1. Clients with Leg Ulcers
DECISION MAKING
Clients with Leg Ulcers

2. Learning Outcomes
Gain an overview of the aetiology of lower limb ulceration.
Be able to recognise signs and symptoms of lower limb wounds.
Understand how the assessment and treatment of leg ulcers fits into the decision reasoning cycle.
To consider the patient’s perspective in concordance with treatment.

3. Epidemiology
Up to 1% of adults will suffer from leg ulceration increases to 5% over 65 years of age. (O’Meara et al, 2009)
On any day between 70,000 and 190,000 people may have an active leg ulcer in the UK.
In one UK study 27% of patients had had continuous ulceration for two years or more
(Posnett and Franks, 2008)
Consider up to five years to heal, recurrence, are these figures up to date??

4. Epidemiology 2
46% of patients have a recurrence of between episodes
The cost to the NHS of treating patients with venous ulceration, mostly in primary care and through community nursing services, is at least £168–198m per year (Posnett and Franks, 2008)

5. Aetiology of Ulceration
Venous disease 70%
Arterial disease 20%
Mixed aetiology %
Rheumatoid disease 9%
Diabetes 5%
(Burns, infections, blood disease, lymphoedema)
(SIGN Guidelines, 2010)

6. Venous blood supply

7. Role of valves in veins

8. Role of calf / foot pumps
Venous pumping system consists of muscle, distal calf pump and foot pump
The muscle has three compartments and activates most of pump system.
Distal calf pump is activated by dorsi-flexion of the ankle when calf muscles are stretched to full capacity- this propels blood proximally.
The foot pump is independent of muscular movements.
During normal walking, these three systems work together in a synchronised way

9. Venous return

10. Venous hypertension

11. Venous hypertension Fibrin cuff theory (Browse and Burnand, 1982)
White cell trapping theory (Coleridge- Smith et al, 1988)
Growth factor ‘trap’ theory (Higley et al, 1995)
Ischaemia-reperfusion injury (He et al, 1997)

12. Signs of venous hypertension
Varicose veins
Staining of the gaiter area
Ankle flare
Atrophy of the skin
Atrophy blanche
Eczema
Inverted champagne bottle shaped leg
Lipodermatosclerosis

13. Signs of venous hypertension

14. Signs of venous hypertension 2

15. Aetiology of leg ulceration 2
Arterial ulcers are a result of tissue ischaemia
Pyoderma gangrenosum
Unknown aetiology starts as small blisters or papules, then rapidly progresses to ulcerated areas. 50% associated with other conditions. Treated with steriods and anti-inflammatories. Often cured but may reoccur. Vary rare.

16. Aetiology of leg ulceration 3
Diabetic ulcers are a result of an interplay between peripheral neuropathy, peripheral vascular insufficiency, and musculoskeletal alterations. (Roberts and Newton, 2011)
Sensory neuropathy
reduced or absent pain, results in unnoticed trauma

17. Aetiology of leg ulceration 4
Motor neuropathy
foot deformities
a changed gait
prolonged pressure
Autonomic neuropathy
absence of sweating
results in dry cracked skin
increases risk of infection

18. Diabetic foot ulcers

19. Aetiology of leg ulceration 5
Rheumatoid arthritis-vasculitis
Burns – sitting too close to a fire
Infections and blood disorders
Lacerations to the lower limb
Pretibial laceration
Rheumatoid ulcers are often associated with high level of rheumatoid factors. Sometimes difficult to diagnose due to mixed aetiology. However do not respond well to antinflammatories
Infections such as TB, leprosy, and sickle cell and thalassaemia

20. Aetiology of leg ulceration 6
Lymphoedema
The lymphatic vessels are damaged in chronic venous hypertension.
Predisposition to recurrent episodes of cellulitis
The evidence seems to suggest Venous and lymphatic insufficiency seem to co-exist in some way.
Lymphoedema complicates healing but venous insufficiency damages local blood vessels.
Lymphoedema is defined as an oedema that has been present for over 3 months and does not reduce on elevation.

21. Aetiology of leg ulceration 8
Malignant disease
Can develop in a chronic ulcer
Malignant melanoma
Karposi’s sarcoma
Iatrogenic ulcers
Removal of adhered dressings
Necrosis due to tight bandaging

22. Clinical Reasoning Cycle
Consider Patient
Collects info & cues
Process info
Identify problems/issues
Establishes goals
Take action
Evaluate outcomes
Reflect on process

23. Assessment of clients with a leg ulcer –collecting information
Holistic
Physical, psychological and social history of the patient
Assessment of the limb
Assessment of the ulcer

24. HIERARCHICAL APPROACH TO SKIN ASSESSMENT
DIAGNOSIS
Solution, evaluation. Knowledge transfer
SMELL Subconscious information gathering
TOUCHING
Hands on fact finding
Madeleine Flanagan- Wound healing and skin integrity
LISTENING – Have a conversation- including patients perspective, develop rapport
PATIENTS GENERAL APPEARANCE AND OVERALL SKIN CONDITION
TOUCHING- Skin temperature, moisture, texture, oedema, reactive hyperaemia, sensitivity to pain, neuropathy
SMELL – an undervalued sense!! Poor personal hygiene, Urine, faeces, infection, exudate, necrosis, malignancy.
LOOKING
Problem clarification
LISTENING
Problem orientation

