1. No category

LEG ULCER PREVENTION AND
MANAGEMENT
CLINICAL PRACTICE GUIDELINE
Tissue Viability Service
Tissue Viability Service Clinical Practice Guideline: Leg Ulcer Prevention & Management
July 2011
CONTENTS TABLE
Section heading
Section
Number
1.0
Policy Summary
2.0
Overriding Duty of Care Statement
1
3.0
To whom this guideline applies
1
4.0
Background & Scope
1
5.0
Aims & Objectives
1
6.0
Quality Assurance & Audit
2
7.0
Dissemination
2
8.0
Definition of a leg ulcer
3
9.0
Assessment
3
9.1
Demographic Details
3
9.2
Current leg ulcer treatment
4
9.3
Medical History
4
9.4
Pain
4
9.5
Nutritional assessment
4
9.6
Ulcer History
4
9.7
Condition of ulcer and surrounding skin
4
9.8
Condition of the legs
5
9.9
Investigations ABPI
5
10.0
Reassessment
5
10.1
Repeat ABPI measurement
6
11.0
Wound & Skin Care
6
11.1
Wound Cleansing
6
11.2
Care Of Surrounding Skin
6
11.3
Contact sensitivities
7
11.4
Debridement
7
11.5
Dressings
7
12.0
Differential Diagnosis and Management
8
12.1
Venous Ulcer Aetiology
8
12.2
Venous Ulcer Management
8
12.3
Arterial Ulcer Aetiology
9
12.4
Arterial Ulcer Management
9
12.5
Mixed Aetiology Ulceration
10
12.6
Mixed Aetiology Ulcer Management
10
12.7
Ulceration In Patients With Diabetes Mellitus
10
12.7.1
Neuropathic Ulcers
10
12.7.2
Ischaemic Ulcers
10
12.8
Management of Ulcers In Patients With Diabetes Mellitus
11
Tissue Viability Service Clinical Practice Guideline: Leg Ulcer Prevention & Management
July 2011
Page
Number
1
12.9
Foot Assessment
11
12.10
Malignant Ulceration
12
12.11
Management of Malignant Ulceration
12
12.12
Ulceration in people with Rheumatoid Arthritis
12
12.13
Vasculitic Ulcers
12
12.14
Management of Rheumatoid & Vasculitic Ulcers
12
13.0
Prevention of Venous Ulcer Recurrence
13
13.1
Compression Hosiery
14
13.2
Classification of compression hosiery
14
13.3
Advice on prescribing hosiery
14
13.4
Advice on fitting compression hosiery
15
13.5
Potential hazards of compression hosiery
15
14.0
Exercises
16
15.0
Education and training
16
16.0
References
APPENDICES
1
Leg Ulcer Assessment Form
2
Pathway for the management of leg ulcers
3
Wound assessment and evaluation form
4
Equality impact assessment
Tissue Viability Service Clinical Practice Guideline: Leg Ulcer Prevention & Management
July 2011
Title
Policy Number
Summary:
Responsibility for Updating
Date
Review Date
Equality Impact
Assessment completed
Approved Via
Policy sign off Group
Distribution
Related Documents
Further Information
This document replaces
POLICY TRACKING TABLE
Leg Ulcer Prevention & Management
Contains guidance for clinical staff on the assessment and
management of patients with or ‘at risk’ of, leg ulceration.
Tissue Viability Nurse Consultant
July 2011
July 2013
Yes
Nursing Development Steering Group
August 2011
All Clinical Directorates. All Clinical staff via intranet. Available to
the public via Freedom of Information.
Wound Management Guidelines
Infection Control Policy
Tissue Viability Service: Dr Caroline Dowsett, Nurse Consultant
0208 475 2120 [email protected]
Wound Management Guidelines: Leg Ulcer Section 2001, Revised
2008
Tissue Viability Service Clinical Practice Guideline: Leg Ulcer Prevention & Management
July 2011
1.0
Policy Summary
This document has been written by the Tissue Viability Service (TVS) and contains
guidance for clinical staff on the assessment and management of patients with lower leg
ulceration. It replaces previous local guidance published in 2001, and takes into account
national and international recommendations (2, 3). The following document should be read
in conjunction with National Guidance and the other Clinical Practice Guidelines in the
Tissue Viability Portfolio.
2.0
Overriding Duty of Care Statement
Should the content or operation of this policy be challenged on any grounds whatsoever
then the impact on the past, present or future duty of care to patients will be taken to be a
primary factor in deciding the outcome of that challenge.
3.0
To whom this Guideline applies
This document is aimed at practitioners who are responsible for the prevention, assessment
and management of patients with lower leg ulceration.
4.0
Background & Scope
Caring for patients with chronic ulceration of the lower leg accounts for a significant
proportion of nursing time (2, 3) and costs the National Health Service (NHS) over £400 million
each year (4). The effects on patients' quality of life and their ability to cope with aspects of
daily living are not so easily quantified (5, 6, 7, 8, 9). There are many causes of leg ulceration (2, 3,
10, 11, 12, 13, 14) and unless the correct diagnosis is made early, patients' may experience long
delays in healing or increased tissue damage.
This document is intended to provide a practical guide for the assessment and management
of patients with the most common causes of lower leg ulceration. It is not intended to replace
national guidance and therefore, should be read in conjunction with full national guidance,
best practice statements and subsequent research publications. Patients with the less
frequent causes of lower leg ulceration or unknown diagnosis require referral to the tissue
viability service for assessment.
5.0
Aims & Objectives
1. To provide a reference guide to the basic assessment and management criteria for
common causes of lower leg ulceration for staff within East London NHS Foundation
Trust, Community Health Newham.
2. To ensure evidence-based, standardised approach to the management of patients with
the more common causes of leg ulceration.
3. To ensure standardised, evidence based approach is taken to the prevention of
recurrence of venous leg ulcers.
4. To provide a framework to ensure that the quality of care for patients in this area can be
monitored and improved in line with the quality agenda.
1
6.0
Quality Assurance & Audit
The principles upon which this document is based are:
 An individualised holistic assessment should be undertaken and evidence-based
treatment plans commenced, which take into account the underlying aetiology, patient’s
circumstances, patient’s wishes, the overall goals of therapy, the practitioners clinical
judgement, available resources and knowledge of more recent research findings.
 Those who undertake assessment, planning, implementation and evaluations of care
should be trained/educated/competent in leg ulcer assessment, management and
prevention of recurrence. They should have attended the two day leg ulcer in-house
training programme and spent supervised time in one of the nurse led leg ulcer clinics.
 The patient and their carers should be fully informed and share in the decision making
process.
 The process should be clearly documented in the patient’s records and made accessible
to all those caring for the patient to ensure continuity of care.
 A collaborative, multi-disciplinary, inter agency approach is taken to meet all the needs
of patients with or 'At risk' of leg ulcer development.
 Patients, staff and carers should have access to the equipment and resources necessary
to deliver quality care.
 Monitoring of ulcer healing rates and recurrence rates as an indicator of quality care will
be undertaken regularly through a clinical audit process.
7.0
Dissemination
This document is available to all staff on the Trust Intranet site and paper copies will be
available in all community nurse led leg ulcer clinics and community nurses bases.
Hyperlinks to relevant national guidance and best practice statements will be included on the
reference list.
A two day leg ulcer courses focussing on an introduction to leg ulcer assessment,
management and prevention of recurrence will be held at least twice a year by the tissue
viability department, to introduce the standards of care within these guidelines. It is
recommended that all health professionals involved in leg ulcer management attend this
course. Further training specific to service need can be arranged by contacting the tissue
viability service. The tissue viability team will work in collaboration with other specialists,
practitioners with specialist interests and services to ensure consistency in information and
application.
2
8.0 DEFINITION OF A LEG ULCER
For the purpose of this document the following definition of leg ulceration will be used:
"A leg ulcer is a loss of skin below the knee, on the leg or foot, which takes more than 6
weeks to heal." (11).
It should be noted that "leg ulcer" is not a diagnosis but a manifestation of the underlying
disease process, which requires diagnosis if the correct treatment pathway is to be selected.
For example, 70 per cent of ulcers are caused by venous disease (12), 10 per cent are caused
by peripheral arterial disease (PAD) (12,13), the remaining are of ‘other causes’ such as, mixed
aetiology, neoplasm, metabolic disease, physical trauma, lymphoedema, oedema, infection,
vasculitis, haematological, connective tissue or immunological disorders.
9.0
ASSESSMENT
All leg ulcers have an underlying cause and an accurate diagnosis is essential to determine
the appropriate treatment pathway. A full clinical history and physical examination
should be conducted for a patient presenting with either their first or recurrent leg
ulcer and assessment should be ongoing thereafter (2). The assessment of the patient
and diagnosis of the cause of ulceration should be based on a thorough clinical history and
physical examination, as well as appropriate laboratory tests. Measurement of blood
pressure, weight, urinalysis and Doppler measurement of ankle/brachial pressure reading
(ABPI) should be undertaken (2). The assessment and clinical investigations should be
undertaken by a health care professional trained in leg ulcer management (2).
The assessment should be documented on the Trust's Leg Ulcer Assessment Form
(Appendix 1). All ulcers should fit into one of the following categories.
 Venous ulcer
 Arterial ulcer
 Mixed aetiology ulcer
 Diabetic Foot ulcer – (Neuropathic, ischaemic,)
 Traumatic
 Rheumatoid
 Vasculitic.
 Unknown
If the diagnosis is unknown or uncertain then the patient should be referred to the tissue
viability team for further assessment
The following should be documented on the Leg Ulcer Assessment Form (Appendix 1).
9.1




