Assessment and Management of Venous Leg Ulcers

Recommendation 1: Assessment and clinical investigations should be undertaken by healthcare professional(s) trained and experienced in leg ulcer management. 

Recommendation 2: A comprehensive clinical history and physical examination includes: 

• blood pressure measurement; 
• weight; 
• blood glucose level; 
• doppler measurement of Ankle Brachial Pressure Index (ABPI); 
• any other tests relevant to presenting patient’s condition;
• ulcer history; 
• ulcer treatment history; 
• medical history; 
• medication;
• bilateral limb assessment; 
• pain; 
• nutrition; 
• allergies; 
• psychosocial status (including quality of life); and 
• functional, cognitive, emotional status and ability for self-care. 

The above should be documented in a structured format for a client presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.

Recommendation 3: A comprehensive assessment of an ulcer should include:

• measurement of the wound and undermining; 
• amount and quality of exudate; 
• wound bed appearance; 
• condition of the wound edge; 
• infection; 
• presence or absence of patient suffering; and
• re-evaluation. 

Measure the surface areas of ulcers, at regular intervals, to monitor progress. Maximum length and width, or tracings onto a transparency are useful methods.

Recommendation 4: Regular ulcer assessment is essential to monitor treatment effectiveness and healing goals.

Recommendation 5: An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy.

Recommendation 6: An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment. 

Recommendation 7: Prior to debridement, vascular assessment, such as Ankle Brachial Pressure Index (ABPI), is recommended for ulcers in lower extremities to rule out vascular compromise and ensure healability.

Recommendation 8: Pain may be a feature of both venous and arterial disease, and should be addressed.

Recommendation 9: Prevent or manage pain associated with debridement. Consult with a physician and pharmacist as needed.

Recommendation 10: Develop treatment goals mutually agreed upon by the patient and healthcare professionals, based on clinical findings, current evidence, expert opinion and patient preference.

Recommendation 11: Local wound bed preparation includes debridement when appropriate, moisture balance and bacterial balance.

Recommendation 12: Cleansing of the ulcer should be kept simple; warm tap water or saline is usually sufficient.

Recommendation 13: First-line and uncomplicated dressings must be simple, low adherent, acceptable to the client and should be cost-effective.

Recommendation 14: Avoid products that are known to cause skin sensitivity, such as those containing lanolin, phenol alcohol, or some topical antibiotic and antibacterial preparations.

Recommendation 15: Choose a dressing that optimizes the wound environment and patient tolerance.

Recommendation 16: No specific dressing has been demonstrated to encourage ulcer healing.

Recommendation 17: In contrast to drying out, moist wound conditions allow optimal cell migration, proliferation, differentiation and neovascularization.

Recommendation 18: Refer clients with suspected sensitivity reactions to a dermatologist for patch testing. Following patch testing, identified allergens must be avoided, and medical advice on treatment should be sought.

Recommendation 19: Venous surgery followed by graduated compression hosiery is an option for consideration in clients with superficial venous insufficiency.

Recommendation 20: Assess for signs and symptoms of infection.

Recommendation 21: Manage wound infection with cleansing and debridement, as appropriate. Where there is evidence of cellulitis, treatment of infection involves systemic antibiotics.

Recommendation 22: The use of topical antiseptics to reduce bacteria in wound tissue should be reserved for situations in which concern for bacterial load is higher than that of healability.

Recommendation 23: The treatment of choice for venous ulceration uncomplicated by other factors is graduated compression bandaging, properly applied and combined with exercise. 

• In venous ulceration, high compression achieves better healing than low compression
• Compression bandages should only be applied by a suitably trained and experienced practitioner. 
• The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting compression stockings. 
• Ankle circumference should be measured at a distance of 2.5 cm (one inch) above the medial malleolus. 

Recommendation 24: External compression applied using various forms of pneumatic compression pumps can be indicated for individuals with chronic venous insufficiency.

Recommendation 25: The client should be prescribed regular vascular exercise by means of intensive controlled walking and exercises to improve the function of the ankle joint and calf muscle pump.

Recommendation 26: Consider electrical stimulation in the treatment of venous leg ulcers.

Recommendation 27: Therapeutic ultrasound may be used to reduce the size of chronic venous ulcers.

Recommendation 28: If signs of healing are not evident, a comprehensive assessment and re-evaluation of the treatment plan should be carried out at three month intervals, or sooner if clinical condition deteriorates.

Recommendation 29: For resolving and healing venous leg ulcers, routine assessment at six-month intervals should include: 

• physical assessment; 
• Ankle Brachial Pressure Index (ABPI); 
• replacement of compression stockings; and 
• reinforcement of teaching.

Recommendation 30: Inform the client of measures to prevent recurrence after healing: 

• daily wear of compression stockings, cared for as per manufacturer’s instructions and replaced at a minimum every six months; 
• discouragement of self-treatment with over-the-counter preparations; 
• avoidance of accidents or trauma to legs; 
• rest periods throughout the day with elevation of affected limb above level of heart; 
• early referral at first sign of skin breakdown or trauma to limb; 
• need for exercise and ankle-joint mobility; 
• appropriate skin care avoiding sensitizing products; and 
• compression therapy for life with reassessment based on symptoms.

Recommendation 31: Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by an ongoing education and training program.

Recommendation 32: Using principles of adult learning, present information at an appropriate level for the target audience, including healthcare providers, clients, family members and caregivers.

Recommendation 33: All healthcare professionals who manage lower limb ulcers should be trained in leg ulcer assessment and management.

Recommendation 34: Design, develop, and implement educational programs that reflect a continuum of care. The program should begin with a structured, comprehensive, and organized approach to prevention and should culminate in effective treatment protocols that promote healing as well as prevent recurrence.

Recommendation 35: Education programs for healthcare professionals who manage lower limb ulcers should include:

• pathophysiology of leg ulceration;
• leg ulcer assessment; 
• need for Doppler ultrasound to measure Ankle Brachial Pressure Index (ABPI); 
• normal and abnormal wound healing; 
• compression therapy theory, management, and application; 
• dressing selection; 
• principles of debridement; 
• principles of cleansing and infection control; 
• skin care of the lower leg;
• peri-wound skin care and management;
• psychological impact of venous stasis disease;
• quality of life; 
• pain management; 
• teaching and support for care provider; 
• health education; 
• preventing recurrence; 
• principles of nutritional support with regard to tissue integrity; 
• mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress; and 
• criteria for referral for specialized assessment.

Recommendation 36: Healthcare professionals with recognized training in leg ulcer care should mentor and transfer their knowledge and skills to local healthcare teams.

Recommendation 37: The knowledge and understanding of the healthcare professional is a major factor in adherence to treatment regimens.

Recommendation 38: Successful implementation of a venous ulcer treatment policy/strategy requires: 

• dedicated funding 
• integration of healthcare services 
• support from all levels of government 
• management support 
• human resources 
• financial resources 
• functional space 
• commitment 
• collection of baseline information about vulnerable populations 
• resources and existing knowledge 
• interpretation of above data and identification of organizational problems.

Recommendation 39: Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

• An assessment of organizational readiness and barriers to education. 
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. 
• Dedication of a qualified individual to provide the support needed for the education and implementation process. 
• Ongoing opportunities for discussion and education to reinforce the importance of best practices. 
• Opportunities for reflection on personal and organizational experience in implementing guidelines.