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Wounds: Leg ulcers

Wounds: Leg ulcers. Key slides. Wound care: leg ulcers NHS CRD (1997) Effective Healthcare 3 (4), 1-12 SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer Clinical Knowledge Summaries_Venous Leg Ulcer_Feb 08.

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Wounds: Leg ulcers

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  1. Wounds: Leg ulcers Key slides

  2. Wound care: leg ulcers NHS CRD (1997) Effective Healthcare 3 (4), 1-12SIGN 26 (1998) The Care of patients with Chronic Leg UlcerClinical Knowledge Summaries_Venous Leg Ulcer_Feb 08 • Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient QoL and NHS workforce time • The evidence base for therapeutics in much of this area is limited • Value for money for the NHS is an important factor when choosing treatments • Leg ulcers are a common, chronic, recurring condition • Prevalence of active leg ulcers is between 1.5 to 3 per 1000 and increases with age. It’s estimated that up to 20 per 1000 people over 80 yrs will suffer from a leg ulcer • Following healing, re-ulceration rates at one year range from 26% - 69% • Available treatments can reduce recurrence rates

  3. Leg ulcer aetiologyClinical Knowledge Summary Venous Leg Ulcers_February 2008 Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50 • Venous insufficiency 80 - 85% Other causes: • Arterial disease • Mixed arterial and venous disease • Diabetes • Rheumatoid arthritis • Systemic vasculitis • Lymphoedema • Trauma • Others including malignancy

  4. Assessment of the patient - historyClinical Knowledge Summary Venous Leg Ulcers_February 2008Royal College of Nursing Clinical Practice Guidelines 2006

  5. Assessment of the leg - examination Clinical Knowledge Summary Venous Leg Ulcers_February 2008CREST Guidelines for the Assessment and Management of Leg Ulcers 1998 Measurement of Ankle Brachial Pressure Index (ABPI) is the most reliable way to detect arterial insufficiency

  6. Assessment of the ulcerClinical Knowledge Summary Venous Leg Ulcers_February 2008CREST Guidelines for the Assessment and Management of Leg Ulcers 1998

  7. Referral to a specialist clinic before treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008 • Uncertain diagnosis • Suspected alternative causes of ulceration: - Arterial or mixed venous/arterial ulcer. Refer people with ABPI <0.8 for further assessment. If < 0.5 refer urgently. • Suspected malignant ulcer or rapidly deteriorating ulcer • Suspected rheumatoid ulcer, or ulcer associated with systemic vasculitis • People with diabetes with an ulcer on the foot (according to local arrangements) • Varicose veins or arterial insufficiency

  8. Lifestyle advice Clinical Knowledge Summary Venous Leg Ulcers_February 2008 Self - care strategies include: • Keep mobile with regular walking if possible • Elevate legs when immobile • Use emollient and examine legs regularly for broken skin, blisters, swelling or redness • Lose weight if appropriate • Stop smoking

  9. Venous leg Ulcer - treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008 • Irrigate the wound with warm tap water or saline, then dry. Strict aseptic technique not required • Remove slough or necrotic tissue by gentle washing • If debridement is needed, it should be carried out by a trained healthcare professional • Consider using potassium permanganate 0.01% soak if the ulcer is malodorous • For uncomplicated, non-infected ulcers apply a low-adherent dressing & replace weekly. (If heavy exudate - more frequent change) • Other dressings may be used if needed - pain (hydrocolloid), heavy exudate (alginate) or slough (hydrogel) • For uncomplicated, non infected ulcers and where indicated by ABPI, apply compression bandaging - 4 or 3 layer if immobile, or 2-layer if mobile

  10. Uncomplicated venous leg ulcer – Follow up during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008 • Assess weekly for the first 2 weeks. If healing underway, assess fortnightly or monthly, then 3 monthly • Change dressings at least once a week. Check for healing and compliance with compression therapy and ask about problems e.g. mobility, sleep, mood • If delayed or no healing, identify problems which may need further treatment or referral • Check for complications • Check lifestyle advice is followed • If ulcer not healing or deteriorating at 12 weeks, look for signs of arterial disease and repeat ABPI