Demographic Details
Date and time of initial assessment
Name, address, contact telephone number, date of birth
District/Community/ nurse name, contact details
GP's name, address, telephone number
3
9.2
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9.3
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9.4
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9.5
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9.6

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

9.7


Current Leg ulcer treatments and investigation
Allergies and medication
Include any patch test results
Results of investigations; Vital signs, BMI, recent blood results
Medical History
Past & Current medical history: e.g. Diabetes mellitus. Tick box as appropriate
Anaemia
Deep vein thrombosis (DVT) in the affected leg
Phlebitis of the affected leg
Number of pregnancies
Obesity
Past surgery: including past venous & arterial operations
Past fractures of the legs and lower limb orthopaedic operations
Any prolonged periods of bed rest i.e. more than 4 days (14).
Smoking & alcohol history
Nutritional and hydration level
Family history including leg ulceration, varicose veins, heart disease, stroke, diabetes etc.
Medications
Pain
Constant or intermittent
Day or night
At dressing change
What helps the patients
Impact of the ulcer on the patients quality of life
Nutritional Assessment
All patients should be screened for 'risk of' or actual malnutrition, and be advised on a well
balanced diet in accordance with their wishes.
Patients considered as 'malnourished', or 'at risk' of malnutrition should be managed
according to local and national guidance (15, 16).
Nutritionally compromised patients who have wounds may have an increased dietary
need and a referral to a Dietician should be considered for further assessment, advice
and supplementation.
Weight, height and body mass index (BMI) should be recorded at initial assessment and
then regularly throughout the treatment phase.
Ulcer History
How the ulcer(s) started
Duration of ulcer(s) past and present
Number of episodes of ulceration
Time to healing in previous episodes
Ankle movement
Measurement of ankle circumference
Condition of ulcer and surrounding skin
Site of ulcer(s) - position on the leg. For example: medial, lateral, anterior, posterior,
within the gaiter area, on the foot, over the malleolus etc.
Size of ulcer(s) - a tracing of the ulcer should be taken with length and width
measurements in centimetres. This should be repeated and compared with previous
4
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
9.8
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

