36 | Nursing in Practice | Autumn 2023
1.5 CPD HOURS
Key points
• Venous hypertension is a treatable condition . Strong compression therapy is evidence-based and fundamental to rapid healing and significantly improving patients ’ lives and wellbeing .
• Mild compression therapy can be applied in mixedaetiology ulcers with specialist support . Compression therapy is contraindicated in arterial ulceration .
• A timely , holistic assessment of the patient , lower limb and ulcer site allows early identification of risk factors and should form the basis of management without delay .
• Patients should be included in decisions about their care so expectations can be set and barriers to engagement addressed in a holistic , timely manner .
• Patient-related and social factors need to inform decisions on the most suitable compression system for the best healing outcomes .
• Health professionals should be well educated , skilled and competent in assessment and management of lower limbs .
This CPD module aims to : 1 Introduce the pathophysiology of venous , arterial , and mixed-aetiology leg ulceration . 2 Offer a guide to performing a holistic lower-limb assessment and determining key risk factors to healing . 3 Introduce the TIMERS framework for comprehensive woundbed assessment . 4 Introduce the key compression therapy methods and lower-limb management principles .
Julie Hewish is national tissue viability clinical lead , Eastern Academic Health Science Network
CLINICAL
Management of
leg ulceration
A leg ulcer is defined as an open wound between the knee and just below the ankle joint ( malleolus ), which has been present for at least two weeks . 1 Ulceration is the breakdown of skin , often caused by trauma or surgery . Underlying disease of the vascular system and existing risk factors can mean the healing process for ulcerated skin is challenging .
Approximately 1.5 % of the UK adult population are affected by active leg ulceration . 2 This equates to 730,000 people . 3 Evidence suggests compression therapy can double the chance of venous ulceration healing within 12 weeks , 4 but variation in care practice means only 47 % of those affected heal within 12 months . 3
Pathophysiology of leg ulceration Venous leg ulceration The most common type of ulcer is caused by venous insufficiency and this type accounts for 60-80 % of cases . 5 It is primarily caused by sustained raised pressure in the veins ( venous hypertension ), which results in damaged valves and weakens the calf muscle pump action . 1
There are multiple risk factors ( see Table 1 ), including deep vein thrombosis ( DVT ), trauma or lower limb surgery . 6
Veins carry deoxygenated blood back to the heart . To prevent backflow ( reflux ) of blood , most veins have valves that rhythmically close and open to keep the blood moving in one direction and prevent it pooling in the lower limb . When valves are damaged or diseased , they become incompetent , failing to move the blood back to the heart effectively . Increased blood filling in the veins can overstretch the vessel wall so the valves move further apart . 6 This gap causes pooling in the blood vessels and leads to symptoms such as lower-limb swelling ( oedema ) and progressive skin changes such as haemosiderin staining and ankle flare . 7
The calf muscle pump is the physical support function for returning venous blood to the heart . Although venous insufficiency is deemed the major cause of lower-limb hypertension , restricted ankle movement can also contribute significantly . 9 The pump action relies on patients having a full range of movement in their ankle joint and foot pump . Patients with venous leg ulceration tend to have significantly reduced function in their ankles , which can have a significant impact on quality of life . 9
Arterial leg ulceration Arterial leg ulcers occur due to reduced arterial blood supply to the lower limb . Atherosclerosis , the build-up of fatty deposits ( atheroma ) in the large vessels , is the most common cause of arterial ulceration . 6 As with venous hypertension , damage to and narrowing of the innermost vessel walls ( tunica intima ) can be caused by sustained raised pressure . This significantly impairs delivery of oxygen and nutrients within skin tissue ( tissue hypoxia ) leaving the skin vulnerable to ulceration on trauma . 7
A number of risk factors , such as smoking , high cholesterol , hypertension and diabetes , can increase the risk of atheroma . This causes arterial insufficiency and increases the risk of ulceration and / or delayed healing . 7
Mixed-aetiology leg ulceration Mixed-aetiology ulceration applies when there is both venous and arterial disease . Often in these cases , the arterial supply is still enough to perfuse the lower limb
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