Journal of Community Nursing - page 62

62 JCN
2013,Vol 27, No 4
WOUND CARE
Venous leg ulcers are one of the
severest complications of venous
disease and are the most common
type of lower leg ulceration (SIGN,
2010), usually affecting older people.
Chronic venous leg ulceration
involves considerable morbidity and
can have a particularly deleterious
effect on quality of life (Persoon et
al, 2004; SIGN, 2010). It is also true
that healing a venous leg ulcer is
only the first stage in what will often
be a long-term management plan,
including compression, as recurrence
rates vary (Anderson, 2013).
ARTERIAL DISEASE
Arterial problems develop when the
flow of blood through the arteries is
impaired. The main cause is build-up
of fatty deposits (atheroma) that form
plaques on the inside of the artery
wall, narrowing the lumen of the
artery over time and impeding blood
flow (Dowsett, 2006). This, in turn,
impairs the supply of oxygen and
nutrients to the lower limb, resulting
in poorly perfused tissues and,
eventually, ulceration.
According to the SIGN guidelines
(2010), up to 22% of leg ulcers
are caused by peripheral arterial
disease, which is indicated by a
history of intermittent claudication,
cardiovascular disease, or stroke
(SIGN, 2010). The absence of
symptoms (see below) does not
necessarily exclude arterial disease,
but it can be ruled out by performing
ankle brachial pressure index (APBI)
measurements using a Doppler
assessment — compression therapy
may be safely used in leg ulcer
patients with an ABPI greater than or
equal to 0.8 (SIGN, 2010).
Symptoms of arterial disease
include (SIGN, 2010):
Ulcers (a ‘punched-out’
appearance)
Pain, cramping, aching in the
lower limb
Lack of hair growth beneath
the knee
Poor toenail growth
Cool feet
Weak or absent pulse in the lower
limb arteries
Slow capillary refill time in foot
Increased pain on elevation of legs.
As well as the initial development
of ulcers, the lack of oxygen delivered
to the lower limbs means that
when they do occur, they may be
particularly hard to heal.
MIXED AETIOLOGY ULCERATION
As the name suggests, mixed
aetiology ulcers have a number of
causes, often displaying both venous
and arterial insufficiency, although
they can also involve diabetes
mellitus and rheumatoid arthritis
(Ousey and McIntosh, 2008). Mixed
aetiology ulcers often occur as a
result of chronic venous problems
in the lower limb being exacerbated
compression can have benefits. The
aim of reduced compression is to
lessen venous pressure and lower
limb oedema, but not to significantly
compress the arteries and impede
arterial blood flow.
As mentioned above, reduced
compression is useful in patients
with an ABPI of between 0.8 and
0.5 (Anderson and King, 2006), but
they should be regularly monitored
for pain or a reduction in their
ABPI. British standard class 1 and 2
compression hosiery can be useful
(Anderson and King, 2006), as there
is low pressure exerted at rest, but
higher pressure on exertion
(Stacey et al, 2002).
Compression in elderly patients
According to the SIGN guidelines,
patients regularly cite problems
with pain, discomfort and lack of
appropriate advice as reasons for
non-concordance with compression
therapy (SIGN, 2010). In elderly
patients, concordance issues can
be exacerbated, due to mobility
(patients with poor mobility may
find it hard to apply compression
themselves) and in some cases,
cognitive impairment. Compression
bandaging requires a time
commitment from patients as well as
the willingness to undergo regular
application.
Compression bandaging is also
dependent on the availability of
clinicians who are able to apply it
and monitor the patient’s suitability.
Similarly, older patients may find it
difficult to access healthcare facilities
on a regular basis in order to have
compression bandaging applied.
In some cases, a user-friendly form
of compression, such as easy-to-
apply hosiery, can be beneficial,
as it is easier for older patients
to use themselves, although this
must be carefully monitored by an
appropriately trained clinician.
The appearance of compression
bandaging can also be an issue for
older people, as it can be bulky and
easily visible, even under clothing,
and restrict their normal footwear.
Palliative care
The aim of palliative care according
‘When treating mixed venous
and arterial ulcers, the aim
is to achieve a balance
between safety and efficacy.’
by arterial insufficiency, although
Anderson and King (2006) note that
the arterial blood supply will not yet
be sufficiently compromised to cause
critical ischaemia.
MANAGEMENT
When treating mixed venous and
arterial ulcers, the aim is to achieve a
balance between safety and efficacy.
Stevens (2004) notes that in the past
there has been little evidence on the
management of mixed arterial ulcers,
although some areas have developed
compression guidelines based on
local practice and a European Wound
Management Association (EWMA)
position document that detailed the
principles of compression therapy
(Stacey et al, 2002). Many of these
local guidelines outline the benefits
of using a reduced compression
regimen in mixed aetiology ulcers
with an APBI between 0.5 and 0.8
(Stevens, 2004).
Applying full compression to
an ulcer with mixed aetiology can
be dangerous, impeding blood
flow to the affected area and
potentially resulting in damage
or even amputation (Vowden and
Vowden, 2001). Therefore, assessment
by an experienced clinician is
vital. However, applying reduced
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