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


9.9



tracings every 4 weeks.
Photographs may be taken with the patient's consent.
Presence or absence of odour and exudate including colour and volume.
Appearance of wound bed including colour i.e. black/grey/green/yellow/red/pink.
Type of tissue i.e. necrotic, sloughy, purulent, granulating, epithelialising, infected.
Clinical observations and changes to the ulcer bed and edges should be documented at
each dressing change. The Trust Wound Assessment and evaluation form should be
used for continuous monitoring (Appendix 2).
Condition of the Legs
Shape of leg. For example: inverted champagne bottle, thin or normal shaped
Presence of oedema. If yes is it pitting? How far up the leg does the oedema extend? Is
this caused by heart failure, prolonged limb dependency or lymphoedema?
Varicose veins, superficial veins, ankle flare, atrophie blanche
Temperature of skin along leg length including foot
Skin condition. For example: dry skin, eczema, broken areas, brown staining, red and
inflamed areas, lack of hair, shiny skin, scars on the leg.
Foot condition. For example: discolouration of toes or feet (white, bluish, red), number of
toes, thickening of toenails.
Foot pulses - present or absent, can they be felt or heard using a hand held Doppler
ultrasound? How many pulse sounds can be heard?
Ankle movement - full/restricted movement or fixed ankle joint?
Walking ability - full/restricted/with aids - is the movement heel to toe to move calf muscle
pump?
Ankle and calf measurements (cm)
Investigations (ABPI)
Measurement of Ankle/Brachial Pressure Index (ABPI) using a hand held Doppler
ultrasound should be taken during the initial assessment. The patient should have
rested, as flat as possible, for at least 20 minutes. Inaccurate readings will occur if the
patient sits up or the legs are dependent or very oedematous.
Ankle systolic pressure: locate, obtain and document pressure readings from all pulse
points if possible and use the highest reading to calculate ABPI. Pulses to identify:
Dorsalis Pedis and Posterior Tibial.
Brachial systolic pressure - using the Doppler ultrasound to take readings from both arms
and use the highest reading when calculating ABPI.
NB: ABPI readings indicate strength of arterial blood flow to the foot. A common
misunderstanding among inexperienced staff is that ABPI readings between 0.8 and 1
indicate the ulcer is venous in origin. This is incorrect. The range represents the arterial
strength required to apply compression therapy if clinically indicated
10.0
Reassessment
All patients should be re-assessed if their condition changes or the ulcer fails to heal in 12
weeks. Please refer to the tissue viability service for further advice
5
10.1
Repeat ABPI measurements
Doppler ultrasound to measure ABPI should be conducted thereafter if
 An ulcer is deteriorating
 Patient presents with ulcer recurrence
 Before commencing compression therapy
 Patient is to commence wearing compression hosiery as a preventive measure
 There is a sudden increase in ulcer size
 There is s sudden increase in ulcer pain
 Foot colour and/or temperature of foot changes
 Ongoing assessment (three monthly)
11.0
WOUND & SKIN CARE
11.1 Wound Cleansing
 Clean the ulcer, where necessary, with warmed (body temperature) tap water or sterile
0.9% sodium chloride (2). In most cases tap water will be suitable, but should be
assessed on an individual basis. Consider: patient comfort, quality of tap water,
environment, equipment available, the need to cleanse surrounding skin, volume needed,
moving and handling of loads (buckets, bowls etc).
 Hypochlorite and other antiseptic cleansing solutions should not be used routinely.
 Use the No Touch Wound Dressing Technique to prevent cross infection. Universal
precautions should be maintained. Hands should be washed before and after using
gloves and between patients.
NB: Povidone iodine, acetic acid, hypochlorites and salt added to water should not be
used routinely. Cotton wool should not be used due to the potential of leaving loose
fibres on the wound surface.
11.2 Care of the Skin surrounding the ulcer
 Use an emollient such as Aqueous cream, Hydromol or Epaderm as a soap substitute to
clean the skin surrounding the ulcer(s).
 Dry skin should be moisturised with bland emollients. For example: 50:50 liquid paraffin
and white soft paraffin, Epaderm, Hydromol cream or Diprobase. The dryer the skin the
more 'greasier' a preparation and more frequent application is required.
 Varicose eczema may benefit from the topical application of steroid ointment or creams
as recommended by the tissue viability or dermatology specialist, which may reduce
inflammation and limit the spread of skin breakdown. It should be noted that topical
steroid therapy should only be applied to eczematous skin and not the ulcer. Use a
cream for wet eczema and an ointment for dry eczema. Apply amount according to size
of surface area affected. For example: 1 fingertip unit to cover the surface area equivalent
to that of two adult hands and use the appropriate potency for the severity of the eczema
(17).
 The surrounding skin should be protected from wound exudate, which may cause
excoriation and/or maceration. For example, Cavilon barrier-cream or liquid-film
dressing.
 If skin problems persist refer to the dermatology nurse specialist for further advice.
6
11.3 Contact Sensitivity
Patients can become sensitised to elements of their treatment at any time (2). Common
sensitizers include lanolin, perfumes, preservatives, natural rubber latex and topical
antibiotics and should be avoided (2). Patients with suspected sensitivity reactions should be
referred to a dermatology specialist to identify the allergen. After patch testing, identified
allergens must be documented, avoided and medical advice on treatment should be sought
(2).
11.4 Debridement
Wounds may be covered by a combination of sloughy or necrotic tissue, fibrin, exudate and
dressing residue, which can harbour bacteria, increase the risk of infection and can delay
healing by prolonging the inflammatory response (18). Therefore, it is important to remove
devitalised tissue and excess exudate to promote healing. This may be achieved through
autolysis, chemical or enzymatic or mechanical debridement (2).
Debridement methods include:
 Autolysis debridement using dressings such as: hydrogels, hydrocolloids, hydrofibres and
foams.
 Enzymatic debridement.
 Bio-surgery otherwise known as sterile larvae (maggots).
 Sharp debridement: using a blade or scalpel, but this must only be undertaken by a
healthcare professional with specific training.
 Surgical excision: performed by a surgeon in sterile conditions
NB: Decisions about debridement method should be made by a registered health
professional that has undergone appropriate training and demonstrated competence.
11.5 Dressings
There is little evidence to support that any individual dressing is more effective in healing leg
ulcers. The underlying cause must be addressed. For example: venous hypertension,
arterial insufficiency. However, the following principles should be considered when choosing
a dressing:
 easy to apply and remove without causing trauma or pain
 able to cope with various amounts of exudate
 able to mask or minimise odour
 hypo-allergenic
 Low or non adherent. Avoid adhesive dressings or tape on the skin. Tubular bandages
(e.g. Actifast) or cotton bandages may be used to retain non-adhesive dressings in place
without the need for adhesive tape.
 Be cost effective
 Acceptable to the patient
NB: Antimicrobial dressings e.g. silver dressings should only be used when the
wound shows signs of clinical infection and should be used for no longer than 14
days. If the problem has not resolved please refer to the tissue viability service.
Wound care for all leg ulcer types should be recorded on the wound assessment and
