Leg Ulcers - PowerPoint PPT Presentation

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Leg Ulcers

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Most common type of leg ulcer. Causes: Result of chronic venous hypertension. Venous stasis due to damage to vessels. Calf muscle pump ineffective. Oedema. – PowerPoint PPT presentation

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Title: Leg Ulcers


1
Leg Ulcers
  • Basic wound care

2
Outline
  • Venous leg ulcers
  • Compression therapy
  • Arterial leg ulcers
  • Mixed aetiology leg ulcers
  • The ideal dressing

3
Venous Leg Ulcers
  • Most common type of leg ulcer.
  • Causes
  • Result of chronic venous hypertension
  • Venous stasis due to damage to vessels
  • Calf muscle pump ineffective
  • Oedema
  • Hb released from RBCs causes staining eczema

4
Venous ulcer
5
Predisposing factors
  • History of DVT
  • Varicose veins (valvular incompetence)
  • Obesity
  • Prevalence increases with age
  • Predominantly affect women
  • Take a long time to heal

6
Where are they usually located?
  • Anterior to medial malleolus
  • Pretibial area
  • Generally lower one third of leg
  • Ulcer characteristics
  • Uneven edges
  • Ruddy granulation tissue
  • No necrotic tissue

7
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8
Assessment
  • Pain
  • Mild to moderate
  • Discomfort relieved by elevation of legs
  • Leaking oedema
  • ? maceration,pruritis and scaling of skin
  • Normal foot and leg pulses
  • Ultrasound will confirm venous incompetence

9
Management
  • Improve drainage
  • Exercise
  • Compression
  • Elevation
  • Ulcer treatment
  • Moist wound healing principles
  • Assist normal processes of healing

10
Compression therapy
  • Graduated compression results from applying a
    bandage at steady and even pressure from toes to
    below knee
  • Inversely proportional pressure to circumference
    of limb
  • More pressure applied at ankle than at calf
  • Graduated compression decreases
  • Capacity pressure in superficial veins
  • Ambulatory venous pressure
  • Oedema
  • Progression of lipodematosclerosis

11
Compression therapy cont/
  • Should be applied early morning when less oedema
  • Skill required for application
  • Different grades of pressure bandage available
    14mmHg 50mmHg
  • Light, moderate, high and extra high compression

12
Application of compression
  • See Carville p.p. 195-198
  • Layer 1 cotton wool applied in spiral
  • Layer 2 crepe applied in spiral
  • Layer 3 light compression applied in figure of
    8
  • Layer 4 cohesive flexible applied in spiral

13
Application of compression cont/
  • Leg gently washed and dried
  • Apply moisturiser
  • Assess pulses , Doppler studies, etc.
  • Dress ulcer
  • Apply padding layers
  • Foot at right angles to floor
  • Apply bandages as per manufacturers instructions
  • Encourage ambulation

14
Classification of bandages
  • Classes range from simple support bandages e.g.
    crepe (Class 2)
  • to high compression e.g. blue line (Class 3D)
  • Stockings are similarly classified e.g. TED
  • Important to use appropriate level of compression
  • Pressure ranges from 14 60mmHg

15
Risks
  • At high pressure possible damage to skin
  • Impair arterial blood supply
  • Important to apply bandages and stockings
    correctly
  • Ridges of puffiness indicate poor technique
  • Stockings must be properly fitted
  • Patient comfort is an issue in compliance

16
Wound healing principles
  • Define aetiology
  • Venous, arterial, mixed
  • Control aspects affecting healing
  • Diabetes (BSLs), other diseases (CCF)
  • Select appropriate dressings
  • Plan for maintenance
  • Risk assessment tools, prevention

17
Wound assessment
  • Dressing choice based on
  • C (Colour)
  • Pink, red, yellow, green, black
  • D (Depth)
  • Stages 1 - 4
  • E (Exudate)

