Journal of Community Nursing - page 43

2013,Vol 27, No 4
atients with disease of the
venous and/or lymphatic
system undergo a number of
skin changes on the lower limb(s)
as a consequence of underlying
disease processes (Timmons and
Bianchi, 2008). These changes
can easily be detected during
routine cleaning and assessment
of the patient’s limb(s) and skin,
and, once identified, can be
appropriately managed to slow
disease progression. If venous or
lymphovenous disease is allowed
to progress untreated, however,
the patient will gradually develop
more severe skin changes over time
(Timmons and Bianchi, 2008). For
example, symptoms such as varicose
veins could eventually lead to leg
ulceration and/or chronic oedema
if the underlying disease process is
not addressed.
The CHROSS Checker: a tool kit to detect
early skin changes associated with
venous and lymphovenous disease
This article describes how
venous and lymphovenous disease
results in skin changes and how to
use the CHRonic Oedema Signs
and Symptoms (CHROSS)Checker
Figure 1
). This tool kit has been
designed to raise awareness of the
signs and symptoms of venous and
lymphovenous disease, and make
skin changes easy to spot and
assess in clinical practice. The kit
also provides recommendations
for the most appropriate
compression hoisery to manage
disease (according to the severity
and type of signs/ symptoms)
as part of an overall treatment
plan to improve patient care and
The venous system
Blood travels through the arteries
away from the heart, carrying oxygen
and nutrients to the tissues and
organs of the body, and returns via
the veins, carrying waste products
and carbon dioxide.
Arteries have thick, elastic walls,
as blood is ejected from the heart
under pressure. The main arteries
branch into smaller vessels, the
arterioles, then into even smaller
ones, the capillaries, that reach the
tissues and organs. The walls of the
capillaries are only one cell thick
so that oxygen, glucose and other
substances can pass from the blood
into the interstitial fluid (the fluid that
bathes all of the cells in the body),
then into the tissues and organs.
The capillaries are where the
arterial system of blood vessels end
and join the vessels that make up the
venous system. From the capillaries,
blood flows into small veins that
are known as venules, which in
turn, join the large veins that return
deoxygenated blood and waste back
to the right side of the heart. The
blood travelling in the veins is under
less pressure than in the arteries, so
these vessels have thinner walls. As
a result, the veins are able to expand
depending upon the volume and
pressure of blood inside. For example,
if there is a low volume of blood and
therefore low pressure in the vein, the
veins are flat, whereas if the volume
and therefore pressure increases,
the vein expands (Starr et al, 2008;
Koeppen and Stanton, 2010).
The venous network is made up of
three types of veins (
Figure 2
Deep veins which lie within the
muscles of the arms and legs and
carry blood back to the heart
Superficial veins, nearer the
surface of the skin, which carry
blood from the skin back to the
deep veins
Perforator veins that join the deep
and superficial systems.
In the lower limbs, blood
returning to the heart has to travel
Janice Bianchi, Independent Medical Education
Specialist and Honorary Lecturer, Glasgow
In patients with venous and lymphovenous disease, skin changes
to the lower limb(s) occur gradually, and become more serious over
time if left untreated. The CHRonic Oedema Signs and Symptoms
(CHROSS) Checker is a tool kit consisting of an assessment chart
and key cards that have been developed to help clinicians easily
identify the skin changes that occur as a result of underlying venous
and lymphovenous disease, when carrying out holistic patient
assessment. It also provides clear guidance on which compression
products can be used to manage the disease type and severity of
skin change. For clinicians unfamiliar with some or all of the signs
and symptoms listed on the CHROSS Checker chart, the key cards
contain further information in the form of a photograph, definition
and cause of each sign and symptom listed. This article will describe
the theory behind the development of the CHROSS Checker tools
and explain how to use them in clinical practice.
Skin changes
Venous disease
Chronic oedema
Lymphovenous disease
CHROSS Checker
Janice Bianchi
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