evaluation form (Appendix 3)
7
11.0
DIFFERENTIAL DIAGNOSIS, AETIOLOGY & MANAGEMENT
A quick reference pathway for the management of leg ulcers has been include (Appendix 2)
12.1 Venous Ulcer Aetiology
The major cause of leg ulcers in the UK is chronic venous hypertension (2, 3, 19, 20).
Predisposing factors for venous incompetence include: DVT, lower leg fractures, previous
vein or joint surgery, thrombophlebitis. Venous hypertension can also be caused by multiple
pregnancies, obesity or intravenous drug use.
Venous ulcers are usually situated within the gaiter area of the leg and are more prevalent
over the malleoli (ankle bones). Varicose veins may be apparent and the skin may feel hard
and indurated in texture. There may be red/brown staining of the skin due to leakage from
red blood cells (hyper-pigmentation), ankle flare (distension of veins around the malleolus
and foot), atrophie blanche (loss of pigment in the skin due to capillary infarction) and venous
eczema (2, 20).
Venous ulcer prevalence increases with age (19, 20), as does the prevalence of peripheral
arterial disease (PAD), therefore, older patients with predominantly venous ulcers may also
have arterial insufficiency. These ulcers are termed "Mixed aetiology" (2, 13) (See section
12.5). As the conservative treatment for venous leg ulceration is compression therapy, an
assessment of the arterial supply, of the lower leg is essential.
12.2 Venous Ulcer Management
 The first line treatment for uncomplicated venous ulcers is graduated compression
therapy (2, 3, 21). Decisions to use compression therapy should be made by a
registered health professional that has undergone appropriate training and
demonstrated competence.
The following compression bandages are recommended for use in Newham
 4 layer compression bandage
 Short stretch bandage
 2 layer compression system
 Compression hosiery kits
Compression Bandage Systems and Hosiery Kits
Ankle pressures
Application
(18-25cm)
4-Layer
1. Sub-compression
Spiral
wadding
To protect bony prominences
2. Crepe
Spiral
No stretch
3. Light compression
50% overlap & 50% stretch
17 mmHg
Figure 8 application
4. Cohesive bandage
Elasticised bandage.
23 mmHg
50% stretch & 50% overlap
Spiral
Use with sub-compression wadding
Pressure when
Inelastic bandage
Short stretch bandages
moving calf muscle Use with sub-compression wadding
40mmHg
2 layer bandage system
Compression hosiery
kits
40mmHg
25mmHg –
40mmHg
Comfort layer
Compression layer Spiral 50%
overlap
Liners or understocking
Overstocking
8
Examples
Porfore1
Profore 2
Hospicrepe
Profore3
Elset
Profore4
Coban
Actico
Coban 2 layer
system
Mediven
Activa
Hosiery kits
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Chose multi-component compression bandage systems or hosiery capable of sustaining
compression for at least a week. For example, four-layer, 2 layer and short stretch
systems. More frequent application may be required if the ulcer is exuding heavily.
Graduated, multi-component, high compression systems aim to provide 40 mmHg of
pressure at the ankle decreasing gradually to 20 mmHg at the knee if applied according
to manufacturers’ instructions on a leg with a normal shape and normal sized ankle (1825cm).
For more unusual leg shapes use Profore 1 to re-shape the leg.
If the ankle circumference is < 18cms or > 25cms please use the recommended kits or
number of layers of bandage e.g. Profore plus or two layers of short stretch bandage
If no improvement is seen within four weeks of treatment refer to the Tissue Viability
Service for re-assessment and advice. Further referral to the vascular team may be
required.
Ankle, Brachial Pressure Index (ABPI) readings must be taken on all patients prior to the
application of compression therapy.
The ABPI should be between 0.8 and 1.2 and the limb should be adequately padded to
prevent pressure damage. If the ABPI is less than (<) 0.8 but greater than (>) 0.7
reduced compression may be indicated, but only under the recommendation of the
Vascular team/Tissue Viability and should be used with caution by experienced
practitioners.
Patients/carers/practitioners are advised to observe for loss of colour, movement,
sensation or increasing pain levels in compressed limbs. If observed the patient should
be advised to remove the compression layer(s) and call for assistance from the nursing
team.
12.3 Arterial Ulcer Aetiology
About 10 per cent of leg ulcers are caused by arterial occlusion, which causes deprivation of
oxygen and essential nutrients to the skin (12, 13). The prevalence of PAD increases with age
and smoking exacerbates the condition; therefore, patients should be advised to stop
smoking. Arterial ulcers can be found on the foot or the lower leg and are usually small (but
may be larger) and are described as having a 'punched out' appearance and may contain
sloughy or necrotic tissue. The leg may be cold and pale or deep red, blanching when
elevated to approximately 45 degrees from level and slowly recovering its colour when
lowered. Capillary refill time is more than three seconds when a toe is squeezed lightly. The
patient may complain of pain when walking, which subsides with rest (intermittent
claudication (13)). Also, the patient may complain of pain when the limb is elevated, which
resolves when lowered. Arterial ulcers are often more painful on elevation, and as a result
these patients often sleep in a chair or get up frequently in the night to walk about. The skin
on the leg may be shiny and hairless and the toenails may have become thickened, owing to
lack of nutrient diffusion from poor blood supply.
12.4 Arterial Ulceration Management
 Patients who have critical limb ischaemia or ischaemia pain must not have compression
therapy.
 Refer to a vascular services to establish the location and extent of the occlusion or the
presence of small vessel disease and to advise on surgical intervention (2, 7).
 If ABPI is less than 0.7 and the patient shows signs and symptoms of claudication ask for
an “URGENT” referral.
 If the patient presents with gangrene of the feet then a dry dressing should be applied
and urgent referral to vascular services.
9
12.5 Mixed Aetiology Ulceration
A percentage of leg ulcers show signs and symptoms of both arterial and venous disease
and are termed "mixed aetiology" (2, 12, 13, 20). For example: signs of venous hypertension may
be present but the arterial blood supply may be lower than normal.
12.6 Mixed Aetiology Ulcer Management
 If ABPI is below (<) 0.8 but greater than (>) 0.7 and the patient does not show signs or
symptoms of claudication then reduced compression may be used cautiously under the
supervision of the vascular team. This should only be applied by registered clinicians
experienced in compression application and leg ulcer management, and with close
observation for compromised circulation.
 If ABPI is less than (<) 0.7 and the ulcer is not healing, this indicates significant arterial
disease and a referral to a vascular surgeon for assessment is indicated.
 If ABPI less than (<) 0.6 and the patient show signs and symptoms of arterial disease the
referral should be marked as “URGENT”.
12.7 Ulceration in patients with Diabetes Mellitus
Patients with diabetes mellitus may have leg ulcers due to any cause. However, there may
be difficulty in establishing the underlying aetiology due to the diabetic disease process. In
addition, at some time in their life 15 per cent of people with diabetes develop foot ulceration
associated with peripheral neuropathy and/or ischaemia (22, 23, 24) and there is a high
incidence of limb amputation in this group. Patients should have their blood glucose level
and blood pressure and lipid levels monitored and controlled, be advised to stop smoking,
and receive dietary, exercise and foot care advice.
There are 2 main types of diabetic foot ulceration:


