affected by the effects of smoking and should be
encouraged to cease smoking as part of their treatment plan.
3.
RESPONSIBILITIES
The Chief Executive has ultimate responsibility for the organisation and is supported by
the Executive Directors.
The policy author is responsible for ensuring the policy follows the appropriate Trust
format and complies with the recognised development, consultation, approval and
ratification process.
Service managers/team leaders are responsible for promoting and implementing the
policy.
All staff are required to complete in full and as directed any templates or proformas as
instructed, for use as part of this policy.
4.
ASSOCIATED DOCUMENTS AND REFERENCES
•
Best Practice Compression therapy Available at http://www.wounds-uk.com/bestpractice-statements/best-practice-statement-compression-hosiery-1 (February 29th
2012)
•
Britton, J. 2003. The use of emollients and their correct application. Journal of
Community Nursing. 17(9):22-25
•
Best Practice in Emmolient Therapy 2007. A statement for Healthcare
Professionals.Dermatology UK.
•
Elson D.20009. Potassium Permanganate revisited. Leg Ulcer Forum Journal Issue 23
Autumn 2009.
•
European Wound Management Association. 2003. Position Statement – Understanding
compression. Medical Education Partnership.Ltd London.
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Management of Leg Ulceration for Adults Policy
•
Moffatt, C. 2004. Four-layer bandaging: from concept to practice part 1: The
development of the four-layer system. Available from
http://www.worldwidewounds.com/2004/december/Moffatt/Developing-Four-LayerBandaging.html (February 29th 2012)
•
Moffatt, C. 2005. Four-layer bandaging: from concept to practice part 2: Application of
the four-layer system. Available from
http://www.worldwidewounds.com/2005/march/Moffatt/Four-Layer-Bandage-SystemPart2.html (February 29th 2012)
•
Moffatt, C. 2006. Four-layer bandaging: from concept to practice part 3: Evidence base
for treating venous leg ulcers. Available from
http://www.worldwidewounds.com/2006/june/Moffatt/Four-Layer-Bandage-SystemPart3.html (February 29th 2012)
•
Royal College of Nursing. 2006. Clinical Practice Guidelines – The nursing
management of patients with venous leg ulcers. London
•
The National Eczema Society. 1998. Topical Steroids. London.
•
Thomas, S. 1997. Compression bandaging in the treatment of venous leg ulcers
•
World Wide Wounds. http://www.worldwidewounds.com (February 29th 2012).
•
Thomas, S. 2002. The use of Laplace equation in the calculation of sub-bandage
pressure. World Wide Wounds. Available from
http://www.worldwidewounds.com/2003/june/Thomas/Laplace-Bandages.html
(February 29th 2012)
•
Thomas, S. 2003. An evaluation of a new type of compression bandaging system.
Available from http://www.worldwidewounds.com/2003/september/Thomas/NewCompression-Bandage.html February 29th 2012)
•
Vowden, P. and K. Vowden. 2001. Doppler assessment and ABPI: Interpretation in the
management of leg ulceration. Available from
http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-andABPI.html (February 29th 2012)
•
World Union of Wound Healing Societies (WUWHS) Principles of best practice:
Compression in venous leg ulcers. A consensus document. London MEP Ltd 2008.
•
Flanaghan Madeleine. Wound Healing and Skin Integrity. 2013 Wiley-Blackwell.
•
NICE clinical guidance, 2013. Varicose veins in the legs. Available from
http://www.nice.org.uk/guidance/cg168
5.
MONITORING COMPLIANCE
The Tissue Viability Service in conjunction with the Clinical Service Managers will carry out
audit at regular intervals to monitor compliance
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Management of Leg Ulceration for Adults Policy
6.
DISSEMINATION AND IMPLEMENTATION
This policy will be made available on the intranet, and publicised through Contact (the
Trust internal electronic newsletter).
7.
CONSULTATION, APPROVAL, RATIFICATION & REVIEW
Trust Community Nursing Team leaders, Tissue Viability Team and The Infection
Prevention Team have been consulted
The policy will be reviewed 2 yearly
8.
VERSION CONTROL
Record of Changes
Date
Version
12/011/14
6.0
27.11.14
6.1
Changes / Comments
Changes in response to feedback
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Management of Leg Ulceration for Adults Policy
APPENDIX A
Patient label or name
LEG ULCERATION DIFFERENTIAL DIAGNOSIS ASSESSMENT FORM
Date of Assessment
Time of Assessment
Name of Assessor
Signature of Assessor
Date of Birth
ID Number
Medical alert/allergies/hypersensitivities
Venous Risk Factors
Abdominal surgery
Multiple pregnancies (3+)
Sedentary occupation
Pulmonary embolism
Deep vein thrombosis
Thrombophlebitis
Leg/hip/foot fracture
Cellulitis
Leg vein surgery
Previous venous leg ulceration
Venous Signs &
Symptoms
Varicose veins
Pigmentation (staining)
Induration (hardness in skin)
Lipodermatosclerosis
Oedema
Atrophe blanche
Ankle flare
Cellulitis
Palpable pedal pulses
Fixed ankle joint
Itching over varices
Eczema
Ulcer in gaiter area
