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Leg ulcers: assessment and management plan

Alison Hopkins
MSc DNCert RGN
Clinical Nurse Specialist
East London Wound Healing Centre
Tower Hamlets PCT
London

Leg ulceration is often quoted as occurring in approximately 1-2% of the population. However, because there are a variety of causes of leg ulceration, it is essential that the aetiology is identified. Not only will this guide the management plan, but a correct and timely assessment aids healing, halts delay and also prevents incorrect or hazardous treatment being applied to the limb. The RCN Guidelines provide an outline of the type of assessment that is required for best practice.(1) Many trusts have developed their own guidelines that utilise this document. It is important for the practitioner to understand that the assessment form is not simply about tick boxes and documentation; it is a process that takes the practitioner through key considerations, thereby guiding them towards a diagnosis. If a diagnosis cannot be made then it is likely that the lesion is either more complex or of mixed ulceration or is of a rarer cause, thus requiring specialist referral.
An in-depth leg ulcer assessment should be completed for all patients who present with a lower leg lesion, not just for those who present with what is thought to be obvious venous ulceration. A systematic and holistic approach may uncover mixed or unusual aetiology, enabling the practitioner to identify specific problems with pain or swelling and helping them to develop a personalised management plan in partnership with the patient. It is also important to note that slow-healing pretibial lacerations, or other traumatic wounds on the lower limb, also benefit from light compression therapy, thereby necessitating a full assessment for all lesions on the lower limb.

Differential diagnosis
It is essential that the cause of the ulcer is identified. An ulcer is simply a nonhealing wound on the lower limb, and the practitioner needs to identify what has either caused it or is stopping it from healing. The two most common reasons for ulceration are venous and arterial disease.
Venous disease is the most prevalent ulcer type and is present in approximately 60% of the ulcer population. Backflow in the venous system produces venous hypertension, which in turn gives rise to skin changes in the gaiter region or above the ankle. Common reasons for this backflow are damage to the venous valves through DVT, obstructing the venous flow through obesity, and simply dependent oedema or armchair legs. For some there is also a familial tendency. Venous hypertension results in changes in the microcirculation and abnormalities in the behaviour of the capillaries and leakage into the skin: red blood cells are broken down, producing the recognisable haemosiderin staining and local irritation, and the presence of oedema, engorged venules and atrophie blanche or thrombosed capillaries. Varicosities may be present. This area of fragile and irritated skin can either spontaneously erode or ulcerate following minor trauma. Typically the venous ulcer will have the following presentation:

  • Always occurs in the gaiter region.
  • Often accompanied by eczema.
  • Larger, superficial but exuding wound bed.
  • Can be sloughy but not necrotic, and never involves underlying structures such as tendons.
  • Pain can be severe but is often reduced with elevation and compression therapy.

Arterial disease is present in approximately 15-20% of lower limb ulcers, but pure arterial ulcers are less common. It is because of the number of mixed aetiology ulcers, and the need to prevent applying hazardous compression therapy, that the role of the ankle brachial pressure index is so important and integral to leg ulcer assessment. Ischaemia is caused by either a blockage or peripheral arterial disease, constricting the arterioles from atherosclerosis. Arterial blood flow is reduced, producing a slow or nonhealing environment for the lesion due to the depletion of oxygen and nutrients. Ischaemic ulcers generally occur over bony prominences or anywhere over the foot or ankle that is prone to trauma. The limb may be cool to the touch and have a dusky or cyanosed appearance. See Box 1 for presentations of typical arterial ulcers.

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Problems occur when a patient has a mixture of symptoms, having venous disease with an element of arterial disease, or in effect a "mixed ulcer". The practitioner then needs to decide, often with specialist support, whether the arterial disease is significant enough to prevent the treatment of the venous disease with compression therapy. This needs to be done on a case-by-case basis.