25. Assessment of the client
Past Medical History
Risk factors
Social situation
Understanding
Nutrition
Assessment of the client
Lifestyle
Drug Therapy
Risk factors, DVTs and other LT conditions such as cardiovascular disease,stroke, MI, Diabetes
Nutrition: consider protein loss, vitamin and calorie intake, high cholesterol
Drug Therapy importance of long term meds such as Steroids, warfarin…. Indication of other conditions
Allergies can influence your decision making with respect to dressings bandages etc
Smoking/Alcohol raise incidence of atherosclerosis, particularly if diabetic. It is the key risk factor for arterial disease.
Body Image Has this been concealed for months/years. Are they embarrassed? What does it mean for them? Will focus your treatment choices. This ties in with Lifestyle
Understanding patients are often experts, but not always fully informed of what they can do to help themselves-what is the worst part for them?
Social: Housing, social and income, support network and services
Body Image
Smoking Alcohol
Allergies

26. Clinical examination-collecting info and cues
(Body Mass Index)
Bloods for: Hb
WBC
C Reactive Protein
U & E’s
Lipids
Protein levels
Temperature
Pulse
Blood pressure
Urinalysis
BG reading
General assessment points to help narrow and focus your diagnosis.

27. Assessment of the limb Colour Temperature Sensation Oedema Foot pulses
Capillary return
Ankle flare
Atrophy blanche
Varicose veins
Induration
Toenails
Hair growth
Shape of the limb - measure
Presence of lipodermatosclerosis
Ankle movement
Condition of skin
Pain

28. Assessment of the limb 2

29. Assessment continued Use of Doppler ultrasound
To ascertain the arterial blood supply to the limb
Locate foot pulses
Listen to arterial sounds
Obtain an Ankle Brachial Pressure
Index

30. Ankle Brachial Pressure Index (ABPI)
Highest ankle systolic blood pressure
Highest brachial systolic blood pressure
Normal >0.9
Some arterial insufficiency >0.5 - <0.9
Severe arterial problem <0.5

31. Assessment of the ulcer
Site
Size
Edges of ulcer
Present ulcer history
Type of tissue
Exudate
Odour
Colonised / infected
Surrounding skin
Pain
Process info

32. Assessment of the ulcer 2

33. Aims of nursing management -establishing goals
Treat the underlying cause
reverse venous hypertension
arterial surgery
control lymphoedema
Provide a wound environment which promotes healthy granulation tissue

34. Nursing management-taking action
Prevent secondary infection
Control oedema
Control excessive exudate
Prevent further skin damage
Control pain
Control odour
Provide a socially and psychologically acceptable treatment
Prevent recurrence

35. Compression therapy Short stretch (inelastic) bandages
Long stretch (elastic) bandages
Multi-layer bandages
Compression hosiery
Really important to measure and obtain correct size of bandages

36. Laplace’s Law
Graduated compression is achieved by the following: P = N x T C x W
P = Pressure exerted by the bandage
N = Number of layers of bandage
T = Tension of bandage
C = Circumference of limb
W = Width of the bandage

37. Bandages

38. Compression hosiery Class I 14 – 17 mmHg Class II 18 – 24 mmHg
Class III 25 – 35 mmHg

39. Patient’s perspective
“…. It is therefore nonsensical to describe a patient as ‘non-concordant’ when describing the behaviour of an individual, as the patient does not exist in isolation, but rather it is the patient’s relationship and the interaction with the clinician that should be defined as concordant/non-concordant” (Brown, 2014)
Shift from terms of compliance, adherence and concordance

40. Reasons for non-concordance in leg ulcer treatments
Compression stockings
Footwear
Odour (McNichol, 2014)
Pain/discomfort
Lifestyle choices (work/personal hygiene)
Restrictions to mobility
Bandages can initially increase pain levels but will diminish if patient perseveres.

41. How can we help?
Reassurance that pain will diminish and advise analgesia.
Shared decision making about treatment options. Is self-management an issue?
Do the patient’s have the capacity to make safe decisions?
Ensuring continuity of care increasing confidence.
Patient education: what their condition is, exercises, rest, guidance post healing (skin care, suitable footwear, vigilance)
General health advice (weight, diet, smoking)
Think about how we give advice, verbal, written, leaflets with pictures.

42. Remember!!
To agree a regime through a shared process of decision making
Listen to patient’s fears, concerns and health beliefs, respect choices.
Choose therapies that improve quality of life that are tolerable, offer choices where possible.
Find solutions that meet lifestyle needs and build trust with patients.

43. References
Brown, A. (2014) Two-component compression: Concordance, evidence and clinical use. Wounds UK. Supplement. p1-5.
Coull, A. (2013) Self-management of leg ulceration using a compression hosiery kit: considerations for service delivery. British Journal of Community Nursing (Suppl) 18. S9 s23-28
McNichol, E. (2014) Involving patients with leg ulcers in developing innovations in treatment and management strategies. Community Woundcare Supplement. s27-32
O’ Meara, S., Cullum, N.A and Nelson, A. (2009) The role of the Public Health Nurse in a Changing Soceity. Journal of Advanced Nursing p

44. References
Posnett, J. and Franks, P. (2008). The Burden of Chronic Wounds in the UK. Nursing Times p44-45
Roberts, P and Newton, V (2011) Assessment and Management of diabetic foot ulcers. British Journal of Community Nursing p
SIGN (2010) Management of chronic venous leg ulcers.
A national clinical guideline. SIGN :Edinburgh