Leg Ulcers
Question Received:
Response:
What is the nursing care involved for someone with chronic venous leg ulcers? Please include nursing care of safety, observations, nutrition, hygiene, wound, medications, social, discharge, and eliminations. What is the pathophysiology of venous leg ulcers?
31st May 1999
Nursing care for leg ulcers
Assessment
A full general nursing assessment will need to be undertaken using both subjective and objective criteria. It is essential that the cause of the ulcer is determined, whether it is venous or arterial. Doppler studies are conducted to enable the cause to be established. A tracing and/or a polaroid photograph of the ulcer will help to provide an illustration of the extent of the ulcer before and after treatment began. An assessment of the individual's ability to comply with the Charing Cross four layer bandaging procedure will need to be undertaken. To be successful the technique does require full co-operation. The nutritional needs of the person will be assessed and their weight obtained.
Care Planning
A balanced diet will be provided in accordance with the person's needs (proteins, vitamin C, mineral salts and trace elements are all essential for wound healing). Where necessary advice from both a dietician and a specialist nurse in tissue viability will be obtained.
Using a team approach, the nursing care will be directed towards both the actual and potential problems that the person may have. In terms of a lower limb ulcer this will include: facilitating rest and elevation, taking a wound swab, applying a non-stick sterile dressing, administering preparations to relieve pain (if present), administering antibiotics if prescribed, and applying a four layer bandage.
Implementation (example)
NB Practice alert: it is recommended that special instruction on the use of the Charing Cross four layer bandaging technique is obtained, and approval from the employing authority sought, before embarking upon the procedure.
The concept of four layer bandaging originated in the 1980s at Charing Cross Hospital, London. Sustained compression of over 40 mm Hg achieved with a multilayer bandage results in rapid healing of chronic venous ulcers that have failed to heal in many months of compression at lower pressures with more conventional bandages. In the four layer technique a wool bandage is applied from the base of the toes to just below the knee joint. This is then followed by the application of a crepe bandage. Next to this an Elset compression bandage, in a figure of eight, is applied followed by a Coban bandage.
Evaluation
These layers are left in place for seven days and then removed and the progress of the ulcer is reassessed. The procedure is repeated until healing of the ulcer has taken place. The person's weight will be monitored regularly, at least weekly.
Pathophysiology of Leg Ulcers
Congenital weakness, pregnancy, pelvic obstruction due to tumour, obesity and standing for long periods are factors which contribute towards strain being placed on both the veins and their valves. Incompetent valves in the deep and perforating veins produces a retrograde flow of blood to the superficial system which leads to venous hypertension (Haslett et al, 1999). The resulting back pressure eventually becomes transmitted to the capillary bed producing a rise in capillary hydrostatic pressure leading to oedema. Varicosed veins are dilated and tortuous veins with incompetent valves.
Varicose ulcers develop as a result of chronic venous insufficiency and increased capillary hydrostatic pressure. "Fibrinogen is forced out through the capillary walls and fibrin is deposited as a precapillary cuff blocking the diffusion of oxygen and nutrients to the skin. The skin ulcerates (usually around the medial malleolus) when a critical degree of hypoxia is reached." (Haslett et al, 1999.) Associated characteristic features are a brownish colouration of the skin due to the deposition of melanin and haemosiderin. The rupturing of blood capillaries releases red blood cells into nearby tissues, and as these cells disintegrate haemosiderin is released.
The veins of the lower limbs carry blood - generally against gravity - to the external iliac vein and thence to the common iliac vein and inferior vena cava which opens into the right atrium of the heart. Unlike arteries, the walls of veins are thinner and contain less elastic tissue and smooth muscle. To maintain unidirectional flow the large veins have a series of valves. Contraction of the nearby skeletal muscles of the lower limbs sqeezes the veins and blood is propelled upwards. The combined effects of the valves and the musculo skeletal pumps enables the blood to be pumped from the superficial veins to the deep veins.
< Diagram showing arrangement of deep and
superficial veins in the leg, and the action of the muscle pump
< Diagram showing venous valve action
References
Franks, P.J., Bosanquet, N., Connolly, M., Oldroyd, M.I., Moffatt, C.J., Greenhalgh, R.M., and McCollum, C.N. (1995) Venous ulcer healing: effect of socioeconomic factors in London. Journal of Epidemiology and Community Health, 49(4), 385-388 (Aug).
Haslett, C., Chilvers, E., Hunter, J.A.A., and Boon, N.A. (editiors) (1999) Davidson's principles and practices of medicine (18th edition). Edinburgh: Churchill Livingstone. (Page 893: Leg ulceration due to venous disease.)
Moffatt, C. (1997) Know how: Four-layer bandaging. Nursing Times, 93(16), 82-83 (Apr 16-22).
Thomson, B., Hooper, P., Powell, R., and Warin, A.P. (1996) Four-layer bandaging and healing rates of venous leg ulcers. Journal of Wound Care, 5(5), 213-216 (May).
Wilkinson, E., Buttfield, S., Cooper, S., and Young, E. (1997) Trial of two bandaging systems for chronic venous leg ulcers. Journal of Wound Care, 6(7), 339-340 (Jul).
We would like to thank: Mrs.Belinda Bennett and Miss Annette Tavender, State Enrolled Nurses, University of Plymouth for their help with information on the Charing Cross four layer bandaging procedure.