Neuropathic ulcers
Ischaemic ulcers
12.7.1 Neuropathic Ulcers.
Damage to the nerves in lower limbs can lead to physiological changes and loss of sensation
in the feet, which increases the risk of developing foot ulcers. Neuropathic ulceration is
associated with callus formation and occurs on the plantar surface of the foot, on bony
pressure points. The skin is usually warm and dry, pulses are palpable but sensation is
impaired. The ulcer may be painless but can penetrate to bone (22). The presence of
neuropathy should be tested using a 10g monofilament and patients should be referred to a
Podiatrist for ongoing sharp debridement of the callus, toe nail cutting, for foot wear
assessment and education (24). Non healing diabetic foot ulcers should be referred to the
multi-disciplinary diabetic foot clinic.
12.7.2 Ischaemic Ulcers
These may be painful, but depends on the degree of neuropathy present. The skin may be
cold, pulses may be absent and ulcers may be seen on the tips of toes. Sensation is often
impaired and there may be evidence of claudication. The patient should be referred to the
vascular team for assessment.
These ulcers are highly susceptible to infection (12) and result in 5-15 per cent of people
needing lower extremity amputation (23). Therefore, medical advice should be sought
immediately if infection is suspected. In addition, the normal signs of infection (redness,
warmth, inflammation and pain), may be absent or diminished therefore wound swabs, for
MC&S, may be taken without other clinical signs of infection being present, especially if the
ulcer is on the foot. All diabetic patients and their carers should be taught how to inspect their
feet daily for trauma and signs of infection. If the patient's sight is also affected by diabetic
10
retinopathy, a suitable supervision plan should be worked out with the patient.
12.8 Management of Ulcers in Patients with Diabetes Mellitus
 Management depends on the underlying aetiology. For example, if venous
hypertension is the cause then treat as Section 12.2, if arterial occlusion is suspected
treat as Section 12.4.
 If the wound is on the foot it is important to inspect the wound daily to detect early any
signs of infection (21).
 Patients at risk of foot ulceration should be identified early and referred to foot clinics,
which offer education, podiatry and footwear advice.
 Patients with non healing diabetic foot ulcers should be referred to the monthly multidisciplinary foot clinic.
 A referral for a vascular assessment is indicated if: the patient has rest pain in the legs,
the ulcers show no signs of healing after four - six weeks, the ulcers are on the foot, or
dry or wet gangrene is apparent. Specialist assessment is essential, as the reliability of
ABPI readings may be limited due to the presence of calcification of the media artery wall.
12.9 Foot Assessment
 Should be carried out by healthcare professionals who have undergone the appropriate
training and competency assessment.
 Monitor blood glucose, pressure and lipid control.
 Foot sensation should be tested using a 10g monofilament.
 Foot pulses should be palpated. A hand held Doppler ultrasound should be used to
detect faint pulses or to assess the quality of the pulse sounds i.e. mono, bi or tri-phasic.
 Inspect both feet for foot deformities and pressure marks from foot wear.
 Identify the patient’s level of risk of developing foot complications using the NICE
guidance (Table 1) (10):
Table 1. Levels of risk associated with foot ulceration and the appropriate action
Category of Risk of Foot
Ulceration
Low Current Risk: normal
sensation, palpable pulses
Increased Risk:
neuropathic or absent
pulses or other factors
High Risk: neuropathy,
absent pulses, foot
deformity, skin changes,
previous ulceration
Foot Ulceration: new
ulceration, pain, swelling,
discolouration
Action

Agree individual management plan including foot care education













Arrange 3-6 monthly reviews by identified clinician
Inspect both feet
Consider need for vascular assessment
Check foot wear
Enhance foot care advice
Arrange 1-3 monthly reviews
Inspect both feet
Consider need for vascular assessment
Specialist footwear and insoles
Enhance foot, skin and nail care and advice
Refer to foot care team within 24 hours
Investigate and treat vascular insufficiency
Initiate and supervise wound management using debridement and
dressings as indicated by wound condition.
Use systemic antibiotics for cellulitis or bone infection
Ensure the weight of the foot is evenly distributed using specialist
footwear, orthotics or casts if necessary
Promote and monitor optimal blood glucose control and other
cardio-vascular risk factors