  11. Venous leg ulcer - treating infectionClinical Knowledge Summary Venous Leg Ulcers_February 2008 • All chronic wounds are colonised with bacteria • Antibiotics should be used only if there is evidence of cellulitis or active infection (e.g. pyrexia, increasing pain, enlarging ulcer) • If there are clinical signs of infection present, clean ulcer with warm tap water or saline before taking a swab • Start immediate empiric treatment with an anti-staphylococcal antibiotic i.e. flucloxacillin or erythromycin 500mg qds for seven days • Change dressing daily or alternate days to assess if infection is improving • Do not use antimicrobial dressings • Do not start compression therapy if ulcer is infected

  12. Infected venous leg ulcer- follow up during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008 SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer • Reassessment and follow up frequency is different for uncomplicated and infected ulcers • Review the patient within 3 days to assess response to treatment, ideally followed by re-assessment every two or three days until clinical improvement is seen • Reassess the ulcer as at initial assessment: dimensions, site, base, odour and exudate • If infection is not responding, consider change of antibiotic based on swab results • If signs of worsening infection, refer • After infection has settled, follow up as for uncomplicated venous ulcers

  13. Venous leg ulcer - dressing choiceSIGN 26 (1998) The Care of patients with Chronic Leg UlcerClinical Knowledge Summary Venous Leg Ulcers_February 2008 There is good evidence that the type of dressing used has no effect on ulcer healing • Uncomplicated ulcer-use simple low-adherent dressing • Sloughy ulcer-hydrogel provides moisture that may help liquefy slough • Moderate to heavily exuding ulcer-alginate or foam dressing may help absorb exudate • Painful ulcer-occlusive hydrocolloid or foam dressing may reduce pain Simple non-adherent dressings are recommended in the treatment of venous ulcers as no specific dressing has been shown to improve healing rates

  14. Venous leg ulcer - compression bandagingClinical Knowledge Summary Venous Leg Ulcers • Below-knee graduated compression is the mainstay of treatment to improve venous return, and to reduce venous stasis and hypertension in uncomplicated venous leg ulcers • Graduated compression delivers the highest pressure at the ankle and gaiter area (40 mmHg), and pressure progressively reduces towards the knee and thigh where less external pressure is needed (18 mmHg) • High compression multilayer (four layer, three layer) bandaging has improved healing rates over single layer bandaging • An appropriately trained person should apply high compression multi-layer bandaging, to avoid the risk of pressure ulceration over bony points

  15. Venous leg ulcer - preventing recurrenceClinical Knowledge Summary Venous Leg Ulcers_February 2008 CREST Guidelines for the Assessment and Management of Leg Ulcers 1998 • Graduated compression stockings should be used for at least 5 years after ulcer healing • Educate and explain to the patient the importance of preventing recurrence through lifestyle changes and use of hosiery • Accurate measurement of limbs for compression hosiery is essential • Follow up with 6-monthly Doppler ABPI checks • Class III (high) compression stockings are associated with less recurrence than Class II (medium) compression stockings, but may be less acceptable to the patient

  16. Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50 • Caused by reduced blood supply to the lower limbs either by a blockin the artery or narrowing of the arteries resulting in hypoxic damage, ulcer formation and necrosis • Arterial ulcers account for 10% - 15% of leg ulcers • Typically occur over toes, heels and bony prominences of foot • Can take months or years to heal, are painful and often become infected • Men over 45 years and women over 55 years are more likely to have PVD, (peripheral vascular disease) and so are prone to arterial leg ulcers • Modifiable risk factors: smoking, hyperlipidaemia, hypertension, obesity, diabetes, decreased activity

  17. Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50Nelson EA et al. Dressings and topical agents for arterial leg ulcers. Cochrane Database of Systematic Reviews 2007, Issue 1. • Infection can cause rapid deterioration of an arterial ulcer • It is not appropriate to debride arterial ulcers as this may produce further ischaemia and formation of a larger ulcer (specialist only) • Compression bandaging should not be applied as severe damage to the leg can result • Choice of dressing is dictated by the nature of the wound • Treatment options include reconstructive surgery or angioplasty

  18. Summary: leg ulcer therapeutics For both venous and arterial leg ulcers • Systematic assessment of the wound is essential for baseline data and to evaluate healing and treatment efficacy • Regular wound reassessment is good clinical practice • There is insufficient evidence that one type of dressing is superior to another in leg ulcer wound healing • Treat infection with systemic antibiotics not topical antimicrobials Management of venous vs. arterial leg ulcers • Compression therapy is the mainstay of venous leg ulcer management, but should not be used for arterial ulceration or infected wounds • Increasing peripheral blood flow is the intervention most likely to affect healing in arterial ulceration

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