Practice Recommendations

PRACTICE RECOMMENDATIONS

*Type of Evidence

Comprehensive Assessment

1

Assessment and clinical investigations should be undertaken by healthcare professional(s) trained and experienced in leg ulcer management.

C

2

A comprehensive clinical history and physical examination includes:

• blood pressure measurement;
• weight;
• blood glucose level;
• doppler measurement of Ankle Brachial Pressure Index (ABPI);
• any other tests relevant to presenting patient’s condition;
• ulcer history;
• ulcer treatment history;
• medical history;
• medication;
• bilateral limb assessment;
• pain;
• nutrition;
• allergies;
• psychosocial status (including quality of life); and
• functional, cognitive, emotional status and ability for self-care.

The above should be documented in a structured format for a client presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.

C

3

A comprehensive assessment of an ulcer should include:

• measurement of the wound and undermining;
• amount and quality of exudate;
• wound bed appearance;
• condition of the wound edge;
• infection;
• presence or absence of patient suffering; and
• re-evaluation.

Measure the surface areas of ulcers, at regular intervals, to monitor progress.Maximum length and width, or tracings onto a transparency are useful methods.

C

B

4

Regular ulcer assessment is essential to monitor treatment effectiveness and healing goals.

C

            Diagnostic Evaluation

5

An Ankle Brachial Pressure Index (ABPI) measurement should be performed by a trained practitioner to rule out the presence of peripheral arterial disease, particularly prior to the application of compression therapy.

B

6

An Ankle Brachial Pressure Index (ABPI) >1.2 and <0.8 warrants referral for further medical assessment.

C

7

Prior to debridement, vascular assessment, such as Ankle Brachial Pressure Index (ABPI), is recommended for ulcers in lower extremities to rule out vascular compromise and ensure healability.

C

            Pain

8

Pain may be a feature of both venous and arterial disease, and should be addressed.

B

9

Prevent or manage pain associated with debridement. Consult with a physician and pharmacist as needed.

C

            Venous Ulcer Care

10

Develop treatment goals mutually agreed upon by the patient and healthcare professionals, based on clinical findings, current evidence, expert opinion and patient preference.

C

11

Local wound bed preparation includes debridement when appropriate, moisture balance and bacterial balance.

C

12

Cleansing of the ulcer should be kept simple; warm tap water or saline is usually sufficient.

B

13

First-line and uncomplicated dressings must be simple, low adherent, acceptable to the client and should be cost-effective.

A

14

Avoid products that are known to cause skin sensitivity, such as those containing lanolin, phenol alcohol, or some topical antibiotic and antibacterial preparations.

C

15

Choose a dressing that optimizes the wound environment and patient tolerance.

C

16

No specific dressing has been demonstrated to encourage ulcer healing.

A

17

In contrast to drying out, moist wound conditions allow optimal cell migration, proliferation, differentiation and

neovascularization.

A

18

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.

B

19

Venous surgery followed by graduated compression hosiery is an option for consideration in clients with superficial venous insufficiency.

A

               Infection

20

Assess for signs and symptoms of infection.

A

21

Manage wound infection with cleansing and debridement, as appropriate. Where there is evidence of cellulitis, treatment of infection involves systemic antibiotics.

B

22

The use of topical antiseptics to reduce bacteria in wound tissue should be reserved for situations in which concern for

bacterial load is higher than that of healability.

C

          Compression

23

The treatment of choice for venous ulceration uncomplicated by other factors is graduated compression bandaging, properly applied and combined with exercise. (Level A)

• In venous ulceration, high compression achieves better healing than low compression. (Level A)
• Compression bandages should only be applied by a suitably trained and experienced practitioner. (Level B)
• The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting compression stockings. (Level B)
• Ankle circumference should be measured at a distance of 2.5 cm (one inch) above the medial malleolus. (Level C)

24

External compression applied using various forms of pneumatic compression pumps can be indicated for individuals with chronic venous insufficiency.

A

25

The client should be prescribed regular vascular exercise by means of intensive controlled walking and exercises to improve the function of the ankle joint and calf muscle pump.

A

         Complementary Therapies

26

Consider electrical stimulation in the treatment of venous leg ulcers.

B

27

Therapeutic ultrasound may be used to reduce the size of chronic venous ulcers.

A

         Reassessment

28

If signs of healing are not evident, a comprehensive assessment and re-evaluation of the treatment plan should be carried out at three month intervals, or sooner if clinical condition deteriorates.

C

29

For resolving and healing venous leg ulcers, routine assessment at six-month intervals should include:

• physical assessment;
• Ankle Brachial Pressure Index (ABPI);
• replacement of compression stockings; and
• reinforcement of teaching.

C

         Client Education for Secondary Prevention

30

Inform the client of measures to prevent recurrence after healing:

• daily wear of compression stockings, cared for as per manufacturer’s instructions and replaced at a minimum every six months;
• discouragement of self-treatment with over-the-counter preparations;
• avoidance of accidents or trauma to legs;
• rest periods throughout the day with elevation of affected limb above level of heart;
• early referral at first sign of skin breakdown or trauma to limb;
• need for exercise and ankle-joint mobility;
• appropriate skin care avoiding sensitizing products; and
• compression therapy for life with reassessment based on symptoms.

C