Leg Ulcers

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Leg Ulcers

• Basic wound care

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Outline

• Venous leg ulcers
• Compression therapy
• Arterial leg ulcers
• Mixed aetiology leg ulcers
• The ideal dressing

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Venous Leg Ulcers

• Most common type of leg ulcer.
• Causes
• Result of chronic venous hypertension
• Venous stasis due to damage to vessels
• Calf muscle pump ineffective
• Oedema
• Hb released from RBCs causes staining eczema

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Venous ulcer
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Predisposing factors

• History of DVT
• Varicose veins (valvular incompetence)
• Obesity
• Prevalence increases with age
• Predominantly affect women
• Take a long time to heal

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Where are they usually located?

• Anterior to medial malleolus
• Pretibial area
• Generally lower one third of leg
• Ulcer characteristics
• Uneven edges
• Ruddy granulation tissue
• No necrotic tissue

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Assessment

• Pain
• Mild to moderate
• Discomfort relieved by elevation of legs
• Leaking oedema
• ? maceration,pruritis and scaling of skin
• Normal foot and leg pulses
• Ultrasound will confirm venous incompetence

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Management

• Improve drainage
• Exercise
• Compression
• Elevation
• Ulcer treatment
• Moist wound healing principles
• Assist normal processes of healing

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Compression therapy

• Graduated compression results from applying a
  bandage at steady and even pressure from toes to
  below knee
• Inversely proportional pressure to circumference
  of limb
• More pressure applied at ankle than at calf
• Graduated compression decreases
• Capacity pressure in superficial veins
• Ambulatory venous pressure
• Oedema
• Progression of lipodematosclerosis

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Compression therapy cont/

• Should be applied early morning when less oedema
• Skill required for application
• Different grades of pressure bandage available
  14mmHg 50mmHg
• Light, moderate, high and extra high compression

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Application of compression

• See Carville p.p. 195-198
• Layer 1 cotton wool applied in spiral
• Layer 2 crepe applied in spiral
• Layer 3 light compression applied in figure of
  8
• Layer 4 cohesive flexible applied in spiral

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Application of compression cont/

• Leg gently washed and dried
• Apply moisturiser
• Assess pulses , Doppler studies, etc.
• Dress ulcer
• Apply padding layers
• Foot at right angles to floor
• Apply bandages as per manufacturers instructions
• Encourage ambulation

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Classification of bandages

• Classes range from simple support bandages e.g.
  crepe (Class 2)
• to high compression e.g. blue line (Class 3D)
• Stockings are similarly classified e.g. TED
• Important to use appropriate level of compression
• Pressure ranges from 14 60mmHg

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Risks

• At high pressure possible damage to skin
• Impair arterial blood supply
• Important to apply bandages and stockings
  correctly
• Ridges of puffiness indicate poor technique
• Stockings must be properly fitted
• Patient comfort is an issue in compliance

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Wound healing principles

• Define aetiology
• Venous, arterial, mixed
• Control aspects affecting healing
• Diabetes (BSLs), other diseases (CCF)
• Select appropriate dressings
• Plan for maintenance
• Risk assessment tools, prevention

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Wound assessment

• Dressing choice based on
• C (Colour)
• Pink, red, yellow, green, black
• D (Depth)
• Stages 1 - 4
• E (Exudate)

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Venous ulcer
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Dressing Classes

• Passive dressings
• Gauze, combine, Interpose, Melolin, tulle gras
• Fulfill very few properties of ideal dressing
• Interactive / bio-active dressings
• Alter the wound environment
• Interact with wound surface
• Encourage normal healing
• Stimulate healing cascade

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Semi-permeable films

• Non absorbing
• Waterproof
• Gas/vapour permeable
• Flexible, conformable, comfortable
• Transparent allow for assessment
• Used on clean superficial wounds with little
  exudate

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Hydrogels

• Moisture donating
• Absorb their own weight in fluid
• Available in gels and sheet form
• Re-hydrate sloughy or necrotic tissue
• Require secondary dressing
• May macerate exudating wounds

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Hydrocolloids

• Low moderate absorbency
• Form soft gel with exudate (resembles pus)
• Adhesive, flexible, comfortable
• Provide physical barrier to bacteria
• Aid in autolytic debriding
• Encourage development of granulation tissue

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Hydrocolloids (cont)

• Available in thin transparent version
• Also in paste and powder for slightly deeper
  wounds
• Require secondary dressing
• Leave in place for a week or a leak

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Foam dressings

• Absorbent
• Fulfill most requirements of ideal dressing
• Highly absorbent, insulating, non-stick
• Used in moderately to highly exudating wounds
  e.g. leg ulcers, pressure ulcers
• A number of varieties available including
  charcoal containing

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Alginates

• Seaweed derived
• Form gel with exudate
• Highly absorbent
• Haemostatic
• Used on moderately to highly exudating wounds
  e.g. donor sites, ulcers, cavities
• Need secondary dressing

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Client education

• Exercise
• Elevate legs
• Protect legs
• Protect from injury, excessive heat, cold
• Wear appropriate elastic support on legs
• Reduce weight if obese
• Comfortable footwear, care of feet

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Things to avoid with leg ulcers

• Obstructing the veins
• Garters, tight clothing, avoid crossing legs
• Do not sit or stand for prolonged periods
• airline DVT, ? venous stasis
• Do not smoke
• Reduces blood flow and slows healing process

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Arterial ulcers

• Less common
• Characterised by extreme pain
• Usually smaller than venous ulcers
• Pedal pulses absent or weak
• Skin changes include
• thin shiny dry skin, thickened nails, pallor,
  limb may be cool

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Treatment of arterial ulcers

• NO COMPRESSION!!
• NO ELEVATION
• Prevent thermal trauma
• Protect from pressure (neuropathy)
• Regular podiatry care
• Elevate head of bed encourage dependant
  circulation

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Ulcers of mixed aetiology

• Assessment very important
• Dress ulcers according to type and severity
• Minimal compression therapy according to Doppler
  ratio
• Advise health promotion strategies
• STOP smoking, skin and foot hygiene
• Combination of dependency, and leg elevation

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Research Activity

• Access the Wounds1.com website and read through
  the information on the anatomy of skin and other
  relevant wound topics
• http//www.wounds1.com/index.cfm

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References

• Body1 Inc. 2008 Wounds1.com accessed 19/5/08
  http//www.wounds1.com/pr_ulc/index.cfm
• Carville, K. 2005 Wound Care, 5th edition.
  Silver Chain Nursing Association, Osborne Park,
  WA (617.14 CAR)
• Stockslager, J. (Ed.) 2003 Wound Care made
  Incredibly Easy!, Lippincott Williams Wilkins,
  Philadelphia (617.14 WOU)
• Templeton, S. (Ed.) 2005 Wound Care Nursing A
  Guide to Practice, Ausmed Publications, Melbourne
  (617.106 WOU)