Leg ulcer assessment and management is complex and requires the input of nurses with specialist training. Irene Anderson provides guidance on the management of residents with leg ulceration.
Leg ulceration affects between 1 and 2% of the population in the UK and many people who suffer with the condition are elderly (Briggs and Closs, 2003). If a person with leg ulcers is admitted to a care-home setting (or develops leg ulcers as a resident) it is very important that she or he has access to skilled and competent clinical practitioners otherwise her or his condition may deteriorate leaving them at risk of further damage to the leg, due to inappropriate management (Anderson, 2003).
Causes of leg ulceration
Most leg ulcers are caused by venous disease (70%) although a significant proportion (10–15%) may be due to arterial disease, particularly in an older population (Moffatt, 2001). Approximately 15–20% may be due to a combination of either factors or other co-existing conditions such as rheumatoid arthritis (Morison and Moffatt, 2004).
Veins carry blood back to the heart and contain valves that prevent backflow of the blood. As we walk and flex our ankle joint, the calf muscle pump pushes the venous blood up the leg. If the valves are damaged by, for example, surgery, trauma or deep vein thrombosis, backflow can occur. If the resident is non-mobile or has a fixed ankle joint, the calf muscle is not activated and venous congestion results. This congestion causes the vein pressure to rise and so the capillaries swell to deal with the extra volume of blood. This makes the capillaries leak fluid and other cells into the tissues, which results in oedema and skin changes (Anderson, 2006).
Managing venous leg ulcers
The management of venous ulcers focuses on elevating the leg when sitting to reduce oedema, mobilising as much as possible, moving the ankle to activate the calf muscle, and compression therapy. Compression may be in the form of bandages or hosiery. To ensure effective treatment and patient safety a full clinical assessment, including the use of a hand-held Doppler to help exclude the presence of arterial disease, needs to be carried out before compression therapy is begun and at intervals thereafter.
The resident may be at risk if compression therapy is not applied by a skilled and trained practitioner (RCN, 2006) and a referral should be made to a specialist as soon as possible. The appropriate person to refer to may be a district nurse or a tissue viability/leg ulcer specialist nurse.
There may be scope in a care home to have personnel with the required competencies in assessment and compression therapy but such competencies need to be practised to remain current. If residents requiring compression therapy are small in number then it is unlikely that the designated nurse will maintain the required level of skill (Anderson, 2003). It may be worth exploring methods of updating in collaboration with other settings (for instance, a local leg ulcer clinic).
If there are a significant number of residents requiring leg-ulcer care then managers need to consider accessing appropriately validated courses for their staff, ensuring that such courses include assessment of competencies and sufficient theoretical components to ensure competent and evidence-based care (Fletcher, 2006).
An algorithm has been published (Aldeen, 2007) that is designed for use in the acute sector where practitioners may not have or be able to maintain appropriate competencies. This is also useful in care homes.
Ensuring safe care
It is vital that the resident receives skilled input as soon as possible and that her or his admission to the care home prompts a further assessment of her or his lower-limb condition. By protecting the resident’s legs, managing the underlying venous disease by promoting venous return, and monitoring for progression of arterial disease, the resident is less likely to experience deterioration and/or recurrence of her or his ulcer.
Author Irene Anderson, MSc, PGCE, BSc, LPE, DPSN, RGN, is senior lecturer, tissue viability, University of Hertfordshire and chairperson of the Leg Ulcer Forum.
Aldeen, L. (2007) Recommendations for leg ulcer care in acute trusts. Nursing Times; 103: 43, 40-42.
Anderson, I. (2006) Aetiology, assessment and management of leg ulcers. Wound Essentials; 1: 20-37.
Anderson, I. (2003) Developing a framework to assess competence in leg ulcer care. Professional Nurse; 18: 9, 518-522.
Briggs, M., Closs, S.J. (2003) The prevalence of leg ulceration: a review of the literature. EWMA Journal; 3: 2, 14–20.
Fletcher, J. (2006) So you want to do a leg ulcer course? Leg Ulcer Forum Journal; 20: 44–46.
Moffatt, C. (2001) Leg ulcers. In: Murray, S. (ed) Vascular Disease: Nursing and Management. London: Whurr.
Morison, M.J., Moffatt, C. (2004) Leg ulcers. In: Morison, M.J. et al (eds) Chronic Wound Care: A Problem-based Learning Approach. Edinburgh: Mosby.
RCN (2006) The Nursing Management of Patients with Venous Leg Ulcers.
For a guide on managing leg ulceration click on Tissue Viability