This article, the first in a three-part series on venous leg ulcer prevention, explains how to identify at-risk patients and take preventive action. It comes with a self-assessment so you can test your knowledge after reading it
Ulceration of the lower limbs results in painful and often debilitating leg wounds that can have a profound effect on patients’ physical, social and psychological wellbeing. It is estimated that the UK spends nearly £2bn each year managing lower limb ulceration but NHS England has highlighted that the care patients receive is often sub-optimal and unwarranted variation results in higher costs and longer healing times. Rates of non-healing are both common and costly, which adds to the burden on patients and the healthcare system. The prevalence of leg ulceration is higher in older age groups and, as our population ages, the problem is likely to increase. All nurses have a vital role in identifying patients at risk of ulceration and supporting them to take preventative action to prevent skin breakdown. This article, the first in a three-part series on the prevention of leg ulceration, looks at how nurses can identify at-risk patients.
Citation: Atkin L (2019) Venous leg ulcer prevention 1: identifying patients who are at risk. Nursing Times [online issue]; 115: 6, 24-28.
Author: Leanne Atkin lecturer practitioner/vascular nurse consultant, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire Trust.
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Lower-leg ulceration affects around 1.5% of adults in the UK, with 730,000 people having often painful and debilitating leg wounds (Guest et al, 2015). Prevalence is highest among people aged 60-80 years, and increases with age (Farah and Davis, 2010), so the ageing population signals a growing problem.
Approximately 70% of lower-leg ulceration relates to venous disease (Casey, 2004), a debilitating condition affecting millions of people worldwide (O’Donnell et al, 2014). Varicose veins are often a first sign of venous disease and are a predictive factor in developing ulceration (Robertson et al, 2011) (Fig 1). The incidence of varicose veins in the adult population ranges from 10% to 60% worldwide (Selçuk Kapısız et al, 2014), and is estimated at 36% in the UK (Robertson, 2013; Evans et al, 1999).
Caring for patients with wounds and associated comorbidities costs the NHS £5.3bn a year, amounting to 4% of the UK public health budget (Guest et al, 2015). Of this, £1.94bn is spent on managing leg ulcers. Non-healing is both common and costly: 41% of patients have leg ulcers that fail to heal within a year, at a cost of £1,719-£5,976 per patient, compared with £698-£3,998 for those whose ulcers do heal (Guest et al, 2017). Non-healing ulcers result in a near doubling of patient numbers each year.
NHS England (2017) highlighted that management of lower-leg ulceration is sub-optimal for many patients, and that such an “unwarranted variation” results in higher costs and longer healing times. Atkin and Critchley (2017) identified care elements that can be standardised using evidence-based pathways, to reduce costs and service demands while improving quality of care and patient outcomes. These include:
- Holistic assessment;
- Timely taking of the ankle brachial pressure index (ABPI, Box 1) to establish arterial perfusion of the lower limb;
- Formal diagnosis to establish the underlying causes;
- Use of appropriate compression therapy.
NHS England and NHS Improvement have commissioned the Academic Health Science Networks to develop a national wound care strategy that will provide clear guidelines to help shape future services and care to:
- Improve patient safety and management;
- Reduce costs.
National initiatives, such as Legs Matter and Betty’s Story (NHS England, 2017) also aim to increase awareness and improve standards for patients with lower-leg ulceration.
The role of venous disease and hypertension
Venous ulceration is the most severe manifestation of chronic venous disease (CVD) caused by venous hypertension. The venous system consists of a deep vein system (femoral and popliteal veins) below the muscle fascia, which transports approximately 85% of total blood volume (Santler and Goerge, 2017), and a superficial venous system (short saphenous and long saphenous vein) between the dermis and the muscle fascia. Perforating veins pass through the muscle layer connecting the two systems.
CVD can occur in the deep or superficial systems, either as a result of venous obstruction or venous reflux (backing up of blood in the veins), or both. Venous pressure is highest at the ankle and gradually diminishes as it gets closer to the heart; the average venous pressure at the ankle in a standing adult is 90-110mmHg (Recek, 2010).
Venous thrombosis (clotting) is the usual cause of venous obstruction. Venous reflux is often caused by failure of one-way valves in the veins, but can also result from inflammation of the vessel wall, failure of the calf or foot muscles to pump properly or haemodynamic factors (Santler and Goerge, 2017). Venous insufficiency causes venous hypertension, which leads to:
- Expression of inflammatory mediators;
- Changes to the endothelial lining of the vein wall;
- Infiltration of white cells (monocytes and macrophages);
- Increase in collagen and reduction in elastin.
This leads to chronic inflammation, which can in turn lead to skin changes, including leg ulceration (Nicholls, 2005).
