Guidelines on management of leg ulcers

All patients should be holistically assessed to determine

• The immediate cause of the ulcer
• Any underlying pathology in the lower limb
• Any problems with the wound site which may delay healing
• Any medical problems which may delay healing
• Social circumstances which may affect healing

Differential diagnosis of the leg ulcer should be made by assessment of the patients

• Past Medical History
• Clinical signs and symptoms, site, size of ulcer. Observe depth, condition and exudate, check surrounding skin, treat and eczema with prescribed cream or ointment
• Clinical assessment:
  • Blood Pressure
  • Blood Sugar
  • Haemoglobin
  • Urinalysis
• Vascular assessment
  • Doppler assessment (see guidelines on Doppler assessment)
• Psycho-social assessment
  • Assess pain level

Following holistic assessment some patients may need to be referred to some of the following services:

• Chiropodist
• Dietician
• Physiotherapy
• Social services

RECORD ALL INFORMATION ON LEG ULCER ASSESSMENT FORM

Guidelines for the nursing management of patients with leg ulceration once their ulcer has healed

Objective

To monitor on a regular basis the vascular status of patients with a history of leg ulceration, to prevent recurrence and ensure that management and treatment strategies are appropriate and effective.

Outcome

All patients with circulatory disorders of the lower limb are offered 3-6 month follow up appointments for the reassessment by a qualified and competent nurse.

Guidelines

• Once the ulcer has healed and prior to the discharge the patient's level of understanding and their ability to maintain the healed limb should be assessed. The patient should be fitted with compression stockings (venous ulcers only) and given educational leaflets regarding the care of their legs.
• All patients are provided with a contact number should they require additional nursing support. A patient information sheet should be given to the patient to reinforce verbal instructions (Appendix 3).
• Ensure that the patient has written instructions on the day to day care of their healed limb(s) and can demonstrate an understanding of activities required to promote health, i.e. hygiene, maintenance of stockings, active lower limb exercises etc.
• Any recurrence of ulceration should be documented and a comprehensive reassessment completed.
• Success in treating leg ulcers cannot be measured solely by the numbers of ulcers healed, because at least 70% will recur at some point. Therefore aftercare is essential and compression hosiery is the treatment of choice. Before prescribing compression hosiery it is imperative to exclude arterial insufficiency. Compression hosiery must be used with caution for Patients with diabetes or rheumatoid arthritis. Compression hosiery gives graduated compression, with the greatest pressure extended at the ankle.
  Stockings are graded into three classes:
  • Class 1 - 14-17 mmHg - Light compression
  • Class 2 - 17-23 mmHg - Medium compression
  • Class 3 - 23-35 mmHg - Strong compression

  Generally, below knee Class 2 is the support hose of choice for the patient with a healed ulcer. Measurements should be taken in the morning and whilst the patient is standing

  • Measurements should be taken on the circumference of the leg:
    1. Above the ankle
    2. The widest part of the calf
    3. Below the knee.

Moira Henry 1999

Brad Cheek:

• Brad Cheek: last updated Dec 2006
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