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JCN supplement
2018,Vol 32, No 4
7
HOLISTIC ASSESSMENT
should be treated immediately with
light Class 1 compression of up to
17mmHg to prevent deterioration
(Wounds UK, 2015; 2016). If the
wound subsequently fails to heal
within two weeks, they should
undergo full holistic assessment,
including vascular examination
(Wounds UK, 2016).
Local service provision and
patient pathways need to be
introduced to follow guidance. The
time needed to complete traditional
ABPI assessment, including the
20-minute resting period, is often
seen as a barrier for its completion to
community nurses faced with high
caseloads and low staff numbers
(Kirby and Hurst, 2014).
It is well known that completion
of traditional ABPI assessment
requires meticulous attention to
ensure that current measurement
values are obtained (Vowden and
Vowden, 2001). As with any other
skill, if this is not routinely practised,
inaccuracies may occur. Also, in the
author’s clinical opinion, there are
many areas where mistakes which
can lead to errors in ABPI readings
can be made; such as incorrect cuff
placement, true systolic pressures
being missed when listening for
returning sounds, using an incorrect
probe or cuff size, or repeatedly
inflating the cuff. Furthermore,
difficulties can occur in patients
presenting with chronic or severe
oedema or tissue fibrosis (Guest
et al, 2015). The calculation of the
pressures themselves to obtain the
ABPI ratio figure is another area
where inaccuracies can occur.
A less time-consuming method
of taking ABPI measurements has
been suggested as a way of helping
clinicians to better manage their time
(Yap Kannan et al, 2016). Furthermore,
developments in science and
technology in health care have been
encouraged in the‘Five year forward
view’(NHS England, 2014), such as
new technology in ABPI assessment,
which offers prompt, accessible
vascular screening, for example, MESI
ABPI MD (Freeman, 2017).
This system was developed
using improved oscillometric
plethysmography technology, which
offers a fast, simple and accurate
solution for the measurement of ABPI
in clinical practice. By utilising three
colour-coded blood pressure cuffs to
either arm and to each ankle, with
the simple push of a button, ABPI
can be measured and calculated in
one minute. The results of the left
and right ABPI are displayed on the
screen with a colour-coded alert to
the presence and level of arterial
disease, as suggested by TASC II
guidelines (Norgren et al, 2007).
This device also provides a visual
image of the pulse wave detected,
which provides further diagnostic
information regarding vascular
status that can be used alongside
holistic assessment. With no need for
lengthy rest periods, mathematical
calculations, subjective listening
skills, or difficult competencies to
learn and maintain, it offers clinicians
working in community settings an
alternative to traditional methods of
obtaining ABPI, particularly where
time pressures may result in absence
of full vascular assessment.
Evidence has shown comparable
results to the handheld doppler
method, and that it offers
comprehensive detection of critical
limb ischaemia (Span et al, 2016). As
MESI ABPI MD is lightweight and
portable, it can be used in a variety of
care settings, such as patients’homes,
community clinics and Leg Clubs.
Staines (2018) identified that nurses,
when asked, stated that they would
use MESI ABPI MD in practice, rather
than the traditional doppler method,
to provide efficient assessment
(
Figure 1
).
For some patients, there may
be difficulties in obtaining accurate
ABPI readings, e.g. those presenting
with chronic or severe oedema or
tissue fibrosis (Guest et al, 2015),
or other medical conditions. If
clinically indicated, patients should
be referred for further assessment or
specialist review.
REASSESSMENT AND WELL LEG/
REDUCTION OF RECURRENCE
Despite successful healing, this is
not the end of the patient journey
and care for those with venous leg
ulceration. With the risk of recurrence
within the next 12 months estimated
to be as high as 26–69% (Harding
et al, 2015), patients need to receive
ongoing maintenance treatment
(Wounds UK, 2016). Maintenance
therapy and monitoring should be
incorporated as a key part of any leg
ulcer care pathway so that patients
can receive ongoing care and advice.
Patient education and
involvement from the onset of care
can help to improve concordance
with self-care both during the healing
and maintenance phases (Jin et al,
2008). Patients need to understand
›
Practice point
Tools commonly used for lower limb vascular assessment, include:
Ankle brachial pressure index (ABPI): bedside test to exclude significant
arterial disease by comparing systolic blood pressure at the ankle and arm
Toe brachial pressure index (TBI): similar to ABPI but the cuff is placed on
the hallux for a toe pressure
Pulse oximetry: a secondary diagnostic tool to measure levels of oxygen in
the blood, although not reliable at excluding peripheral vascular disease
Arterial duplex scan: non-invasive ultrasound scan of the arteries; used to
provide visual assessment of vessels.
›
Practice point
In venous leg ulcer management,
lack of diagnosis and documented
assessment can impact on effective
care management and wound
healing. With venous leg ulcers
accounting for 40–85% of leg ulcers
(Harding et al, 2015), it is essential
to ensure that holistic assessment is
completed to optimise care.