Aching / heaviness in legs
Warm foot
Random Blood Sugar
Wound swab
YES
R
R
R
R
R
R
NO
L
L
L
L
L
L
R
R
R
R
R
R
YES
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
L
L
L
L
L
L
NO
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
Arterial Risk Factors
Diabetes
Ischaemic heart disease
Myocardial infarction
Transient ischaemic attack
Stroke
Smoker
Angina
Hypertension
Arterial surgery
Rheumatoid arthritis
Intermittent claudication
Peripheral vascular disease
Arterial Signs &
Symptoms
Loss of hair on leg
Muscle wasting
Atrophic / shiny skin
Thickened toe nails
Cool / cold foot
Foot / toes blanche when 
Pain in foot when elevated
Pain relieved when dependent
Red / blue / purple colour
Delayed capillary refill time
Ulcers on toes / foot
Gangrene on toes / foot
Palpable pedal pulses
Oedema
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
Other Investigations
FBC
x-ray
HbA1c
General Assessment Issue
Does the patient go to bed at night?
Is the foot of the bed elevated?
Is the head of the bed elevated?
Does the patient elevate their legs during the day?
Does the patient have to hang legs out of the bed during the night?
Does the patient have mobility issues?
Is the patient able to walk heel to toe (i.e. normal gait)?
Can the patient dorsiflex / planterflex the ankle?
Can the patient circle the ankle?
Page 15 of 32
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YES
NO
R
R
R
R
R
R
R
R
L
L
L
L
YES
R
R
R
R
R
R
R
R
R
R
R
R
R
R
U/E
Other
YES
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
NO
R
R
R
R
R
R
R
R
R
R
R
R
R
R
L
L
L
L
L
L
L
L
L
L
L
L
L
L
NO
Management of Leg Ulceration for Adults Policy
Patient label or name
Date of Assessment
Time of Assessment
Date of Birth
Name of Assessor
Signature of Assessor
ID Number
Arterial Assessment using Doppler Ultrasound
Length of resting prior to procedure
Position during procedure
20 mins
Flat
Locate pulses and record quality of sound
Identify both brachial pulses and two pedal pulses on
each foot (use highest for calculation)
Pulse Name
Brachial Artery
Dorsalis Pedis Artery
Posterior Tibial Artery
Anterior Tibial Artery
Peroneal Artery
Right
Ankle Brachial Pressure Index
(ABPI)
< 5 mins
Upright
Sound =
Triphasic (T); Biphasic (B); Monophasic (M)
Palpable
Y
N
Y
N
Y
N
Y
N
Y
N
Right
15 mins
10 mins
Semi-recumbent
Sound
T
B
T
B
T
B
T
B
T
B
Left
M
M
M
M
M
Palpable
Y
N
Y
N
Y
N
Y
N
Y
N
Sound
T
B
T
B
T
B
T
B
T
B
M
M
M
M
M
Left
Nursing Diagnosis of Leg Ulcer Aetiology
Venous
Arterial
Mixed Venous / Arterial
Other (assess further)
Treatment Decision
Full Compression
Reduced Compression (10
R
L
R
L
No Compression
R
L
(40mmHg)
– 30mmHg)
Ankle circumference
Right cm
Left cm
Limb Measurements for Compression Hosiery
Right Leg
centimetres
Left Leg
centimetres
Length of foot
Length of foot
Ankle circumference (narrow point)
Ankle circumference (narrow point)
Calf circumference (widest point)
Calf circumference (widest point)
Thigh circumference (widest point)
Thigh circumference (widest point)
Back of knee to bottom of heel
Back of knee to bottom of heel
Further Action Needed
For Pulse Oximetry
For referral to Tissue
Viability Specialist
For referral to Vascular
Specialist
For referral to Dermatology
Other Information
Patient information leaflet given
Yes / No
Verbal information given
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Yes / No
Page 16 of 32
Management of Leg Ulceration for Adults Policy
LEG ULCERATION – WOUND ASSESSMENT FORM
Patient label or name
Date of Assessment
Time of Assessment
Date of Birth
Name of Assessor
Signature of Assessor
ID Number
Medial View
Map Position of Ulcers
Posterior View
Anterior View
Lateral View
Left
Leg
Right
Leg
Record description
Sloping/Beached
Rolled over
Deep/Cliff
of ulcer edge
Record condition of
Dry eczema
Wet Eczema
Macerated
surrounding skin
Use generic wound assessment form for details of size, wound tissue, odour, exudate level etc.
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Management of Leg Ulceration for Adults Policy
APPENDIX B
DOPPLER ULTRASOUND PROCEDURE
This procedure must be carried out only by clinical staff that have been trained to
undertake it, have been assessed as competent and have knowledge of how to interpret
the results.
Equipment
•
Couch or bed to enable patient to lie down.
•
Cover any existing wounds with a sterile dressing.
•
Appropriate sized blood pressure cuff, single patient use or disposable advised if used
over a wound and is available.
•
Sphygmomanometer.
•
Ultrasound Gel.
•
Hand-held Doppler.
•
8 mHz probe.
•
5 mHz probe for oedematous limbs.
•
Calculator or ABPI reference chart.
•
Liquid soap and water
•
Disposable latex-free gloves and disposable plastic apron
Use the Doppler ultrasound machine to measure brachial and ankle systolic pressures (do
not use a stethoscope). An 8 mHz probe will be adequate in most circumstances but it
may be necessary to use a 5 mHz probe for those patients with oedematous feet.
Pedal Pulses
The pulses commonly located for ABPI measurement are the dorsalis pedis and the