The causes of CVD are complex and still not fully understood, but there are several key risk factors (Yun et al, 2018). These include:
- Increasing age;
- Being female or pregnant;
- Family history of venous disease;
- High body mass index (BMI);
- Occupational risk.
All the above factors increase an individual’s risk of venous hypertension and varicose veins, as explained below.
Degenerative changes and atrophy of the smooth muscle layer in the vein increases susceptibility to dilatation (Robertson et al, 2011; Nicholls, 2005).
Being female or pregnant
Cyclical changes in women’s progesterone levels affect the vein wall and valves. This risk increases during pregnancy, when blood volume is increased, and venous return is restricted by the enlarging uterus (Nicholls, 2005). The risk of varicose veins is 82% higher in women who have a history of pregnancy compared with those who have never been pregnant (Ismail et al, 2016). The case study in Box 2 describes the management of a pregnant woman with venous insufficiency.
Box 2. Case study
Tracy Smith,* aged 33, presents with lower-leg oedema and red/brown discolouration around her inside ankle (Fig 2). She is 32 weeks into her second pregnancy and has a history of venous disease, with an onset in her first pregnancy. Her body mass index is slightly elevated. Clinically, there is evidence of soft, mild-to-moderate oedema in both legs (the right being worse than the left), and mild haemosiderin staining. Her skin is intact and appears well hydrated.
Ms Smith says she finds the swelling in her legs and the tight feeling of her skin uncomfortable. The size of her legs makes it hard to wear her normal footwear and she is concerned about the skin discolouration, which she finds unsightly. She is worried about developing ulceration and her symptoms worsening towards the end of her pregnancy.
There are no signs of arterial insufficiency, as Ms Smith has palpable foot pulses and her ankle brachial pressure index is normal. The nurse advises her to apply regular moisturising cream to her lower limbs to keep the skin hydrated. Ms Smith is also encouraged to try to lose a little weight and to exercise, although it is acknowledged this could be difficult at this stage in her pregnancy.
The nurse measures the circumference of Ms Smith’s legs at the ankle and calf, and sizes her for stockings according to product guidance. Ms Smith is prescribed EU class 1 stockings (these are more appropriate than British Standards for oedema management) and is advised to return to the clinic in two weeks to assess whether her symptoms are improving and check that the hosiery was comfortable. Post pregnancy, the nurse will decide whether to refer Ms Smith to vascular services to assess for venous incompetency, with a view to intervention.
*The patient’s name has been changed
Family history of venous disease
Varicose veins in a first-degree relative substantially increases the risk of developing venous disease, with evidence suggesting there is a genetic component (Beebe-Dimmer et al, 2005).
Being overweight puts extra pressure on the venous system and increases the risk of valvular incompetence. In patients with morbid obesity (BMI of >40, or >35 with obesity-related complications), the increased intra-abdominal pressure can directly hinder venous and lymphatic drainage. A high BMI plays a specific and independent role in the development of varicose veins, the risk increasing lineally with the rise in BMI (Iannuzzi et al, 2002).
Prolonged standing is known to increase the risk of venous disease, when the ankle venous pressure generated by the column of blood above may be as high as 100mmHg (Raffetto and Khalil, 2008). This sustained high pressure is thought to lead to venous distention and secondary valvular incompetence (Nicholls, 2005). Moving around causes the pressure in the veins to drop significantly (Vayssairat, 2003).
Identifying patients at risk of ulceration
Not all people who have CVD will develop ulceration; specific risk factors are associated with ulceration in this patient group.
Skin changes are the biggest predictor of lower-leg ulceration: patients with CVD who have varicose veins, lipodermato-sclerosis (fibrosis or thickening of the skin) or venous eczema are at significantly increased risk (Robertson et al, 2009).
Oedema is the most common cause of lower-leg oedema and present in 90% of cases (Vayssairat, 2003). It occurs when the rate of capillary filtration (lymph formation) exceeds lymphatic drainage because of increased capillary filtration (as a result of venous hypertension), inadequate lymphatic flow or both (Gorman et al, 2000). This leads to a build-up of interstitial fluid, causing the lower legs to swell. Chronic oedema (persisting for more than three months) is common and its prevalence rises with age – from 3.93 per 1,000 in the general adult population to 28.75 per 1,000 in people aged >85 years (Moffatt et al, 2017).
Lower-limb oedema and CVD both significantly reduce quality of life. Symptoms can include pain, heaviness in the legs, cramps and itching, as well as significant aesthetic effects (Greene and Meskell, 2017). When severe, this can lead to reduced mobility, poor body image and social isolation (Cooper, 2018; Moffatt et al, 2017).