11
12.10 Malignant Ulceration
Malignancy is a rare cause of ulceration and more rarely a consequence of chronic ulceration
but the possibility should not be overlooked (2). Malignancies may include:- squamous cell
carcinoma, basal cell carcinoma, malignant melanoma, Kaposi's sarcoma, Marjolins ulcer (12,
26). Some characteristics of some malignant ulcers are displayed in Table 2.
Table 2. Characteristics of malignant ulcers
Type
Characteristics
Presentation
Basal Cell
 common, slow
 red/brown
Carcinoma
growing
 dome shaped nodule
 locally invasive
 central ulceration
 raised rolled border
 Translucent pearly appearance
Squamous Cell  aggressive,
 opaque, skin coloured
Carcinoma
malignant
 fleshy papules, nodules or
tumour
plaques
 rapid
 scaly
deterioration
 may have friable surface
Malignant
 malignant
 change in appearance of existing
Melanoma
growth of
mole
pigmented cells  fragile
 inflamed border
 may bleed or discharge fluid
Referral Pathway
 refer to dermatologist for
biopsy and diagnosis
 refer urgently to
dermatologist for biopsy and
diagnosis
 refer urgently to
dermatologist for biopsy and
diagnosis
12.11 Management of Malignant Ulceration
All ulcers suspected to be in this group require urgent referral to the appropriate specialist
for biopsy, diagnosis and treatment. Please refer to tissue viability or dermatology specialist
nurse for Skin Suspected Cancer referral (2 week wait).
12.12 Ulceration in People with Rheumatoid Arthritis
Leg ulceration is common among people with rheumatoid arthritis and this group is at very
high risk of developing coronary arterial disease and peripheral vascular disease (12, 27), even
if they have never smoked. Therefore, they should be referred to a vascular consultant for
assessment. The underlying aetiology in this group is thought to be a combination of:
 local vasculitis
 poor venous return due to immobility of the ankle joint
 Debilitating effect of prolonged steroid therapy on the skin (19).
The ulcers appear:
 deep and well demarcated
 punched out
 very slow to heal
 Often situated on the calf or dorsum of the foot.
NB: Patients with rheumatoid arthritis may also develop ulcers associated with other
diseases (7), so a full holistic assessment is required prior to diagnosis.
12.13.1 Vasculitic Ulcers
Ulcers caused by vasculitis tend to appear suddenly and deteriorate rapidly and are slow to
heal. They may present as multiple, small, 'punched out', painful ulcers. Vasculitic ulcers
are also associated with other, less common, inflammatory connective tissue disorders (12), or
rarely may be caused by reactions to medications.
12.14 Management of Rheumatoid / Vasculitic Ulcers
The treatment is usually systemic steroid therapy, bandaging and bed rest. If vasculitic ulcers
are suspected, the patient should have a medical and vascular assessment as soon as
possible, vasculitic blood screen with potential wound biopsy.
Refer to the pathway for the management of leg ulcers for quick reference (Appendix
2)
12
13.0
PREVENTION OF VENOUS ULCER RECURRENCE
Venous ulceration is associated with a high rate of recurrence, unless the underlying venous
disease can be improved surgically (29, 30). Therefore, all patients whose venous ulcer has
healed should have an individualised prevention of recurrence programme (7, 28).
Programmes should include:















Compression Hosiery - usually for the patient's lifetime (31, 32, 33).
Regular ABPI readings to exclude arterial insufficiency: Three monthly for patients with:
diabetes, immobility, previous ABPI of less than 0.9 and for those who develop symptoms
of claudication. 6-12 monthly for mobile patients with no signs or symptoms of arterial
disease. As a general rule the ABPI should be repeated when the patient is measured
for new hosiery.
Limb measurements - use a disposable tape measure for each patient to prevent cross
infection, these are available from NHS Logistics Authority catalogue. Record limb
measurements in centimetres and document in the patient's notes.
Ankle circumference - taken just above the malleolus at the narrowest point while the
patient is standing or has their foot flat on the floor.
Calf circumference - taken at the widest point while the patient is standing or has their
foot flat on the floor.
Foot length - taken from tip of great toe to heel, for closed toe hosiery and from the base
of the toes to the heel for open toe hosiery. Measure while the patient is standing or has
their foot flat on the floor. Open toed hosiery is recommended when the patient: requests
them, wants to wear a sock on top, has arthritic or misshapen toes, needs to use certain
application aids, (for example, a Chinese slipper), requires podiatrist care or has a fungal
infection.
Below knee length - taken from just below the back of the knee to the base of the heel,
while the patient is standing or has their foot flat on the floor.
Thigh circumference (for thigh length hosiery) - taken at the widest point while the
patient is standing.
Length of the leg (for thigh length hosiery) - taken while the patient is standing. Thigh
length hosiery is usually advised where varicose veins extend above the knee, or when
oedema accumulates above the knee joint or arthritic changes to the knee increase
discomfort from below knee hosiery.
All leg measurements should be taken after a period of elevation, directly on removal of
compression bandaging and preferably just as the patient gets out of bed, before oedema
can develop.
Measure legs separately if compression hosiery is required for both legs.
Patients should be advised to apply the hosiery before they put their feet to the floor in
the mornings, before oedema can develop.
If not already in use, patients with oedema may require treatment with compression
bandages prior to measurement and fitting of compression hosiery.
Condition of skin - the skin on the lower leg should be checked regularly by the patient
or carer, for; dry skin, varicose eczema, ulcer recurrence, pressure damage from
compression, oedema. Patients/carer should be shown how to maintain basic skin care
such as washing with a soap substitute and using an emollient regularly to prevent
dryness, itching and skin cracking. Patients/carers should be advised to apply creams or
ointments in downward strokes to prevent the product accumulating at the base of the
hair shaft, reducing the risk of folliculitis. Products containing perfumes, lanolin or
preservatives should be avoided as these can cause sensitivities, irritation or allergy. Oilbased emollients should be avoided as these can accumulate and damage the material.
Condition of feet - a podiatrist or orthotist may be required if specialist footwear or nail
care is indicated.
13





Allergies or contact sensitivities - ask the patient about allergies to products such as
natural rubber latex, nylon, Lycra, perfumes, emollients etc.
As compression hosiery must be worn every day to be effective it is important to involve
the patient in the decision making process, this includes which stocking, style and colour
they prefer. This may increase concordance.
Depending on the patient/carers abilities the hosiery may be removed at night and
reapplied in the morning or worn for a period of up to 7 days.
Patient education - including skin care, how to apply and when to remove hosiery, how
to launder hosiery, leg and foot exercises, mobility, leg elevation when not mobilising,
when and who to contact at the first sign of ulcer recurrence and when the hosiery is
damaged or due for replacement.
Vascular referral - for investigations such as colour venous duplex studies and surgery if
appropriate. Developments in venous surgery have reduced the need for general
anaesthesia and hospital admission. However, if the patient is adamant they do not want
surgical intervention referral can be omitted. However, it should be documented in their
records that this has been discussed as an option. If the patient changes their mind at
any time then a referral should be made.
13.1 Compression Hosiery
Ready made hosiery is available on FP10, however, for patients with limb sizes outside the
ranges, hosiery can be made to measure and is also available on FP10.
13.2 Classification of Compression Hosiery
There are a number of classification systems for compression hosiery. RAL hosiery offers
higher pressures and is the recommended first choice. However some patients may not be
able to tolerate higher pressures and therefore British class hosiery offers an alternative.
TITLE
AVAILABLE
STRENGTHS
FEATURES
Support Hosiery
Retail Shops
Less than 10mmHg.
Non-Medical
Anti-Embolism
Stockings
Hospitals, for DVT
Prophylaxis
Thrombexin 18®
16 – 18 mmHg.
For patients pre, peri &
post surgery.
Travel Socks
Over the Counter or
mediven® travel
Direct from medi UK
20 mmHg.
(medi is clinically proven)
British Standard
Hosiery
FP10 Prescription
cl 1
14 – 17 mmHg
cl 2
18 – 24 mmHg
cl 3
25 – 35 mmHg
For travel on planes,
trains, cars, coaches and
long journeys.
Clinically effective for up
to 3 months.
4 sizes.
Lower Limb only.
RAL Standard Hosiery
Hospital Prescription
mediven®
Appliances/Orthotics
cl 1 18 – 21 mmHg
Vascular Specialist
cl 2 23 – 32 mmHg
Available on FP10
cl 3 34 – 46 mmHg
cl 4 over 49 mmHg
Clinically effective for up
to 6 months.
7 off the shelf sizes/
custom made.
Comprehensive range of
styles and colours.
13.3 Advice on Prescribing Hosiery
 Article and brand name, for example: Medi compression hosiery
 Compression level: Class 1, 2 or 3.
 Length - below knee or thigh length
 Quantity - single or number of pairs, it is usual to have two stockings per leg, one to wash
and one to wear.
14