posterior tibial but either the anterior tibial or the peroneal could be used if the other
two are difficult to locate. It should be noted, however, that the dorsalis pedis and the
anterior tibial are different pulse locations on the same artery.
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Page 18 of 32
Management of Leg Ulceration for Adults Policy
Preparation of the Patient
•
Ensure the patient is lying flat (or as flat as possible) and is rested.
•
If the patient is not able to lie completely flat, elevate the legs to the level of the heart.
•
Explain the purpose of carrying out this procedure and what will be happening to them.
•
Ensure that a full leg ulcer assessment has been carried out to obtain information
about the patient’s medical history, signs and symptoms and presenting factors.
Measure the brachial systolic blood pressure
•
Wash hands with liquid soap and water
•
Put on disposable latex-free gloves and disposable plastic apron if wound present
•
Place an appropriately sized cuff around the upper arm (the bladder part of the cuff
should cover ¾ of the arm circumference).
•
Ensure the equipment and arms are at heart level, with the patient rested and supine.
•
Locate the brachial pulse and apply ultrasound contact gel.
•
Angle the Doppler probe at 45º and move it to obtain the best signal.
•
Inflate the cuff until the signal is abolished; then deflate the cuff slowly and record the
pressure at which the signal returns, being careful not to move the probe from the line
of the artery.
•
Repeat the procedure on the other arm.
•
Use the higher of the two values as the best estimate of central systolic pressure to
calculate the ABPI.
•
Measure the ankle systolic pressure.
•
Place an appropriately sized cuff around the ankle above the malleoli, having first
protected any ulcer or fragile skin that may be present with a sterile dressing.
•
Examine the foot, locate the dorsalis pedis pulse and apply contact gel.
•
Angle the Doppler probe at 45º and move it to obtain the best signal.
•
Inflate the cuff until the signal is abolished; then deflate the cuff slowly and record the
pressure at which the signal returns, being careful not to move the probe from the line
of the artery.
•
Repeat on the posterior tibial artery, and if required, the peroneal and / or anterior
tibial arteries.
•
Use the highest reading obtained to calculate the ABPI for that leg.
•
Repeat on the other leg regardless of where ulcers are located to obtain a complete
picture.
•
Remove protective clothing and wash hands with liquid soap and water
•
Calculating the Ankle Brachial Pressure Index (ABPI).
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Excellent care at the heart of the community
Management of Leg Ulceration for Adults Policy
The ABPI is then calculated by dividing the ankle systolic pressure by the brachial systolic
pressure using a chart or calculator:
ABPI = Highest pressure recorded at the ankle for that leg
Highest brachial pressure obtained for both arms
Interpretation of Doppler readings
•
A ratio of 1.3 or above could indicate arterial calcification (see paragraph below).
National and European guidelines recommend: Do not compress.
•
A ratio of 1.0 indicates normal arterial blood flow, full compression can be applied
safely.
•
A ratio of 0.9 or 0.8 indicates a mild degree of arterial disease, but full compression can
still be applied.
•
A ratio of < 0.8 indicates significant arterial disease. Referral to the Vascular
Department for further investigation is recommended. Do not use compression therapy
unless reduced compression is prescribed by a specialist nurse or medical practitioner.
•
A ratio of 0.5 indicates severe arterial disease. An urgent referral to the Vascular
Department is required. Do not use compression therapy.
Frequency of Reassessment of Ankle Brachial Pressure Index
Ideally it is recommended that the Doppler procedure is repeated for all patients with leg
ulceration at 3 monthly intervals as there is evidence that significant reductions in ABPI
can occur over relatively short periods of time (3-12 months) and ABPI will also fall with
age. However, this standard can be reduced to 6 monthly intervals for those patients who
show no clinical signs of developing or deteriorating arterial disease.
Arterial Calcification
Accurate calculation of ABPI is dependent on the ability to compress the artery with the
cuff during the procedure. If the arteries are calcified they will be rigid and therefore not
compressible. This may give rise to a false high reading. Small vessel arterial disease may
be present and compression therapy may not be appropriate.
Brighton and Hove
Further investigation is indicated and this can be requested via the Non-Invasive Vascular
Laboratory at Royal Sussex County Hospital (664650 or ext. 4084).
West Sussex:
Patients should be referred via their GP to the Vascular Service.
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Page 20 of 32
Management of Leg Ulceration for Adults Policy
Problems and Errors
