Journal of Community Nursing - page 46

46
JCN
2013,Vol 27, No 4
WOUND CARE
Competent
venous valve
Incompetent
venous valve
Figure 5.
Skin changes occurring as a result of venous insufficiency. If the venous valves are
competent, blood is prevented from flowing backwards on relaxation of the calf muscle.
However, if there is valvular incompetency, blood flows backwards causing venous
congestion and high pressure in the veins, which ultimately result in skin changes.
Varicose veins
Varicose eczema
Ulceration
Induration
Hyperpigmentation
Oedema
trigger inflammatory processes in the
tissue, which results in skin changes
such as induration, varicose eczema
and lipodermatosclerosis.
The increased volume of blood
also puts extra pressure on the
perforating and superficial veins. As
these veins stretch, their valves do
not close properly so they can no
longer prevent a backflow of blood.
The volume of blood within the veins
increases further, raising blood pressure
in the vein, causing it to stretch and
resulting in more fluid leaking out
into the tissues. Stretching of the veins
leads to their becoming varicose.The
lymphatic system then becomes unable
to cope with the extra volume of fluid,
leading to a worsening of oedema and
chronic high blood pressure in the
vein (venous hypertension).This is the
main underlying cause of venous leg
ulceration and lymphovenous oedema.
Severe skin changes, such as leg
ulceration, or swollen or wet leaky
legs, can have a huge negative impact
upon patient quality of life, and can
lead to social isolation and depression
(Persoon et al, 2004; Jones, 2008).
Furthermore, these outcomes are
costly in terms of treatment and carry
an increased risk of the development
of complications, including cellulitis
(Anderson, 2006; 2008). Once a
patient contracts cellulitis, they are
at increased risk of further episodes,
which can result in admission to
hospital and associated spiralling costs
(Clinical Resource Efficiency Support
Team [CREST], 2005).
Such severe signs and symptoms
of venous and/or lymphatic disease
generally do not occur out of the blue,
but begin as mild skin changes that
can become worse with time if the
underlying failure of the venous and
lymphatic systems is left unchecked.
However, if these skin changes are
recognised as signs that the venous
and lymphatic systems are not working
normally, further assessment of the
patient will allow a management plan
to be put in place that prevents or
delays the worsening of the condition.
THE CHROSS CHECKER
The CHROSS Checker chart (
Figure 1
)
allows an easy three-step approach to
identifying signs of venous/lymphatic
disease during skin assessment, and
aids the user in selecting an appropriate
compression product to manage the
limb(s), according to disease severity, as
part of an overall care plan.
An article by Bianchi and Timmons
(2008) first outlined the concept of
skin changes and disease progression.
Following a consensus meeting of
clinical experts, they identified key
skin changes that occur as a result of
venous/lymphatic disease, and graded
them according to severity and a need
for preventive, early/moderate or
intensive intervention. The CHROSS
Checker takes these principles and
presents them in a simplified three-
step chart that is quick and easy to use
in clinical practice.
The CHROSS Checker should
be used as part of holistic patient
assessment, to raise awareness and
detection of skin changes on the
lower limb. It can be used while
assessing any patient to identify the
early signs of venous disease, the
worsening of skin changes, or for
advanced skin changes and severe
symptoms presented for the first time.
Even the most severe skin changes
can be improved through correct
management, so it is never too late to
identify them and intervene.
For clinicians unfamiliar with
any of the conditions listed on the
chart, CHROSS Checker key cards
are available, providing further
information on each of the conditions,
including a photograph of the skin
change, a description of the condition,
a brief explanation of its cause (
Figure
6
) and, on its reverse, the compression
management strategy recommended
(
Figure 7
). The signs/symptoms listed
on the key cards are colour-coded
according to their presentation on
the chart (green for those requiring
preventative management, orange for
eary/medium intervention and red
for intensive management), for quick
referencing.
When using the CHROSS
Checker in conjunction with holistic
patient assessment, the clinician
can systematically examine the limb
for skin changes and implement
treatment if appropriate.
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