In patients with venous leg ulcers, education in prevention is just as important as education during treatment. Once a patient develops a wound related to venous insufficiency, it will take compliance and effort from the patient and caregiver to reduce the risk of reoccurrence. The patient needs to be aware that they do have control over this situation and, with some work and guidance from you, future wounds and complications can be avoided.

Assessment and Characteristics

Thoroughly examine and assess the patient while going through patient history with the caregiver, who is present if possible. These wounds can be chronic for decades and can lead to social isolation and depression if the patient does not feel they can adequately manage the draining wounds. Review with your patient and caregiver a comprehensive history, starting with family history of venous disease, varicose veins, lifestyle behaviors (sedentary), obesity, advanced age, trauma, surgery or fractures, multiple pregnancies, deep vein thrombosis, or pulmonary edema. In a healthy individual, normal blood flows from the superficial venous system to the deep venous system, assisted by unidirectional values and calf muscle contraction. Calf muscle pump dysfunction and/or incompetent valves in the venous systems leads to a reduction in sufficient venous blood flow.

Venous leg ulcers typically develop above the medial aspect of the leg, superior to the medial malleolus and are usually surrounded with brownish staining or discoloration called hemosiderin staining. The discoloration comes from a decrease in the ability of the veins to effectively circulate blood back up through the legs due to incompetent valves or calf muscle pump dysfunction. As the body gets older and there is a decrease in the veins’ ability to circulate properly, the valves do not have the capability to pump blood back up to the heart effectively. This causes iron deposits to be left behind in the lower legs (due to gravity) which evidences as discoloration of the skin. Once the skin becomes discolored, it cannot be reversed. Many patients and their caregivers ask about the discoloration and it is important to educate on the circulation insufficiency and, most of all, the appropriate preventive and treatment measures.

Examine the entire leg from knee down to medial malleolus. The wound edges in venous leg ulcers (VLU) will be irregular and the wound bed can be found with ruddy red, yellow adherent slough or granulation tissue. Undermining and tunneling are uncommon. Normal palpitation to both dorsalis pedis and posterior tibial pulses is common but can vary based on the level of edema present.

Moderate to large amounts of exudate are common and can cause maceration to the peri-wound or leave crusty and scaling skin. Peri-wound appearance depends on the patient’s ability to cleanse the area and perform effective hygiene. Edema is commonly noted with venous insufficiency and the patient may develop blisters to the lower extremities from swelling. Once the blisters open, a wound will be present. Venous ulcers with large amounts of exudate can be difficult for the patient to control. Lack of proper management of these wounds, which can cause odor or wet clothing, can lead to self-isolation—not leaving the house for fear of being embarrassed.

Edema and Elevation

Education on elevation, decreased salt intake, proper compression treatment, and edema management will assist in reducing drainage from the wound. One way we explain this to our patients and caregivers is with an analogy. With an increase in swelling or edema in the legs, the fluid in the body is going to try to exit any way it can. The easiest place for this to occur is often the legs. Gravity pulls the fluid into our legs during the day as we are walking and standing. Edema typically worsens with prolonged standing and diminishes with elevation. When the fluid finds an area on the skin of the legs that is not as strong as the others, it will create and opening (wound) for the fluid to exit, like water coming out of a faucet. The longer the area (faucet) stays open, the greater the risk for infection. Without proper edema control, the wound will not heal because the fluid will continue to leak out of the open areas, making it impossible for the skin to heal.

This is an important factor of education with elevation and edema control. Decreasing the amount of edema in the legs, by turning off the faucet, will control drainage and allow proper healing to begin. The combination of compression, elevation, proper nutrition, and medical intervention (such as diuretics as per physician order) all need to be discussed with the caregivers and healthcare team to provide a complete plan of care to assist in wound healing.

It is important the fluid leave the body for the patients overall health; with the assistance of a diuretic, the patient can urinate out the excess fluid to begin wound healing. There must be complete education to the patient and caregiver on the benefits of taking the diuretic as prescribed by the physician, since this medication can cause fear of having an incontinent episode when out of the house. A diuretic can be seen as a necessary evil by most patients, but based on the patient’s comorbidities and medications, the level of edema will affect the wound treatment plan and may require medical intervention to address the swelling. That said, elevation and behavioral changes for edema control are the first steps to encourage wound healing.

Testing and Diagnosis

Once the appropriate professional has reviewed the patient history and assessed the wounds, proper treatment can be determined. An Ankle Brachial Index (ABI) is a noninvasive vascular screening test to identify peripheral arterial disease by comparing systolic blood pressures in the ankle to the higher of the brachial systolic blood pressures. This is the best estimate of central systolic blood pressure.

