Notes for users of these guidelines

Evidence Base

The evidence base for these recommendations came from the Effective Health Care Bulletin, Compression Therapy for Venous Leg Ulcers, NHS CRD and updated sections of an original systematic review (Cullum 1994). Recommendations without a strong evidence base were informed by expert opinion and are thought to reflect current good clinical practice.

This document contains recommendation statements which were graded as follows:

I Generally consistent finding in a majority of multiple acceptable studies;

II Either based on a single acceptable study, or a weak or inconsistent finding in multiple acceptable studies;

III Limited scientific evidence which does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality. This includes published or unpublished expert opinion.

(adapted from Waddell et al 1996)

The evidence grade alerts the reader to the type of evidence supporting each statement. However, this grading should not be interpreted as indicative of the strength of recommendation. All of the recommendations are equally strongly endorsed and are not regarded as optional, despite the strength of evidence grade accorded to them.

Updating of the guideline

The guideline was completed in mid-1998. Resources permitting, it is envisaged that the guideline will be updated 2-yearly.

Audit

Audit criteria based on this guideline are being piloted in 1999 and will be available in 2000. This work is being undertaken as part of a national sentinel audit project funded by the NHS Executive, in partnership with the Royal College of Nursing, Centre for Evidence Based Nursing, Eli Lily National Clinical Audit Centre, the Royal College of Physicians, The Royal College of General Practitioners and the Tissue Viability Society.

Disclaimer

Guideline users should be mindful that, as with any clinical guideline, recommendations may not be appropriate for use in all circumstances. Clearly, a limitation of any guideline is that it simplifies clinical decision-making processes and recommendations (Shiffer 1997). Decisions to adopt any particular recommendation must be made by the practitioner in the light of available resources, local services, policies and protocols, the particular patient's circumstances and wishes, available personnel and equipment, clinical experience of the practitioner and knowledge of more recent research findings.

The reader is referred to the document: Clinical practice guidelines. The management of patients with venous leg ulcers. Technical report: guideline objectives and methods of guideline development for further information on the methods used to develop the guideline and its evidence base. Evidence tables and the Effective Health Care Bulletin on Compression Therapy for Venous Leg Ulcers that summarize the evidence base of the guideline are appended to this document. The Technical Report can be obtained from RCN Publishing, Nursing Standard House, 17-19 Peterborough Road, Harrow HA1 2AY.

Summary recommendations

Assessment of leg ulcers

Assessment and clinical investigations should be undertaken by a health care professional trained in leg ulcer management	III
A full clinical history and physical examination should be conducted for a patient presenting with either their first or recurrent leg ulcer and should be ongoing thereafter	III
Record the following, which may be indicative of venous disease: family history of venous disease, varicose veins; proven deep vein thrombosis in the affected leg; phlebitis in the affected leg; suspected deep vein thrombosis; surgery/fractures to leg; episodes of chest pain, haemoptysis or history of a pulmonary embolus	III
Record the following, which may be indicative of non-venous aetiology: family history of non-venous aetiology; heart disease, stroke, transient ischaemic attack; diabetes mellitus; peripheral vascular disease/intermittent claudication; cigarette smoking; rheumatoid arthritis; ischaemic rest pain	III
In mixed venous/arterial ulcers, patients may present with a combination of the features described above	III
The person conducting the assessment should be aware that ulcers may be arterial, diabetic, rheumatoid or malignant, should record any unusual appearance and if present refer the patient for specialist medical assessment	III
Information relating to ulcer history should be recorded in a structured format and may include: year first ulcer occurred; site of ulcer and of any previous ulcers; number of previous episodes of ulceration; time to healing in previous episodes; time free of ulcers; past treatment methods; previous operations on venous system; previous and current use of compression hosiery	III
Examine both legs and record the presence/absence of the following to aid assessment of ulcer type:	III
venous disease: usually shallow (usually on gaiter area of leg); oedema, eczema; ankle flare; lipodermatosclerosis; varicose veins; hyperpigmentation; atrophie blanche
arterial disease: 'punched out' appearance; base of wound poorly perfused and pale; cold legs/feet; shiny, taut skin; dependent rubour; pale or blue feet; gangrenous toes
mixed venous/arterial: features of venous ulcer in combination with signs of arterial impairment
The presence of oedema, eczema, hyperkeratotic skin, maceration, cellulitis, degree of granulation tissue, signs of epithelization, unusual wound edges (eg rolled), signs of irritation and scratching, purulence, necrosis, slough, granulation and odour should be recorded at first presentation and as part of routine monitoring thereafter	III
Blood pressure measurement, weight, urinalysis and Doppler measurement of ankle: brachial pressure index (APBI) should be recorded on first presentation	III
Routine bacteriological swabbing is unnecessary unless there is evidence of clinical infection such as: inflammation /redness/evidence of cellulitis; increased pain; purulent exudate; rapid deterioration of the ulcer; pyrexia	I
All patients presenting with an ulcer should be screened for arterial disease by Doppler measurement of ABPI	I
Doppler measurement of ABPI should be done by staff who are trained to undertake this measure	II
Doppler ultrasound to measure ABPI should also be conducted when: an ulcer is deteriorating; an ulcer it not fully healed by 12 weeks; patients present with ulcer recurrence; before recommencing compression therapy; patient is wearing compression hosiery as a preventive measure; there is a sudden increase in size of ulcer; there is a sudden increase in pain; foot colour and/or temperature of foot change; and, as part of ongoing assessment (3 monthly)	II
A formal record of ulcer size should be taken at first presentation, and at least at monthly intervals thereafter	III
Specialist medical referral may be appropriate for: treatment of underlying medical problems; ulcers of non-venous aetiology; suspected malignancy; diagnostic uncertainty; reduced ABPI; increased ABPI; rapid deterioration of ulcers; newly diagnosed diabetes mellitus; signs of contact dermatitis; cellulitis; healed ulcers with a view to venous surgery; ulcers which have received adequate treatment and have not improved after 3 months; recurring ulceration; ischaemic foot; infected foot; pain management	III

Management of venous leg ulcers

Graduated multi-layer high compression systems (including short-stretch regimens), with adequate padding, capable of sustaining compression for at least a week, should be the first line of treatment for uncomplicated venous leg ulcers (ABPI must be >= 0.8)	I
The compression system should be applied by a trained practitioner	II
Health professionals should regularly monitor whether patients experience pain associated with venous leg ulcers and formulate an individual management plan, which may consist of compression therapy, exercise, leg elevation and analgesia to meet the needs of the patient	II
Use of compression stockings reduces venous ulcer recurrence rates	II
Other strategies for the prevention of recurrence may also include the following, depending on the needs of the patient:	III
Clinical: venous investigation and surgery; lifetime compression therapy; regular follow-up to monitor skin condition for recurrence; regular follow-up to monitor ABPI
Patient education: compliance with compression hosiery; skin care; discourage self-treatment with over-the-counter preparations; avoidance of accidents or trauma to legs; early self-referral at signs of possible skin breakdown; encouragement of mobility and exercise; elevation of the affected limb when immobile

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SOURCE: Produced by the RCN Institute, Centre for Evidence-Based Nursing, University of York and the School of Nursing, Midwifery and Health Visiting, University of Manchester
Royal College of Nursing 1998
*Complete Article can be obtained by visiting the Royal College of Nursing web site.

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