Problems and errors can arise if:
•
The cuff is repeatedly inflated or inflated for long periods – this can cause the ankle
pressure to fall.
•
The cuff is not placed at the ankle – the pressure recorded may be higher than the true
ankle pressure.
•
The pulse is irregular or the cuff is deflated too rapidly – the true systolic pressure may
be missed.
•
The vessels are calcified, the legs are large, fatty or oedematous, the cuff size is too
small, or the legs are dependent – an inappropriately high reading will be obtained.
Difficult to obtain Doppler readings
On a small number of patients it may not be possible to obtain accurate readings using this
procedure in the patients normal care environment or with the hand-held equipment. In
these cases further investigation is indicated and a referral should be made as below.
Brighton and Hove
Non-Invasive Vascular Laboratory specifying the aetiology as determined from clinical
assessment and the difficulties encountered with the Doppler procedure.
Vascular Assessment Unit – Royal Sussex County Hospital (664650 or ext. 4084).
West Sussex
Referral should be made to the Tissue Viability Service.
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Excellent care at the heart of the community
Management of Leg Ulceration for Adults Policy
APPENDIX C
EXAMPLES OF BANDAGE AND COMPRESSION SYSTEMS ON
BRIGHTON AND HOVE AND WEST SUSSEX WOUND CARE
FORMULARY
1.
Full Compression – 40 mmHg at ankle
Four-Layer Bandage System Ankle measurement 18-25cm
•
K-Four Bandage Kit.
•
K-Soft, K-Lite, K-Plus and Co-Flex.
Two-Layer Bandage Systems
•
K-Two Bandage System –measure ankle circumference to ensure the correct kit is
chosen.
Short-stretch Bandage System Ankle measurement 18-25cm
•
K-Soft/Flexiban and Actico Cohesive (100% tension).
Hosiery System
•
2.
Activa 40 mmHg Hosiery Kit.
Reduced Compression – 17 – 23 mmHg at ankle
•
K-Soft, K-Lite and K-Plus = 17 mmHg pressure at ankle.
•
K-Soft, K-Lite and Ko-Flex – 23 mmHg pressure at ankle.
3.
Retention Bandage – no compression
•
K-Soft and K-Lite –West Sussex.
•
K-Soft and Elastocrepe – Brighton and Hove.
•
K-Soft and Setocrepe – Brighton and Hove.
•
K-Band – West Sussex.
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Page 22 of 32
Management of Leg Ulceration for Adults Policy
APPENDIX D
FINGER TIP UNITS
One finger tip unit is equal to the amount of cream which is placed on the tip of the finger
as illustrated below:-
Please note:
Ungloved hand
for
demonstration
purposes only
Topical Steroids can be helpful to calm irritation and should be used as a treatment over
several weeks with a care plan to reduce the frequency of application to avoid a rebound
effect.
Wash hands/use alcohol gel and apply gloves. Apply patient designated emollient to the
limb and allow this to absorb for a while. Do not use the same pot/tube for multiple
patients. Dispense steroid to a tray or single use spatula and apply three finger tip units
over the lower leg (add 1 finger tip unit if the foot also affected).
Use a moderate potency ointment (e.g. Eumovate™ or Betnovate RD™) daily for 1 week,
alternate days for 1 week, twice weekly for 1 week then once the following week before
discontinuing.
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Excellent care at the heart of the community
Management of Leg Ulceration for Adults Policy
APPENDIX E
ANKLE EXERCISES TO AID LOWER LIMB CIRCULATION
When sitting or lying – flexing the foot.
When sitting or lying – rotating the ankle.
When standing – move up and down on your
toes.
Excellent care at the heart of the community
Page 24 of 32
Equality Analysis
9.
EQUALITY ANALYSIS
The Trust aims to design and implement services, policies & other procedural documents and measures that meet the diverse
needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.
Under the Equality Act 2010, policy or other procedural document authors have a statutory duty to give “due regard” to issues of
race, disability, gender (including transgender), religion or belief, age, sexual orientation and human rights when developing their
policy or other procedural document. This means that policy or other procedural document authors have to assess the potential for
their document to discriminate on any of these grounds. Alternatively, the impact of the policy or other procedural document on
these groups might be positive or the same for everyone.
1 Name of Policy or Service
Management of Leg Ulceration for Adults Policy
2 Service and
Tissue Viability. Adult Services
Directorate
3 Objectives
This document will outline the Trust’s expectations of staff involved in treating
patients with leg ulceration and will offer guidelines on how to approach the
patient’s treatment plan.
What is the purpose of this policy or
service?
Page 25 of 32
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4 Analysis completed By
a) Name
b) Title
Jane Saunders
Tissue Viability Nurse Specialist
5 Does the policy or service have an effect on Staff and/or the Public? (please √)
Staff
Yes