The purpose of the ABI is to support the diagnosis of vascular disease by providing an objective indicator of arterial perfusion to a lower extremity. Indications for an ABI are to rule out lower extremity arterial disease (LEAD), establish diagnosis of arterial disease in patients with suspected LEAD, and determine if there is adequate arterial blood flow in the lower extremities prior to compression to assess wound healing.

If the blood flow is normal in the lower extremities, the pressure at the ankle should be equal or slightly higher that the arm pressure with an ABI of 1.0 or more. An elevated ABI (>1.3) might be due to calcification of medial arteries at the ankle in patients with diabetes, renal failure, and rheumatoid arthritis.

Treatment

Based on patient results of the ABI, you can decide the best treatment option to reduce edema, control drainage, and promote wound healing. Patient education is again an important portion of patient success. Adequate compression, based on the patient ABI results, is a starting point in the treatment process. If the patient is being treated at a wound center because of the need for wound debridement, edema management, or advanced care modalities, compression wraps can begin. Compression is either 2- or 4-layer, based on physician order and patient history and testing results.

Compression wraps are typically done weekly by a trained clinician in order to provide accurate compression. Standard compression therapy is between 30 and 40 mmHg; the level of required compression depends on the physician order and patient comorbidities (www.wocn.org, 2013). Compression wraps can be used initially for patients who will have difficulty in applying stockings depending on hand dexterity, ability to reach feet, and risk of falls while applying stockings daily.

If compression wraps are not necessary, the patient can be introduced to compression stockings, which will aid in treatment as well as preventing wounds in the future. Compression stockings are an option for edema control as long as the patient and/or caregiver is physically able to apply and remove the stockings daily. Compression stockings must be worn daily to help prevent further wound development by reducing swelling. Certain stockings will require calf measurements that can be done either in the office or in the patient home.

Stockings should be replaced every 3 months to provide optimal compression strength. Education on compression therapy benefits should be provided with each visit to encourage patient and caregiver compliance. Skin must be assessed by the patient or caregiver daily with the removal of compression stockings. Do not allow the patient to sleep in compression stockings, as this can lead to breakdown should the stockings be too tight; besides, the skin should be allowed to rest while in bed.

The stockings are to be put on immediately upon waking at or before getting out of bed when swelling is at its lowest. During the day, from gravity, the legs become more swollen and stockings are more difficult to apply. Assess the ability of the caregiver and patient to apply stockings. There are several options of stockings where a zipper or Velcro may be easier for patient compliance and should be discussed with the physician if a regular stocking is too difficult for the patient to apply.

Compression pumps are utilized if stockings are not a viable option to promote reduction in edema. Compression pumps require a physician order and are used 1 to 3 times a day. They pump the fluid up out of the legs so it can be urinated away. Accurate assessment of patient compliance will determine which is the appropriate option for a successful patient outcome.

Treatment and education are based on comorbidities that can possibly delay wound healing, compliance, and awareness of any medications that will interfere with healing (eg, steroids, immunosuppressive agents). Lifestyle changes should be reviewed for weight management and exercise to help prevent reoccurrence. Proper nutritional instructions to reduce salt and increase protein can be given in literature form to remind the patient and caregiver of healthy choice. Smoking cessation education is beneficial as smoking affects proper circulation throughout the body and delays healing.

The patient should avoid constricting garments and crossing legs, which affects circulation, as well as high heels that will reduce venous return. Encourage calf muscle exercises to promote circulation and strength, Maybe as simple as walking around the block once a day. Instruct patient and caregiver on signs and symptoms of infection with open wounds and the importance of calling the appropriate healthcare provider if an infection occurs.

Encourage patient compliance by discussing the benefits of edema control with wound healing and that we must reduce the swelling. With compression therapy, most of all, always receive cardiac clearance from the patient’s primary or cardiologist.

Topical wound care is performed according to the wound bed appearance, with treatment that will be best for the patient and caregiver to perform effectively. Utilize a wound care center if debridement is required. With large draining wounds, peri-wound protection must be included as part of the care plan to keep the wound size from increasing and damaging more tissue.

The goals for venous insufficiency patients are to maintain intact skin, reduce pain if present, and reduce edema with effective lifestyle changes to prevent future complications. Involvement of the patient and caregiver in the treatment process can encourage confidence in future self-management and prevention measures. Remember that some of these patients have been dealing with these wounds for many years and will require a great deal of encouragement as they may already feel defeated by having the wounds for so long.

What do you want to do first?

Cleanse the wound and culture to check for any underlying infection. Referral to wound center will be beneficial for debridement to clean the stagnant wound and encourage new tissue growth. ABI testing will determine if patient is compressible. Patient has not been interested in compression wraps in the past. Educate the patient on the benefits of compression wraps—that there is an increase in pressure weight compared to stockings. Edema control will be necessary to begin the wound healing process. Topical treatment must encourage a moist wound healing environment and also manage exudate to prevent peri-wound maceration.