Practice development Top tips for managing venous leg ulcers
presence of arterial disease. This involves measuring the blood flow in the arteries of the lower leg compared to that in the upper arm and is recorded as the ankle brachial pressure index (ABPI). In the absence of arterial disease, the systolic blood pressure should be equal to or exceed that in the arm, giving an ABPI of at least 1[5]
.
Anyone undertaking this procedure should be suitably trained in the technique as management regimens are often based on ABPI results, although not in isolation from risk and skin assessments.
5
Ulcer management: There is no evidence to support the superiority of any
dressing type over another when applied under compression bandaging[6]
,therefore,
it is recommended that, where possible, a simple non-adherent dressing should be used. Remember that it is the treatment of the underlying cause through the use of compression therapy that will ultimately heal the leg ulcer. If the ulcer is clinically infected then appropriate antimicrobial dressings may be of benefit in the short term and if the wound is highly exuding, more absorbent dressings or an increase in the frequency of dressing change would prevent the skin from becoming macerated. Attention should be given to the causes of the symptoms in the first instance.
6
Elastic compression therapy: The mainstay of venous leg ulcer treatment is compression
therapy, which aims to reverse venous hypertension. This can be achieved through the application of compression bandages or hosiery. Elastic or long-stretch bandages, of which the four-layer system is an example, provide a pressure profile of between 35– 40mmHg at the ankle. This pressure can be sustained for a week as the bandages have an ability to accommodate changes in limb shape and movement[7]
. It is important to measure
the ankle circumference prior to bandage selection and most bandages are developed to apply the correct amount of pressure for an ankle circumference between 18–25cm[8] Training is required before applying multi-
.
layered compression bandages, both in the theory of compression therapy and its practical application. The shape and size of the limb are important factors in achieving the appropriate compression levels to heal venous ulcers. Bandages that are inappropriately applied can lead to pressure necrosis, skin breakdown
and increased pain if too tight, and slow ulcer healing if the pressure is too light. Competence can be improved and maintained through practising the technique repeatedly on willing subjects. Some patients find that applying four-layers of bandages is not practical because they cannot wear their normal shoes, therefore, staff should be mindful of this when making a bandage selection.
7
Inelastic compression therapy: These type of bandages are known as short-stretch and,
as such, have little extensibility, forming a tube around the leg rather than a graduated compression from the ankle to the knee. Pressure is exerted against the bandage when the leg or foot is exercised through movement of the calf muscle and the pressures can range between 30–60mmHg. Low resting pressures and high working pressures are achieved using this system and, therefore, are suitable for patients with mixed aetiology ulceration and chronic oedema, under supervision. Many staff find short-stretch bandages easier to apply than the four-layer system and they are generally less bulky for patients. The bandage should be applied by rolling
it around the leg and 'tugging' as it passes around the back of the leg to ensure full stretch. It is important to remember that when used on oedematous legs, the fluid can reduce rapidly and, therefore, the bandages should initially be renewed more frequently in order to control the oedema.
8
Compression hosiery: The range of compression hosiery has significantly
increased over the past 10 years, with stockings, socks and tights now available in both standard and made-to-measure sizes.
Figure 1. Ankle flare and venous skin changes.
References
7.World Union of Wound Healing Societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. 2008; MEP Ltd, London.
8. Beldon P. Bandaging: which bandage to use and when.Wound Essentials. 2009; 4: 52–61.
9. Dowsett C. Treatment and prevention of recurrence of venous leg ulcers using RAL hosiery. Wounds UK 2011; 7(1): 115–19.
10. Lindsey E. Compliance with science: benefits of developing community leg clubs. Br J Nurs 2001; 10(22): S66–74.
www.woundsinternational.com
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Practice development
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