18
Venous ulcer
19
Dressing Classes
  • Passive dressings
  • Gauze, combine, Interpose, Melolin, tulle gras
  • Fulfill very few properties of ideal dressing
  • Interactive / bio-active dressings
  • Alter the wound environment
  • Interact with wound surface
  • Encourage normal healing
  • Stimulate healing cascade

20
Semi-permeable films
  • Non absorbing
  • Waterproof
  • Gas/vapour permeable
  • Flexible, conformable, comfortable
  • Transparent allow for assessment
  • Used on clean superficial wounds with little
    exudate

21
Hydrogels
  • Moisture donating
  • Absorb their own weight in fluid
  • Available in gels and sheet form
  • Re-hydrate sloughy or necrotic tissue
  • Require secondary dressing
  • May macerate exudating wounds

22
Hydrocolloids
  • Low moderate absorbency
  • Form soft gel with exudate (resembles pus)
  • Adhesive, flexible, comfortable
  • Provide physical barrier to bacteria
  • Aid in autolytic debriding
  • Encourage development of granulation tissue

23
Hydrocolloids (cont)
  • Available in thin transparent version
  • Also in paste and powder for slightly deeper
    wounds
  • Require secondary dressing
  • Leave in place for a week or a leak

24
Foam dressings
  • Absorbent
  • Fulfill most requirements of ideal dressing
  • Highly absorbent, insulating, non-stick
  • Used in moderately to highly exudating wounds
    e.g. leg ulcers, pressure ulcers
  • A number of varieties available including
    charcoal containing

25
Alginates
  • Seaweed derived
  • Form gel with exudate
  • Highly absorbent
  • Haemostatic
  • Used on moderately to highly exudating wounds
    e.g. donor sites, ulcers, cavities
  • Need secondary dressing

26
Client education
  • Exercise
  • Elevate legs
  • Protect legs
  • Protect from injury, excessive heat, cold
  • Wear appropriate elastic support on legs
  • Reduce weight if obese
  • Comfortable footwear, care of feet

27
Things to avoid with leg ulcers
  • Obstructing the veins
  • Garters, tight clothing, avoid crossing legs
  • Do not sit or stand for prolonged periods
  • airline DVT, ? venous stasis
  • Do not smoke
  • Reduces blood flow and slows healing process

28
Arterial ulcers
  • Less common
  • Characterised by extreme pain
  • Usually smaller than venous ulcers
  • Pedal pulses absent or weak
  • Skin changes include
  • thin shiny dry skin, thickened nails, pallor,
    limb may be cool

29
Treatment of arterial ulcers
  • NO COMPRESSION!!
  • NO ELEVATION
  • Prevent thermal trauma
  • Protect from pressure (neuropathy)
  • Regular podiatry care
  • Elevate head of bed encourage dependant
    circulation

30
Ulcers of mixed aetiology
  • Assessment very important
  • Dress ulcers according to type and severity
  • Minimal compression therapy according to Doppler
    ratio
  • Advise health promotion strategies
  • STOP smoking, skin and foot hygiene
  • Combination of dependency, and leg elevation

31
Research Activity
  • Access the Wounds1.com website and read through
    the information on the anatomy of skin and other
    relevant wound topics
  • http//www.wounds1.com/index.cfm

32
References
  • Body1 Inc. 2008 Wounds1.com accessed 19/5/08
    http//www.wounds1.com/pr_ulc/index.cfm
  • Carville, K. 2005 Wound Care, 5th edition.
    Silver Chain Nursing Association, Osborne Park,
    WA (617.14 CAR)
  • Stockslager, J. (Ed.) 2003 Wound Care made
    Incredibly Easy!, Lippincott Williams Wilkins,
    Philadelphia (617.14 WOU)
  • Templeton, S. (Ed.) 2005 Wound Care Nursing A
    Guide to Practice, Ausmed Publications, Melbourne
    (617.106 WOU)
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