The purpose of this guideline is to identify best nursing practices in the treatment of venous leg ulcers. The recommendations are designed to help practitioners to apply the best available research evidence to clinical decisions and improve outcomes for venous leg ulcer clients.
The purpose of this guideline is to identify best nursing practices in the treatment of venous leg ulcers. The recommendations are designed to help practitioners to apply the best available research evidence to clinical decisions and improve outcomes for venous leg ulcer clients.
As an introduction, we’ve provided summaries of the practice recommendations from the BPG document — but we strongly encourage downloading RNAO’s official PDF.
Assessment and clinical investigations should be undertaken by healthcare professional(s) trained and experienced in leg ulcer management.
A comprehensive clinical history and physical examination including blood pressure measurement, weight, urinalysis, blood glucose level and Doppler measurement of Ankle Brachial Pressure Index (ABPI) should be recorded for a client presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.
Information relating to ulcer history should be documented in a structured format.
Examine both legs and record the presence/absence of the following to aid in the assessment of underlying etiology.
Measure the surface areas of ulcers, at regular intervals, to monitor progress. Maximum length and width, or tracings onto a transparency are useful methods.
The client’s estimate of the quality of life should be included in the initial discussion of the treatment plan, throughout the course of treatment, and when the ulcer has healed.
Assess the functional, cognitive and emotional status of the client and family to manage self-care.
Regular ulcer assessment is essential to monitor treatment effectiveness and healing goals.
Venous disease of the leg is most commonly detected by a combination of clinical examination and measurement of a reliably taken Ankle Brachial Pressure Index (ABPI).
Doppler ultrasound measurement of Ankle Brachial Pressure Index (ABPI) should be done by practitioners trained to undertake this measure.
If there are no signs of chronic venous insufficiency and the Ankle Brachial Pressure Index (ABPI) is abnormal (greater than 1.2 or less than 0.8), arterial etiology should be assumed and a vascular opinion sought.
Vascular assessment, such as Ankle Brachial Pressure Index (ABPI) is recommended for ulcers in lower extremities, prior to debridement, to rule out vascular compromise.
Assess Pain.
Pain may be a feature of both venous and arterial disease, and should be addressed.
Prevent or manage pain associated with debridement. Consult with a physician and pharmacist as needed.
Choose the technique of debridement, considering the type, quantity and location of nonviable tissue, the depth of the wound, the amount of wound fluid and the general condition and goals of the client.
Cleansing of the ulcer should be kept simple; warm tap water or saline is usually sufficient.
Dressings must be simple, low adherent, acceptable to the client and should be low cost.
Avoid products that commonly cause skin sensitivity, such as those containing lanolin, phenol alcohol, or topical antibiotics.
Choose a type of dressing depending on the amount of exudate and the phase of healing.
No specific dressing has been demonstrated to encourage ulcer healing.
In contrast to drying out, moist wound conditions allow optimal cell migration, proliferation, differentiation and neovascularization.
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.
Venous surgery followed by graduated compression hosiery is an option for consideration in clients with superficial venous insufficiency.
Biological wound coverings and growth factor treatments should not be applied in cases of wound infection.
Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection.
Assess for infection.
An infection is indicated when > 105 bacteria/gram tissue is present.
The treatment of infection is managed by debridement, wound cleansing and systemic antibiotics.
Antibiotics should only be considered if the ulcer is clinically cellulitic (presence of some of the following signs and symptoms: pyrexia; increasing pain; increasing erythema of surrounding skin; purulent exudate; rapid increase in ulcer size).
Do not use topical antiseptics to reduce bacteria in wound tissue, e.g., povidone iodine, iodophor, sodium hypochlorite, hydrogen peroxide, or acetic acid.
Topical antibiotics and antibacterial agents are frequent sensitizers and should be avoided.
The treatment of choice for clinical venous ulceration uncomplicated by other factors, is graduated compression bandaging, properly applied, and combined with exercise. Graduated compression is the main treatment for venous eczema.
High compression increases venous ulcer healing and is more effective than low compression, but should only be used where ABPI ≥ 0.8 and ulcer is clinically venous.
Compression bandages should only be applied by a suitably trained and experienced practitioner.
Venous ulceration should be treated with high compression bandaging to achieve a pressure between 35-40 mm Hg. at the ankle, graduating to half at calf in the normally shaped limb, as per La Place’s Law.
Use protective padding over bony prominences when applying high compression.
Arterial insufficiency is a contraindication to the use of high compression. A modified form of compression may be used under specialist supervision.
Use compression with caution in clients with diabetes, those with connective tissue disease and the elderly.
Compression therapy should be modified until clinical infection is treated.
Bandages should be applied according to manufacturer’s recommendations.
When using elastic systems such as “high compression” bandages, the ankle circumference must be more than or padded to equal 18 cms.
Ankle circumference should be measured at a distance of 2.5 cm (one inch) above the medial malleolus.
The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting compression stockings.
Graduated compression hosiery should be measured and fitted by a certified fitter.
To maintain a therapeutic level of compression, stockings should be cared for as per manufacturer’s instructions, and replaced every six months.
Graduated compression hosiery should be prescribed for life.
External compression applied using various forms of pneumatic compression pumps is indicated for individuals with chronic venous insufficiency.
The client should be prescribed regular vascular exercise by means of intensive controlled walking and exercises to improve the function of the upper ankle joint and calf muscle pump.
Consider electrical stimulation in the treatment of venous leg ulcers.
Hyperbaric oxygen may reduce ulcer size in non-diabetic, non-atherosclerotic leg ulcers.
Therapeutic ultrasound may be used to reduce the size of chronic venous ulcers.
With no evidence of healing, a comprehensive assessment should be carried out at three-month intervals, or sooner if clinical condition deteriorates.
For resolving and healing venous leg ulcers, routine assessment at six-month intervals should include:
Measures to prevent recurrence of a venous leg ulcer include:
Inform the client after the ulcer has healed regarding:
Guidelines are more likely to be effective if they take into account local circumstances and are disseminated by an ongoing education and training program.
Develop educational programs that target appropriate healthcare providers, clients, family members, and caregivers. Develop programs that maximize retention, ensure carryover into practice, and support lifestyle changes. Present information at an appropriate level for the target audience using principles of adult learning.
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.
All healthcare professionals should be trained in leg ulcer assessment and management.
Education programs for healthcare professionals should include:
Healthcare professionals with recognized training in leg ulcer care should cascade their knowledge and skills to local healthcare teams.
The knowledge and understanding of the healthcare professional is a major factor in adherence to treatment regimens.
Successful implementation of a venous ulcer treatment policy/strategy requires:
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:
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus.