Leg ulcer assessment
The leg ulcer assessment should encourage a systematic approach to the investigation of cause. The following information needs to be ascertained:

  • History of ulceration: date and cause of onset, treatment so far, previous episodes and treatment.
  • Presence of swelling: duration, reduction overnight, family history.
  • Description of pain: when, where, what is required to control it.
  • Skin changes that point to either venous or ischaemic changes.
  • Signs of infection or eczema.
  • Description of the wound bed, photograph or measurements.
  • Medical history: previous stroke, heart disease, obesity, leg fractures, arthritis and ankle mobility, diabetes, smoking history, allergies, venous history such as known DVT, phlebitis and surgery for varicose veins.
  • Social aspects: whether they sleep in a bed or have dependent limbs, any problems with odour, social isolation and what the patient actually believes will heal the wound.

The role of the Doppler
The Doppler is now familiar to the majority of community nurses and has an indispensable role in leg ulcer assessment. The handheld portable Doppler ultrasound is a noninvasive method to assess the main arteries of the lower leg carried out using a strict protocol.(2) The ankle brachial pressure index (ABPI) is a ratio that provides a comparison of the brachial and pedal systolic pressures. Unfortunately there is a misconception that its use helps diagnose the cause of the ulcer; it does not.
The Doppler is a tool in the assessment process that can determine whether there is any arterial disease present, thus preventing the hazardous application of compression therapy. A malignant ulcer will still be malignant regardless of the presence of ischaemia. Key facts to remember are:

  • Simply palpating pulses is not sufficient.
  • The Doppler does not diagnose the cause of the ulcer.
  • The Doppler assesses main arteries only, thus can be a problem for diabetics who may have microvascular disease.
  • The Doppler is utilised to guide treatment of venous or mixed ulcers.
  • 0.8-1.3 high compression can be applied.3
  • 0.5-0.8 light compression may be applied with specialist advice.(3)

It is essential that practitioners are taught how to utilise the Doppler ultrasound and are competent in its use; if the results are incorrectly interpreted the subsequent management is likely to be wrong. It is good practice to assess both legs for baseline and comparison.

Pain
The presence of pain can be significant for all types of ulceration, and it is often undertreated.(4) Many qualitative studies reveal insight into the devastating impact on the patient's life of unresolved pain, and this must be addressed boldly.(5) For those with venous ulcers, uncontrolled pain can prevent the patient accepting compression therapy, thereby preventing healing and producing more pain and so on. Often morphine sulphate is required in the initial phases to enable the patient to tolerate the treatment. Addiction is not a problem, and this analgesia is automatically reduced as the ulcer heals. For those with longstanding and unresolved pain, extreme sensitivity at the ulcer and surrounding skin can be a problem not readily believed by practitioners. Understanding more about the physiology of pain could make an impact on both the ulcer pain and the patient's quality of life.(6) It is clear that pain can be complex in both nature and whether it is pointing towards an aetiology. As a rule of thumb, pain at night or on elevation may point to an ischaemic cause, but sometimes people experience more pain when they have fewer distractions such as in bed. Thus a careful appraisal needs to be carried out in conjunction with limb assessment and psychosocial issues.
 
Treating the cause of the ulceration
Do not assume that a previous diagnosis is the cause of the present ulceration. Many practitioners have been caught out this way. A classic mistake would be to assume that a recurrent venous ulcer requires the high compression therapy that healed it previously, yet the increasing heart disease or effects of smoking over the intervening years has reduced their ABPI, rendering high compression a hazard. Again, this shows the importance of a new assessment at each episode, looking at their symptoms with fresh eyes.