Oedema and CVD also have a substantial physiological impact on the skin, causing multiple chemical inflammatory mediators to be released, resulting in the tissue becoming chronically inflamed. This can lead to haemosiderin staining (changes in skin pigment), lipodermatosclerosis and, ultimately, cellular hypoxia (oxygen-starved cells) and ulceration (Fig 3).
Preventing lower-leg ulceration
Given how distressing and debilitating leg ulcers are for patients, and how expensive and time consuming they are for the NHS, preventative strategies are needed. Nurses should be aware of the risk factors – such as lower-limb oedema, skin changes and varicose veins – and actively assess patients’ risk of developing ulceration before implementing prevention strategies. This should include assessing their overall risk factors and identifying those that are modifiable.
Nurses should advise patients how to reduce their modifiable risks, for example by offering advice on weight loss and skin care, or simple exercises – such as heel raises and ankle flexion – to reduce occupational risk. Box 3 outlines measures that can be taken to reduce the risk of varicose veins.
Box 3. Measures to reduce risk of varicose veins
- Avoid weight gain
- Eat a balanced diet
- Keep skin hydrated with regular moisturising
- Don’t smoke
- Avoid standing or sitting still for long periods; try to move around every 30 minutes
- Take regular breaks throughout the day, and raise the legs on pillows while resting to ease discomfort
- Exercise regularly – this can improve circulation and help maintain a healthy weight
Treating varicose veins
For many years patients were told that varicose veins had no serious health implications, and their removal was cosmetic; however, it is well established that they can lead to further complications such as skin ulceration (Robertson et al, 2009). All patients with symptomatic varicose veins – presenting with pain, itching, skin changes, ulceration – should be referred to a vascular centre to assess whether they need endovenous treatment, in line with guidance from the National Institute for Health and Care Excellence (2013).
Compression therapy plays an important role in prevention as, it directly affects venous and lymphatic return, improving microcirculation and reducing local inflammation (Lim et al, 2018). Known to improve both venous and lymphatic function, it simultaneously:
- Improves venous pump function;
- Counteracts increased capillary filtration;
- Increases movement of fluid into the lymphatic system;
- Decreases venous hypertension (Kolluri, 2011; Földi et al, 2005).
Compression can be achieved using bandages, hosiery or wraps; all have been shown to improve symptoms, reduce oedema and help skin condition (Williams, 2016; Ashby et al, 2014; Clarke-Moloney et al, 2014; O’Meara et al, 2012). However, compression should only be applied by health professionals who have been trained to do so.
Before any form of compression therapy is applied, the patient should be given a holistic assessment to identify any underlying causes and establish their medical history and any contraindications, such as peripheral arterial disease. The health professional should then gauge the optimal level of compression to manage that patient’s symptoms; the best practice statement Compression Hosiery (Wounds UK, 2015) is a useful guide and the following pointers are beneficial:
- Patients with varicose veins (Fig 4) should wear class 1 or class 2 British Standard hosiery, depending on the severity;
- Patients with previous ulceration (Fig 5) will need to wear compression hosiery for life to prevent recurrence – class 2 British Standard stockings are recommended, upgrading to class 3 if symptoms are not controlled (NICE, 2017);
- If oedema is present the equivalent EU compression garment should be considered. These are constructed to contain oedema and may, therefore, be better tolerated than British Standard hosiery if limb swelling is present;
- Patients with venous ulceration need a compression system providing at least 40mmHg pressure at the ankle.
The choice of compression system depends on patients’ individual needs; factors that nurses should take into consideration are outlined in Box 4.
Box 4. Choosing a compression system
Consider the following factors when selecting the appropriate compression system for a patient:
- Limb size
- Presence of skin folds
- Patient’s ability to apply/remove it
- Presence of ulceration
- Degree of desired compression
- Practitioner’s competency
- Bulkiness of compression
- Patient’s choice of clothing/footwear
- Fragility of the skin
- Hygiene needs
Compression therapy has an important role to play in the prevention of leg ulceration but a greater emphasis on prevention is needed if the considerable burden of managing leg ulceration is to be reduced. Nurses should actively assess patients’ legs for signs of venous disease and oedema, and undertake opportunistic assessment whenever possible. Ensuring appropriate early intervention will improve patient outcomes and result in significant cost savings to health services.
- Lower-leg ulceration affects 1.5% of adults in the UK, and an ageing population means the number is likely to grow
- Prevention and management are often sub-optimal, leading to non-healing and a near doubling of patients each year
- Venous leg ulceration is the most severe manifestation of chronic venous disease caused by venous hypertension
- Skin changes are the biggest predictor of ulceration, with lower-limb oedema also being a risk
- Nurses need to spot the early signs of venous leg ulceration and take preventative action, such as using compression therapy
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