No
Public
Yes

No
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Page 26 of 32
Equality Analysis
Equality law
protects people on
the following
grounds:
Is your policy
or service
relevant to
this area of
equality or
human
rights?
Yes
No
If relevant, is the
effect positive or
negative
Positive
Evidence of the effect
(e.g. statistics, research, surveys, results of
engagement, etc)
Negative
effect
Is further
action
required?
*Yes
No
effect
Age

Disability


Gender (including
pregnancy and
maternity)


Transgender


Race and Ethnicity


Page 27 of 32
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The effect of this policy is the same on all groups

Religion and Belief


Sexual Orientation
(including civil
partnership)


Human Rights


* Complete the following Equality Analysis Action Plan only for equality grounds marked: *Yes further action required.
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Page 28 of 32
Equality Analysis
Equality Analysis Action Plan
Equality
grounds
Does your policy or service:
Any action taken Action to be taken
to date
Target
date
ticked
*Yes
Discriminate?
requiring
further
action:
Page 29 of 32
Eliminate
discrimination
or promote
equality?
Promote
good
relations
between
groups?
Excellent care at the heart of the community
Responsible
Person(s)
Expected
Outcome
(including
monitoring
arrangeme
nts)
Equality Analysis: Equality and Diversity Lead sign off
Signed Jourdan Durairaj (Equality and Diversity Lead)
Date
26 November 2014
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Page 30 of 32
10. RATIFICATION CHECKLIST
Trustwide Clinical Governance Group.
Agenda Item:
The meeting administrator should be able to provide this
Policy Title
Management of Leg Ulceration for Adults Policy
Policy Author
Jane Saunders
Presented By
Purpose
Ratification
Checklist for Ratification
1
Format
Yes
Has the standard SCT template been
used?
2
Comments:
Consultation
Please identify who has been consulted in the writing of this document :Clinical Nurse Mangers Senior
Locality Nurses
Community Nursing Team Leaders Tissue Viability Nurses Infection Prevention team
3
Does the committee agree that the right
people been consulted with?
Yes/No
(please delete)
Comments
Does anybody else need to be consulted
prior to ratification:
No
Please state who:
Approval
Please state the name of the Group that
has approved this document?
Date of Group Approval
Trustwide Clinical Governance Group.
th
Date: 25 November 2014
Page 31 of 32
4
Equality Analysis
Has the Equality Impact Assessment
been completed?
5
Yes
Comments
Review
Please state the timescale for review:
2 yearly
For completion by the Chair of the Committee
Policy Ratified
Yes / No (please delete)
Signature of Chair
(Executive Director)
(Print Name): Dr Richard Quirk – Medical Director / Susan Marshall – Chief Nurse
Additional actions
required for
ratification:
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Page 32 of 32