Chronic Wound Management: Leg Ulcers

Introduction:

This essay is a part of the study of nursing practices in chronic Wound Management based on venous leg ulcers. The essay covers the various aspects of this particular medical condition, its symptoms, causes, after effects, various treatment therapies in the UK and costs incurred by NHS every year in treating Venous Leg Ulcers. The study begins with an introduction to the Venous Leg Ulcer, its definition, symptoms, percentage of prevalence in the United Kingdom and is intended to obtain an insight to efficient wound management practices.

Venous Leg Ulcers:

Definition:

According to the information provided by the NHS on Venous leg ulcers, a leg ulcer is an area of damaged skin below the knee on your leg or foot that takes longer than six weeks to heal. The most common type of leg ulcer is a venous leg ulcer, accounting for 80-85% of all cases, costly to treat, and respond best to early diagnosis and treatment. [1] 

When veins in one’s legs do not work properly it is termed venous insufficiency and leads to venous leg ulcers and are attributable to the major risk factors like diabetics, obesity, family history and lifestyle. Venous leg ulcers are more popular among the elderly compared to the youth. And as Myers (2004, p.230) points out that ‘women are three times more likely than men to have a venous insufficiency ulcer’. [2] One of the major implication of Venous leg Ulcer is that it is a chronic wound with poor healing system and chances are high for a recurrence.

Symptoms:

The main symptoms of a venous leg ulcer are itching, swelling, eczema, aching, pain, edema and varicose veins. [3] 

Management of the Wound:

According to Vowden (2010), there are four phases to effective leg ulcer management: assessment, treatment, review of progress and management of the healed ulcer. [4] Hartmann (2008) says venous leg ulcer is a chronic wound with a poor or absent healing tendency and that chronic wounds like venous leg ulcer also heal in a phase-specific manner. Regardless of the type of wound and the extent of tissue loss, every wound healing process proceeds in phases which overlap in time and cannot be separated from each other. In practice, the three phases of wound healing are known for short as the cleansing, granulation and epithelisation phase. [5] 

Diagnosis:

According to Hartmann (2008, p.16) an exact diagnosis is essential since ‘about 90 % of leg ulcers develop as a result of venous hypertension secondary to severe chronic venous insufficiency and about 6 % of the venous leg ulcers are attributable to reduced peripheral arterial blood supply and about 4 % to specific skin diseases. This requires taking a detailed medical history, a clinical and instrumental examination and differential diagnostic procedures to rule out non-venous etiopathological factors.’ [6] 

Doppler studies:

Doppler study is a test carried out to confirm a diagnosis of venous leg ulcer conducted on both of the patient’s legs to check for arterial insufficiency (high blood pressure due to poor blood flow). Like venous insufficiency, arterial insufficiency refers to blood not flowing properly through your arteries. Signs of arterial insufficiency include hair loss in the affected area and the skin in the affected area being pale and cold to the touch. [7] However, there are some conditions like diabetes, atherosclerosis, systemic vasculitis, rheumatoid arthritis etc that can make the results of Doppler studies unreliable in which case a specialized treatment is required. [8] As per Hartmann Medical Edition (2008), the only technique which can provide further diagnostic information in this situation is acral oscillography or possibly colour duplex sonography. [9] 

Treatment:

The treatment options for venous leg ulceration are diverse and contentious, ranging from topical agents, compression therapy, pharmaceuticals and surgery, to natural therapies and nutritional intervention. [10] Treatment goals should be to decrease the swelling, any pressure in the veins focused on a healing with minimized complications. Since ulcers can be of both arterial and venous insufficiency a carefull and detailed assessment is required befire deciding the treatment option. Where there is no arterial problem, treatments can be based on exercise, elevation of the leg at rest positions and compression therapy.

Vowden (2010) is of the opinion that peri-wound skin management is important, particularly if high levels of exudate are present. Topical steroids are generally not required. Pain management is an important element in treatment. Increasing pain can indicate a rising bacterial load, peri-wound skin damage or bandage problems, and should be investigated promptly. [11] 

Cleaning the wound

No matter what the cause of the ulcer, meticulous skin care, and cleansing of the wound are essential. [12] Hartmann (2008) says experience has shown that this initial phase demands great patience and will need more time to complete the longer the ulcer has existed. [13] Rigorous cleansing of the wound bed runs the risk of damaging new, fragile tissue but gentle cleansing of the surrounding skin will reduce the risk of excoriation. [14] 

Wound dressings

There is a whole range of specialized dressings available to assist with the various stages of wound healing classified as non-absorbent, absorbent, debriding, self-adhering etc. Dressings are usually occlusive as ulcers heal better in a moist environment. Generally, it is found that dressing selection appears to have little influence on ulcer healing rates and that a simple non-adherent dressing is usually sufficient. [15] Vowden (2010) in his work has evaluated the EWMA position documents identifying criteria for wound infection which found that antimicrobial dressings may be required if an increasing bacterial load is suspected or local infection is present. [16] Briggs et al (2010) are of the opinion that ‘as these ulcers are often painful some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes’. [17] 

