Venous Leg Ulcers: Applying best practice into

the clinical setting

Cathy Hammond

Session 1A

The Impact

• Quality of life

• Pain

• Loss of earnings

• Visits to clinics

• Time/waiting

• Isolation

• Reduced mobility

• Community support

Heinen, M., Persoon, A., van de Kerkhol, P., Otero, M. & van Achterberg. (2006). Ulcer-related problems and health care needs in patients with venous leg ulceration: A descriptive, cross-sectional study. International Journal of Nursing Studies.44. 1296-1303

The Impact

• Dressings and bandages

• Nursing time

• Doctors time

• Medication costs

• Financial support eg W&I

• Admissions to hospital

EWMA Position Document: Hard-to-heal wounds: a holistic approach.London. MEP Ltd. 2008.

Leg Ulcer Prevalence

• Australia - 3 per 1000 adult population • NZ - 2.48 per 1000 adult population • Risk increases over the age of 65 • Venous leg ulcer recurrence between 22-69% • 80% venous ulcers

• Majority managed in community • 50% Community Nurses practice

Trans-Tasman Collaboration

• Increase awareness

• Optimize prevention, assessment, management

• Dissemination best practice

• Simplify clinical decision making

Australian and New Zealand clinical Practice Guideline for the Prevention and Management of Venous Ulcers. 2011

Evidence based guideline

www.nzwcs.org.nz

Guideline Development Process

• National Health & Medical Research Council • Endorsed by NZGG • Robust process • Grading of evidence A,B,C,D and CBE • Practice points • Lack of evidence not lack of effect • Further reading: Barker, J (2010) Developing

clinical practice guidelines for prevention and management of venous leg ulcers. Wound Practice and Research, 18(2), 62-71

National Health and Medical research Council. How to put the evidence into practice: Implementation and dissemination strategies. Canberra. 2000

Preventing Initial Occurrence VLU

• DVT prophylaxis

• Early detection & management DVT

• Access venous & phlebology intervention

• Compression hosiery

Assessment: History

VLU risk – familial, DVT/PE, leg trauma, ↓ mobility, VV’s, obesity, multiple pregnancies

Ulcer history - duration, past treatment, recurrence

Nutrition - nutritional intake, BMI, weight changes

Assessment: History

Pain assessment

Mobility – foot/calf muscle pump

Psychosocial/QoL - impact to patient

Examination

• Skin changes

• Ulcer location

• Ulcer characteristics

• Surrounding skin

• Pulses

CEAP Clinical Classification assessing venous disease

CEAP Clinical Eitiology, Anatomy, Physioloy

C0 No sign of venous disease

C1 Telangiectasias (spider veins) or reticular veins (small dilated torturous veins)

C2 Varicose veins

C3 Presence of oedema

C4a Eczema or pigmentation

C4b Lipodermatosclerosis or atrophie blanche

C5 Evidence of a healed venous leg ulcer

C6 Active venous leg ulcer

Antignaini, P. (2009). The CEAP classification and its evolution. EWMA Journal, 9(1), 19-24.

Investigations

• Blood pressure

• ABPI

• TBPI

• Duplex ultrasound

• Blood screen

• Microbiology

• 10gram monofilament screen

When to Refer to a Specialist

• Diagnostic uncertainty • Atypical ulcer characteristics/location • Suspicion of malignancy • Treatment underlying condition eg vasculitis • ABPI ↓0.8 or ↑1.2 • Failed to heal in 12/52 despite compression • Recurrence • Antibiotic-resistant ulcers • Uncontrolled pain • Unresolved eczema

Patient Education Provide appropriate education on condition/management

• Explanation

• Informed choice

• Consistent message

• Regular reinforcement

Psychological Support Psychological support an essential component

• Include patient in developing plan of care

• Information on progress

• QoL scales may be used

Exercise Progressive resistance exercise improve calf function

• Weight bearing foot and ankle exercises

• Gait analysis

• Consider referral to physiotherapy

• Elevation level of heart when sitting

Prepare the Ulcer

• Cleanse leg and ulcer

• Debridement

• Use TIME framework

Manage Surrounding Skin Treat eczema/impaired skin promptly

• Differentiate eczema, sensitivity, infection

• Barrier preparations

• Topical steroids

• Zinc impregnated bandages

Antimicrobial Treatment

• Cadexomer iodine

• Topical silver

• Topical honey

• Other topical antimicrobials

• Topical antibiotics

• Systemic antibiotics

Compression Therapy when no contraindications apply compression therapy to promote healing in VLU (Grade B)

Considerations:

• Shape and size leg

• Patient tolerance

• Clinician experience

• Environment

• Application/removal

• Access

• Other co-morbidities

• Patient activity

• Cost

Inappropriate compression hosiery can result

in damage and possible amputation

Achilles tendon

Tibial crest

Ankle joint

Compression Hosiery

Nelson, E., Bell-Sayer, S. & Cullum, N. (2000). Compression for preventing recurrence of venous ulcers. (Review). The Cochrance Database of Systematic Reviews, Issue 4.

Patient education is crucial to compliance and effectively wearing hosiery

Monitor Progress

• Reduce by ≥ 25% in 4 weeks

• Heal within 12 weeks

• Comfort and tolerance

• Maintaining their plan of care

• Identify and manage issues

Flow Chart Assessment and Management

Patient Information

NZ Implementation Strategy

• Venous Leg Ulcer Advisory Group

• Strategic leadership in the implementation of the guidelines

• Multidisciplinary representation

• Publications

• Education

• Leg Ulcer Pathway

Kaikoura Rural Wound Clinic

References Antignaini, P. (2009). The CEAP classification and its evolution. EWMA Journal, 9(1), 19-24. Australian and New Zealand clinical Practice Guideline for the Prevention and Management of Venous Ulcers. 2011 Barker, J (2010) Developing clinical practice guidelines for prevention and management of venous leg ulcers. Wound

Practice and Research, 18(2), 62-71 EWMA Position Document: Hard-to-heal wounds: a holistic approach.London. MEP Ltd. 2008. Heinen, M., Persoon, A., van de Kerkhol, P., Otero, M. & van Achterberg. (2006). Ulcer-related problems and health care

needs in patients with venous leg ulceration: A descriptive, cross-sectional study. International Journal of Nursing Studies.44. 1296-1303

National Health and Medical research Council. How to put the evidence into practice: Implementation and

dissemination strategies. Canberra. 2000 Nelson, E., Bell-Sayer, S. & Cullum, N. (2000). Compression for preventing recurrence of venous ulcers. (Review). The

Cochrance Database of Systematic Reviews, Issue 4. Nelson E, Cullum N & Jones J. Wenous leg ulcers. British Medical Journal (Clinical Research Edition) 2006;172(11):1447-

1452. Walker N, Vandal A, Holden J et al. Does capture-recapture analysis provide more reliable estimates at the incidence

and prevalence of leg ulcers in the community. Australia and New Zealand Journal of Public Health 2002;26:451-5