Size required - measure ankle, calf and foot to select appropriate size from manufacturers
measuring guide.
Open or closed toe.
Colour - ask the patient as this may improve compliance. See manufacturer’s guide.
For made to measure hosiery: measure limb according to manufacturers instructions, fill
in made to measure form, attach form to prescription sheet requesting made to measure
hosiery from the named company.
13.4 Advice on Fitting Compression Hosiery
Compression hosiery is not put on like ordinary socks, stockings or tights. If the compression
stocking is gathered together in the typical 'doughnut' fashion, the effect of the elastic
material is multiplied and it becomes hard to apply.
To apply correctly: Insert a hand down the shaft of the stocking to the heel pocket only and turn stocking
inside out.
 Position stocking over foot up to heel pocket position, pulling the garment as far along the
foot as possible.
 Gradually unfold/peel the stocking up the leg from the top opening. The last piece of
material to be fitted should be just below the knee or thigh.
 Hosiery should be applied with care to prevent skin trauma and damage to the hosiery.
Using a tubular bandage as a liner may aid application e.g. Tubifast.
 The patient's ability to apply and remove the stockings should be assessed and
application aids considered. For example, Chinese slipper, Actiglide or Medi 2 in 1 which
are available on FP10.
 Patients unable to apply stockings will need assistance from a relative, friend or other
carer who should be trained to apply the hosiery correctly.
 The patient/carer should be advised about how to care for the stockings and the
information should be given verbally from the manufacturers instructions as well as
leaving the instructions for them to read. For example, wash in warm soapy water, let the
stockings dry naturally away from direct heat and not over a radiator or near a fire, ensure
nails and hands are free from snags to prevent ladders.
 Once the patient has been fitted with hosiery they should be followed up to check
comfort, fit, skin condition and their ability to manage and level of compliance. It is also
important to check that the hosiery is having the desired therapeutic effect.
 Patients should be advised to contact a named healthcare professional immediately if
they have problems or concerns about the skin on their leg. Early intervention might
prevent ulcer recurrence or deterioration.
 As a general guide, patients should be re-measured, re-Doppler and stockings replaced
every 6-12 months (see manufacturer’s instructions for details).
 Patients/carers should be supplied with an educational leaflet to reinforce any advice
given verbally.
13.5 Potential Hazards of Compression Hosiery
 Pressure damage due to undiagnosed arterial disease or badly fitting hosiery.
 Friction or pressure damage due to ill fitting hosiery. Usually seen over the tips and joints
of toes, mid foot, medial and lateral malleoli, tibial crest or the anterior bend in the ankle
 Tourniquet effect caused by badly applied hosiery.
 Skin irritation or allergies.
 Compression hosiery should be used with caution when treating patients with diabetes
mellitus or rheumatoid arthritis because these patients are susceptible to small vessel
disease and compression could cause further occlusion and pressure necrosis.
15
14.0
EXERCISES
Poor mobility and fear of falling are common problems for older patients with leg ulceration.
An assessment of the patient's ability to walk should be performed and documented. The
problems may be due to oedema, pain, joint stiffness and obesity etc. It is important that a
patient’s mobility is maintained and improved, as this will aid venous return, by moving the
calf muscle pump, in addition to reducing the risk of developing other problems associated
with immobility (12). Patients should be advised to walk, where possible and, if able, perform
ankle and foot exercises while sitting and standing. A referral to the physiotherapist may be
indicated. When resting, those patients with venous disease and/or oedema should be
advised to elevate their legs, with ankles slightly above hip level, rather than sitting with their
legs hanging down. This may be more easily achieved by resting on a bed or sofa with
pillows/cushions underneath the lower section of the leg. Foot stools are not recommended
as they are generally not high enough to reverse venous hypertension and reduce oedema
and they can increase pressure at the heel, which may increase the risk of pressure
ulceration in this area for 'At Risk' patients.
15.0
EDUCATION & TRAINING
Health care professionals involved in the care of patients with leg ulcers should have
attended the two day leg ulcer workshop and be knowledgeable and skilled in the following
areas;
 Pathophysiology of leg ulceration
 Leg ulcer assessment & differential diagnosis skills
 Use of Doppler ultrasound to measure ABPI
 Normal and abnormal wound healing
 Compression therapy - theory, management and application
 Dressing selection
 Skin care and management
 Health education
 Prevention of recurrence
 Criteria for referral for specialised assessment, including vascular services
16
REFERENCES
1. Local Guideline for the assessment and management of leg ulcers. (2003) Tissue
Viability Service. Enfield Community Services.
2. RCN. (2006) Clinical Practice Guidelines: The management of patients with venous
leg ulcers. London. Royal College of Nursing.
http://www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf
3. World Union of Wound Healing Societies (WUWHS) (2008). Principles of best practice:
Compression in venous leg ulcers. A consensus document. London. MEP Ltd.
http://www.wuwhs.org/datas/2_1/9/Compression_VLU_English_WEB.pdf
4. Callum MJ., Ruckley CV., Harper DR., and Dale JJ. (1985) Chronic ulceration of the leg:
extent of the problems and provision of care. British Medical Journal. 290. 1855-1856.
5. Bosanquet N. (1992) Cost of venous ulcers: from maintenance therapy to investment.
Phlebology. 7 supplement 1. 44-46.
6. Charles H. (1995) The impact of leg ulcers on patients' quality of life. Professional Nurse.
10. (9): 571-574.
7. Price P., and Harding K. (1996) Measuring Health-Related Quality of Life in Patients with
Chronic Leg Ulcers. Wounds. 8. (3). 91-94.
8. Hayes M. (1997) Quality of life in patients with chronic leg ulceration. Journal of Wound
Care. 67. 348-349.
9. Franks PJ. (1998) Who suffers most from leg ulceration? Journal of Wound Care. 7. (8):
383-385.
10. NICE (2004) Clinical Guidelines for Type 2 Diabetes: Prevention and management of foot
problems. National Institute for Health and Clinical Excellence.
http://www.nice.org.uk/nicemedia/pdf/CG10fullguideline.pdf
11. Dale J. (1996) The Aetiology of Leg Ulceration. In Cullum N. and Roe B. (eds) Leg
Ulcers- Nursing Management: A research based guide. London. Bailliere Tindall. 9-15.
12. Morison M., and Moffatt C. (1994) A Colour Guide to the Assessment and Management
of Leg Ulcers. Mosby. Bucks.
13. Herbert LM. (1997) Caring for the Vascular Patient. London. Churchill-Livingstone
14. THRIFT Guidelines (1992) British Medical Journal. 305. 567-574.
15. NICE (2005) Nutritional Support in adults: Clinical guideline. National Institute for Health
and Clinical Excellence. London www.nice.org.uk/page.aspx?o=292900
16. DH (2003) Essence of Care Patient-focus benchmarks for clinical governance: Food &
Nutrition. Department of Health.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4127
915.pdf
17
17. BNF (2009) September. British National Formulary.
18. Flanagan M. (1997) Wound Management. Churchill Livingstone. London.
19. Browse N., and Burnand KG. (1982)The cause of venous ulceration. Lancet 2. 243-245.
20. Cullum N. and Roe B. (1996) Leg Ulcers: Nursing Management - A Research-based
Guide. Bailliere Tindall. London.
21. European Wound Managment Association (2003) Understanding Compression Therapy.
EWMA Position Document. Medical Education Partnership Ltd. London.
22. Boulton A., Connor H., and Cavanagh P. (1995)The Foot in Diabetes. Wiley. Chichester.
23. Edwards L. and Foster A. (1999) The complexities of wound management in the diabetic
foot. Journal of Community Nursing. 13. (2). 20 - 30.
24. Effective Health Care Bulletin (1999) Complications of diabetes: Screening for retinopathy
& Management of foot Ulcers. NHS Centre for Reviews and Dissemination. University of
York. Churchill Livingstone.
25. Ackroyd J.S, and Young AE. (1983) Leg ulcers that do not heal. British Medical Journal.
286. 207-208.
26. Baldursson B., Sigureirsson B., Lindelof B. (1995) Venous leg ulcers and squamous cell
carcinoma: a large scale epidemiological study. British Journal of Dermatology. 133.
571-574.
27. King B. (2005) Diagnosing and treating unusual aetologies of lower leg ulcers. Nursing
Times. 100. (4). 44-46.
28. Lambert E., and McGuire J. (1989) Rheumatoid leg ulcers are notoriously difficult to
manage. How can one distinguish them from gravitational and large vessel ischaemic
ulceration? What is the most cost effective treatment? British Journal of Rheumatology.
28. (5). 421.
29. Coull A., and Clark M. (2005) Best Practice Statement for compression hosiery. Wounds
UK. 1. (1). 70-78.
30. Callum M.J., Harper D.R., Dale J.J. and Ruckely C.V. (1987) Chronic ulceration of the
leg: clinical history. British Medical Journal. 294: 1389-1391.
31. Moffat C.J., Franks P.J., Oldroyd M., Bosanquet N., Brown P., Greenhalgh R.M. and
McCollum C.N. (1992) Community clinics for leg ulcers and impact on healing. British
Medical Journal. 305. 1389-1392.
32. Armstrong S. (1997). Compression Hosiery. Professional Nurse Supplement. 12. (7).
S10-S11.
33. Moffatt C. and O'Hare L. (1995) Graduated Compression Hosiery for Venous Ulceration.
An update on compression hosiery for the management of venous leg ulcers. Journal of
Wound Care. 4. (10). 459-462.
18
34. Blair S., Blackhouse C., and Wright D. (1988) Sustained compression and healing
chronic venous ulcers. British Medical Journal. 297. 1159-1161.
APPENDIX 1
Leg Ulcer Assessment Form
19
LEG ULCER ASSESSMENT
NAME
GP
ADDRESS
GP ADDRESS
TELEPHONE NO.
DATE OF BIRTH
GP TEL NO.
INITIAL ASSESSMENT DATE:
DATE OF LAST
To be reassessed on:
ABPI
DATE OF LAST
ASSESSMENT
PREVIOUS
ULCER
TREATMENTS:
DRUG
ALLERGIES:
ALLERGIES TO TOPICAL
PRESENT
PREPARATIONS/DRESSING/ MEDICATION:
PATCH TEST RESULTS:
MOBILITY
NEGOTIATES STAIRS
SLEEPS
NO LIMITATIONS
WALKS WITH AIDS
CHAIR BOUND
TOILET
TO GO TO BED
WHEN OUT
IN BED
IN CHAIR
OTHER
OTHER INFORMATION
HEIGHT
HB
WEIGHT
WBC
BODY MASS INDEX
IRON
URINALYSIS
ALBUMIN
To be reassessed on:
20
DATE
RESULT
BM stick
SUGAR
BLOOD PRESSURE
OTHER
WATERLOW SCORE
HB
ULCER SWABBED?
SMOKE
S
No. per day
never
Gave up how long ago?
RELEVANT MEDICAL HISTORY: (PLEASE TICK)
ANAEMIA
DIABETES
PULMONARY EMBOLISM
ISCH. HEART DISEASE
T.I.A / CVA
ABDOMINAL
SURGERY
VASCULAR SURGERY
MYOCARDIAL INFARCTION
PAIN
CONSTANT
CLAUDICATION
MALIGNANCIES
ARTHRITIS
PREGNANCY
INFLAMMATORY BOWEL
DISEASE
CELLULITIS
THROMBOPHLEITIS
DEEP VEIN THROMBOSIS
LEG OEDEMA
LOWER LEG FRACTURES
OTHER
VARIOSE VEINS
V.V SURGERY
INTERMITTENT
DURING DAY
AT NIGHT
AT DRESSING
CHANGE
NONE
MODERATE
SEVERE
HAS PAIN BECOME WORSE DURING THE LAST TWO WEEKS?
YES
NO
WHAT HELPS?
Refer to Pain Team as appropriate
Date referred:
Outcome:
HOW DOES THE ULCER AFFECT THE PATIENT? (WRITE PATIENT’S OWN WORDS)
NUTRITION: (IF ANY TICK BOX BELOW TICKED PLEASE COMPLETE FULL DIETARY ASSESSMENT SHEET)