Diagnosis guides treatment
The diagnosis of the ulcer can now guide the treatment plan. For the majority of ulcers this can be fairly straightforward. Venous ulcers caused by venous hypertension need this reversing through the provision of compression therapy. This was discussed in depth in the previous article in this series. Simply put, if compression is not being applied to a venous ulcer then they are not being treated.
Dressing choice is usually a simple nonadherent that allows the exudate to come through the dressing into the sub-bandage wadding. If more absorption is required due to excessive exudate, then a hydrofibre dressing may be required. However, it is important to check that the limb is getting the required compression; a larger limb requires higher compression therapy to heal and reduce oedema (always refer to manufacturer guidelines regarding their product), and thus a different compression bandage or regime may be required.
For the arterial or ischaemic ulcer the patient needs to be referred to a vascular surgeon to ascertain whether anything can be done to increase the blood flow to the limb, angioplasty being the most common procedure. The choice of dressing will be based on ulcer pain, wound bed type and exudate.

Partnership
A holistic assessment will also enable the practitioner to pick up other factors that will influence the choice of therapy and aid acceptance of treatment, such as attending to pain, fear, problems with footwear or previous difficulties with compression therapy. Through careful listening to the patient's concerns, many problems can be alleviated. Partnership in care will then be encouraged through sensitivity and acknowledgement of their experience and expertise.

Importance of skin care
It is important not to forget the importance of good skincare. Legs under dressings and bandages can become very dry and irritated. Add venous disease and eczema to this and the irritation can actually prevent people from tolerating the treatment. Thus it is considered best practice now to soak the limb in warm water with an emollient; this will cleanse the wound and leg, softening the dry skin and allowing easy removal. Then the leg must be moisturised with aqueous or white soft/liquid paraffin mix. Eczema needs to be treated with topical steroids such as betnovate or stronger. If recurrence is a problem then referral for patch testing is required.

Referral for specialist advice
A holistic leg ulcer assessment should guide the practitioner towards a diagnosis. If there are any anomalies with regard to site, excessive pain or appearance, or it simply fails to heal with the correct management, then referral for advice is necessary.
If the patient cannot tolerate compression therapy, do not assume nothing better can be done. There are a variety of compression therapies that can be tried, so do refer on for help. There are also two-layer compression hosiery kits available that are helping those with smaller ulcers who prefer to self-manage. These provide class 3 compression but are easier to apply due to the liner sock and offer real benefits to some patients.(7)
 
Prevention of recurrence
As usual this section is at the end of the article, but that must not detract from the prevention programme being an integral part of management. Recurrence of venous ulceration is extremely high, and practitioners need to plan their care to reduce this. Compression hosiery is the mainstay of treatment, but it is often poorly tolerated by the patient. This can also be a competency issue for practitioners; increased knowledge about options, variety of hosiery and hosiery aids will mean better tolerance of lifelong hosiery. A recent best-practice statement on compression hosiery by Wounds UK has laid out essential practice that should increase use.(8) Hosiery can be difficult to use and difficult to supply for a variety of complex reasons. Again refer on for specialist advice, because if compression therapy does not continue once the venous ulcer has healed you will be seeing them again for recurrence in the near future.
This article has demonstrated how assessment and management are linked. It is therefore essential for practitioners to be trained if evidence-based care is to be provided. If you do not believe you are adequately competent to manage patients on your caseload, you need to ensure that training is part of your professional development plan. In order to promote development of practitioners and a consistent approach to care, the RCN guidelines recommend that certain elements be part of an education package (see Box 2).(1)

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References

  1. Cullum N, et al. Clinical practice guidelines: the management of patients with venous leg ulcers. London: RCN Institute; 1998.
  2. Vowden KR, Vowden P. Br J Community Nurs 2001;6(9):4-11.
  3. Calne S, editor. Position statement in: Understanding compression therapy. London: MEP; 2003.
  4. Briggs S. Prof Nurse 2005;20(6):39-41.
  5. Krasner D. J Wound Ostomy Cont Nurses 1998;25:158-68.
  6. Principles of best practice: minimising pain at wound dressing-related procedures. A consensus document. London: MEP; 2004.
  7. Hampton S. Br J Community Nurs 2003;8(6):279-83.
  8. Wounds UK. Best practice statement: Compression hosiery. Available from URL: http://www.wounds-uk.com/downloads/compression_hosiery_statement.pdf