Surgery:

In cases where the venous ulcers do not heal with conservative measures and when the ulcers are large and painful, surgery is opted. Assessments of the venous and arterial systems are first carried out and then any infection is treated, and thereafter any underlying risk factors are to be controlled. In some patients, the ulcers fail to heal by themselves and require surgery and this can be done by skin grafting i.e. taking skin from elsewhere on the patient’s body and placing it over the ulcer. [18] 

Compression therapy

Compression therapy is an important part of the management of venous leg ulcers and chronic swelling of the lower leg. This mode of treatment helps in healing of about 40-70% of chronic venous ulcers usually within 12 weeks. Compression is not used if the ABPI is below 0.8 [19] or when there is an arterial disease. In a study conducted by Vowden (2010), the data given out by WUWHS (2008) is analyzed and as such it is found that a number of factors, such as the practitioner’s knowledge and skill, the limb shape and the materials used, as well as patient acceptance influence the application of effective compression. These factors will also influence the patient experience, patient outcome and treatment costs. Hosiery may be a suitable alternative for some patients with small ulcers and low levels of exudate, and its role along with that of intermittent pneumatic compression is outlined by the WUWHS (2008). [20] 

In the view of Susan (EWMA 2008) Demands to be met for compression therapy are high level of safety, high patient compliance, highest healing rate, sustainable sub-bandage pressure, socio-economical (personnel time spent, bandages, lost earnings). [21] Susan (EWMA 2008) in her work examines the study on compression therapy carried out by Satpathy et al in whose opinion compression must be applied with the correct sub-bandage pressure cf. ankle-brachial pressure index ABPI. If elastic, inelastic or multi-layer bandages are used, the outcome depends on the applying nurse’s estimate of how to apply the bandage, resulting in possible ineffective treatment if the bandages are applied too loosely and risking severe injury if the bandages are applied too tightly. This risk can be avoided by using bandages with pressure indicators and/or by teaching staff how to apply the bandages with a sub-bandage pressure measuring device, which can also be used in routine clinical practice. Hosiery provides the highest level of assurance for correct sub-bandage pressure. [22] 

Elastic and Inelastic Bandages:

Although compression is a cornerstone for treating venous-ulcerated patients, health professionals claim that there are many limitations to its use, such as discomfort and intolerance, resulting in poor compliance. Elastic stockings have been reported to be not tolerated initially in hypersensitive areas adjacent to an active wound or in a previously healed ulcer. High pressures applied initially to the wound also contribute to intolerance.

Recurrence of Venous Ulcers:

The European Wound Management Association (EWMA) in their position documents (2005, 2006) deals with recurrence of healed ulcers, the percentage and management of the same and accordingly with appropriate management 50-60% of venous leg ulcers should heal within 12 weeks. Venous ulcer recurrence remains a major problem, some 60% of ulcers undergoing treatment at any one time being recurrent. [23] Management of the healed ulcer is therefore important. Hosiery and maintenance skin care remains the mainstay of treatment. [24] 

Chronic venous leg ulcers have a significant impact on older individuals’ well-being and health care resources. Chronic leg ulcers are associated with restricted mobility, pain, poor psychological health and decreased quality of life. In recurrent leg ulceration, patients may feel it is inevitable but live with the uncertainty of when the ulcer will reappear. [25] 

Costs and Quality of Life:

Anand et al’s review of quality of life tools examines the studies that found that leg ulcer management costs £600 million per year, and approximately 2% of the budget of the NHS resources is spent on the management of venous diseases (Marlow 1999). Nelzen’s study indicates a conservative estimate of £1200 is spent on every patient per annum based on a visit per week by a district nurse. Factors influencing the cost of treatment include time to heal, use of dressing regime, and ability to prevent recurrence and Quality of Life. [26] 

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and social isolation. [27] Limitations to physical activity were also prevalent in the ulcer-specific studies and were attributed either directly to the ulceration or, for some, as a result of the pain. [28] In chronic venous leg-ulcerated patients, elimination or cure of disease is not attainable and the treatment could be longer than first anticipated. A plethora of wound dressings and bandages are used to assist the treatment of venous ulcers, and have an impact on patients’ wellbeing. Anand et al (2003) has highlighted the study by Callam et al finding that venous leg ulcers affect greatly the life of patients and their mobility, causing people a significant burden to life. [29] 

Conclusion

Going through the various studies conducted on the nursing practices for venous leg ulcers, it is found that a new approach to the management of patients with chronic venous leg ulcers is required. Focus is required to equip the health professionals to develop services in tune to the patient’s requirements, [30] helping the patient to adapt to life with the ulcer since a complete healing is not always practical and chances of recurrence are always there. The associated psychological conditions alike depression and quality of life shall be dealt with by improving self efficacy of the patient. As Vowden (2010) rightly points out, an integrated multidisciplinary approach based on accurate initial assessment and an understanding of the disease process that causes venous ulceration, the application of an effective compression system and the early recognition of the hard-to-heal wound with referral of difficult or non-healing ulcers at an early stage will ensure cost-effective care and improve patient outcomes. [31]