WEIGHT LOSS IN LAST THREE MONTHS (NON INTENTIONAL)

BODY MASS INDEX BELOW 19

POOR APPETITE/INTAKE

HIGH EXUDATE FROM LEG ULCER/CELLULITIS/INFECTION
21
ULCER HISTORY:
(PLEASE TRACE ULCER AND ATTACH WITH WOUND ASSESSMENT FORM)
RIGHT LEG
DURATION OF PRESENT
ULCER (MONTHS)
TIME SINCE FIRST ULCER
APPEARED (YEARS)
NUMBER OF EPISODES
SURROUN
DING SKIN
INTACT
DRY ECZEMA
WET ECZEMA
CELLULITIS
MACERATION
LYMPHOEDEMA
LEFT LEG
RIGHT
LEFT
RESTRICTE
D
FIXED
R
L
ULCER BASE
R
L
FLAT
‘PUNCHED OUT’
EPITHELIALISING
GRANULATING
LOOSE SLOUGH
SLOUGH WITH SOME
GRANULATION
HARD, YELLOW SLOUGH
HARD, BLACK SLOUGH
INFECTED
TENDONS VISIBLE
HIGH EXUDATE
MODERATE EXUDATE
ROLLED EDGE
LEFT
OEDEMA
BLANCHED
EXCORIATED
SHINY
HARD
ANKLE
CIRCUMFERENCE:
ANKLE
MOBILITY
FULL
RIGHT
DATE:
NOTE:
NURSING DIAGNOSIS OF AETIOLOGY
OF ULCER
CLINICAL FINDINGS TOGETHER WITH
ABPI AND DOPPLER SOUNDS MUST BE
CONSIDERED BEFORE DIAGNOSIS IS
MADE
VENOUS/ ARTERIAL/ MIXED AETIOLOGY/
TRAUMATIC/ DIABETIC/ RHEUMATOID/
VASCULITIC/ OTHER__________________________
PLAN OF ACTION
REMEMBER TO CHOOSE THE APPROPRIATE BANDAGE SYSTEM BASED ON ANKLE CIRCUMFERENCE
REFERRALS:
INFORMATION GIVEN TO PATIENT:
ASSESSMENT MADE BY
DATE:
VERBAL
DATE
WRITTEN
PRINT NAME
22
DOPPLER REASSESSMENT SHEET
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
DATE:
RESTING PRESSURE INDEX: POSITION OF PATIENT DURING DOPPLER =
DOPPLER (INSERT
RIGHT
LEFT
TRI-PHASIC/BI-PHASIC/MONO-PHONIC SOUNDS?
PRESSURE
BRACHIAL
DORSALIS PEDIS
POST TIBIAL
ABPI
23
APPENDIX 2
Pathway for the Management of Leg
Ulcers
24
Pathway for the Management of Leg ulceration
Patient presents
with a wound on
the lower leg
Complete a
full leg ulcer
assessment
Wound
assessment and
measurement
Make a differential diagnosis. If
unsure of ulcer aetiology refer to
tissue viability service
Venous leg
ulcer
Commence compression therapy based on
ankle circumference
Arterial leg
ulcer
Vascular referral for further investigations
Local wound care and non compression
Mixed leg ulcer
Refer to tissue viability service for possible
reduced compression
Diabetic foot
ulcer
Refer to foot health/vascular service
Local wound care and non compression
Ulcers of
unusual
Refer to tissue viability service.
Malignant ulcers for biopsy.
Vasculitic/rheumatoid for vascular review
Outcome
Ulcer fails to heal
Reassess
Education
Refer to tissue viability
for advice
Ulcer heals
Education
Prevention of
recurrence
Hosiery
25
APPENDIX 3
Wound Assessment and Evaluation Form
26
WOUND ASSESSMENT & EVALUATION FORM
Patient Name: _________________
Date of birth: ______________
Assessment date: ______________
Named nurse:____________
Location of wound:
Type of wound:
Pressure Ulcer
 Leg Ulcer
o Venous
o Arterial
o Mixed
 Diabetic Ulcer
 Traumatic wound
 Skin tear / laceration
 Burn / scald
 Surgical wound
 Fungating lesion
 Other (please state)
__________________

Cause of Wound (e.g. pressure, shear, trauma,
Wound Duration (e.g. age of
shoes, etc.)
wound _______________
Cause of Wound (e.g. pressure, shear,
trauma, shoes, etc.)
Factors which could delay healing
Wound Duration (e.g. age of
wound _______________
 Immobility
Factors
which could delay healing
Anaemia
Circulatory disorders
Respiratory
Anaemia disorders
Allergies
Circulatory disorders
Other
________________
Respiratory
disorders
Allergies
Other (please state)
Diabetes
 
Poor
nutritional status
Immobility
 
Dehydration
Diabetes
 
Incontinence
Poor nutritional status
 
Infection
Dehydration
 Incontinence
Dressing regime (tick primary and secondary)
 Infection






Hydrogel
Alginate
Hydrofibre
Hydrocolloid
Other _______________
Foam
Antimicrobial : name____________
Semi-permeable film
Dressing Frequency _____________
27
WOUND EVALUATION
Please enter amount or tick as appropriate
Start
Week
Date
1
2
3
4
5
6
Wound
Length in cm
Width in cm
Depth in cm
Black ~
% necrotic
Green ~
% infected
Yellow ~
% sloughy
Red ~
% granulating
Pink ~
% epithelialising
Wound margin
oedema
erythema
macerated
healthy / intact
*Wound exudate
high
moderate
low
Wound odour
(yes / no)
Pain [at dressing
change]
(yes /
no)
Dressing Frequency
Signature / initials
*Exudate
S - Serous
H - Haemoserous
28
P - Purulent
7
8
APPENDIX 4
Equality Impact Assessment
29
Equality Impact Assessment for Clinical practice Guideline
Leg ulcer prevention and management
Directorate
Tissue Viability
Specialist
Services
Provider
Name of Function or Policy or Major Service Change
Leg ulcer prevention and management
Clinical practice Guideline
Manager responsible for assessment
Date of assessment
New or existing?
Dr Caroline Dowsett
Nurse Consultant
28.7.2011
New
Defining what is being assessed
1. Briefly describe the purpose and
objectives
2. Who is intended to benefit, and in
what way?
3. What outcomes are wanted?
5. Who are the main stakeholders?
6. Who implements this and who is
responsible?
To raise awareness of leg ulcer prevention and
management strategies
To provide a basis for standardised, evidence
based care
To support the development of quality care for
patients
To support the implementation of NICE
guidelines on leg ulcer assessment and
management
All Newham patients at risk of or with an
existing leg ulcer
Multi-disciplinary teams and agencies involved
in the patients care pathway
All patients with an ulcer on the lower limb to
have a full leg ulcer assessment
The patients management plan to address the
underlying cause of the ulcer
Improved outcomes for patients: Healing
rates/recurrence rates
Patients and carers
General practitioners and community nurses
Allied health professionals
Specialists services
Tissue Viability team and all users of the policy
Assessing impact
7. Are there concerns that
there could be a differential
impact due to racial groups?
YES
Brief statement of main issue
NO√
What evidence exists for this?
Guideline covers all groups
30
8. Are there concerns that
there could be a differential
impact due to disability?
YES
Brief statement of main issue
NO√
What evidence exists for this?
9. Are there concerns that
there could be a differential
impact due to gender?
Guideline covers all service users
YES
Brief statement of main issue
NO√
What evidence exists for this?
10. Are there concerns there
could be a differential impact
due to sexual orientation?
Guidelines relevant to all genders
YES
Brief statement of main issue
NO√
What evidence exists for this?
11. Are there concerns there
could be a have a differential
impact due to faith or belief?
What evidence exists for this?
12. Are there concerns there
could be a differential impact
due to people’s age?
What evidence exists for this?
13. Are there concerns that
there could be a differential
impact due to being transgendered or transsexual?
What evidence exists for this?
14. Are there any other groups
that would find it difficult to
access/make use of the
function (e.g. people with
caring responsibilities or
dependants, location or those
with an offending past)?
YES
Brief statement of main issue
NO√
Guidelines relevant to all groups regardless of faith
or belief
YES Brief statement of main issue
NO√
Guideline are not age specific
YES
Brief statement of main issue
NO√
Guideline does not specify gender
If yes, which group(s)?
YES
NO√
What evidence exists for this?
15. Are there concerns there
could be a have a differential
impact due to multiple
discriminations (e.g. disability
and age)?
What evidence exists for this?
YES
Brief statement of main issue
NO√
31
Conclusions & recommendation
16. Could the differential
impacts identified in
questions 7-15 amount to
there being the potential for
adverse impact?
17. Can the adverse impact be
justified on the grounds of
promoting equality of
opportunity for one group? Or
another reason?
YES
NO
YES
Brief statement of main issue
N/A
Please explain
N/A
NO
Recommendation to proceed to a full impact assessment?
NO
This function/ policy/ service change complies with the requirements of the
legislation and there is evidence to show this is the case.
NO,
BUT
…
What is required to ensure
this complies with the
requirements of the
legislation? (see EIA
Guidance Notes)?
YES
Minor modifications necessary (e.g. change of ‘he’ to ‘he or
she’, re-analysis of way routine statistics are reported)
Give details of key person
responsible and target
date for carrying out full
impact assessment (see
EIA Guidance Notes)
32
Tissue Viability Service Clinical Practice Guideline: Leg Ulcer Prevention & Management
2011