Removing the fear from venous ulcer assessment and application of compression

Practice

Sylvie Hampton, RGN, Wound Care Consultant, Eastbourne

Background reading<h2>Background reading</h2><p>Principles of compression in venous disease: a practitioner's guide to treatment and prevention of venous leg ulcers. <a href="http://www.woundsinternational.com/clinical-guidelines/principles-of-compression-in-venous-disease-a-practitioners-guide-to-treatment-and-prevention-of-venous-leg-ulcers">http://www.woundsinternational.com/clinical-guidelines/principles-of-compression-in-venous-disease-a-practitioners-guide-to-treatment-and-prevention-of-venous-leg-ulcers</a></p>

Introduction

There is a plethora of articles in nursing and medical journals describing venous leg ulcers and the use and application of compression; twenty two trials identified by the Cochrane Data review consistently showed that compression encouraged healing of ulcers [1]<h2>Reference 1</h2><p>Cullum N, Nelson EA, Fletcher AW, Sheldon TA. (2004) <em>Compression for venous leg ulcers</em>. Cochrane Database Syst Rev. (2): CD000265</p> . In spite of this, 50–60% of patients with venous leg ulcers are not being treated with compression [2,<h2>Reference 2</h2><p>Vritis MC. (2013) The economic impact of complex wound care on home health agencies. <em>J Wound Ostomy Continence Nursing.</em> 40; 4: 360-63</p> 3]<h2>Reference 3</h2><p>Srinivasaiah N, Dugdall H, Barrett S, et al. (2007) A point prevalence survey of wounds in north-east England. <em>Journal of Wound Care. </em>16; 10: 413-6, 418-9</p> . The reason for this is unclear, although anecdotally, it is suggested that:

that practitioners may be frightened of undertaking a new process
or that they cannot obtain the necessary equipment
or that they lack the knowledge of how to use the required equipment in order to assess the arterial status of the patient

There is certainly a worrying lack of understanding about the key concepts underlying compression therapy [4]<h2>Reference 4</h2><p>Barrett S, Cassidy I, Graham MM. (2009) National survey of Irish community nurses leg ulcer management practices and knowledge. <em>Journal of Wound Care. </em>18; 5: 181-2, 184 - 186</p> .

Given the difference compression can make to a patient’s quality of life, neglecting to offer this treatment modality is unacceptable. This article will endeavour to remove the fear of assessment and compression and to provide advice on simplistic assessment and tips for treating the venous ulcers.

Venous ulcer assessment

The assessment for venous ulceration has been simplified by new technology; for example, the Dopplex ABIlityis machine (Figure 1)<h2>Figure 1: Dopplex ABIlityis machine</h2><p><img src="https://pcnr.co.uk/images/180_dopplex-machine.jpg"></p> . Each of the colour-coded leads is placed on the limb and results obtained within three minutes at the press of a button. If the Ankle Brachial Pressure Index (ABPI) is between 0.8 and 1.0, it is safe to compress with bandages. This machine is so simple to use health care support staff and carers could use it and report the results to a qualified nurse.

A hand held Doppler can also be used to assess foot pulses. There are three sounds to listen for, two of which indicate a lessening in the artery elasticity, the third indicating a normal elastic artery. A sound similar to a ‘dog barking’ or a ‘steam train’ results from an artery that is furred and inelastic, and thus uncompressible.

Pulse oximetry is a simple screening tool for arterial disease, a contraindication to, or indication of the need to modify compression. It is useful where Doppler ultrasound cannot be used [5,<h2>Reference 5</h2><p>Bianchi J, Zamiri M, Loney M, et al. (2008) Pulse oximetry index: a simple arterial assessment for patients with venous disease. <em>Journal of Wound Care. </em>17; 6: 253-260</p> 6]<h2>Reference 6</h2><p>Cooper, R. (2005) Using finger-toe pulse oximetry to assess arterial blood flow. <em>Nursing Times. </em>101; 46: 47</p> , and can be particularly useful when measuring the oxygen levels pre-and-post application of compression. If the bandage is applied correctly and the arteries are fairly patent, then the oxygen level can be expected to climb; if it reduces, the bandaging is unsafe.

Although assessment can be simplified, there are certain rules that must be obeyed:

if the ankle circumference is less than 18cms, it is safer for the inexperienced practitioner to use either a reduced compression short stretch bandage, or (simpler still) to apply a double layer of Setocrepe (Mölnylcke Health Care) (as described below). This will provide a pressure of between 12mmHg and 15mmHg which can be safely used in poor arterial supply
if the ankle circumference is over 25cms, then a stronger application is required in order to overcome the oedema
if the patient has heart disease, diabetes, arthritis or renal disease, it would be wise to use Setocrepe

Compression

Compression is dangerous if poorly applied or applied to an artery that is not fully patent. This is probably the one thing that nurses fear in compression but this is simply overcome by selecting appropriate bandages.

A short-stretch bandage is very unlikely to over-compress as it is applied at full stretch. Using elastic (or multilayer) bandages for compression requires education to ensure that the pressure applied is correct. Examples are indicated in table 1<h2>Table 1: Examples of compression bandages</h2><p><img src="https://pcnr.co.uk/images/187_compression.jpg"></p>.

Setocrepe is a simple non stretch crepe that acts as an excellent and very safe method of low compression when unsure of which compression to apply. It is ideal for all leg wounds and can be used safely by qualified and unqualified staff. Application is as follows:

one layer applied in a figure 8 from toe to knee
a second layer is applied using a figure of 8, from ankle to knee

This has been successfully and safely used throughout Eastbourne for ten years and is used as a ‘back up’ until an ABPI can be obtained, or when the nurse requires some compression for a venous ulcer when the condition of the arteries make it a ‘mixed’ diagnosis.

One of the simplest methods of compression is with Juxta Cures (Figure 2)<h2>Figure 2: Juxta Cures system</h2><p><img src="https://pcnr.co.uk/images/181_juxta-cures.jpg"></p> ( which can be easily applied independently by the patient. This empowers the patient in their own care and increases the potential for healing as the compression will always be the same and appropriate.

Recognising the condition related to the ulcer

Venous ulcers are usually around the ankle area and are shallow (usually) and irregular in shape, often described as ‘butterfly wings’ (Figure 3)<h2>Figure 3: Venous leg ulcer</h2><p><img src="https://pcnr.co.uk/images/182_venous-leg-ulcer.jpg"></p>. Venous ulcers cause dependent pain. Compression is suitable.

Arterial ulcers are often ‘punched out’ and more regular in shape (Figure 4)<h2>Figure 4: Arterial ulcer</h2><p><img src="https://pcnr.co.uk/images/183_arterial-ulcer.jpg"></p>. These can appear anywhere on the leg or foot. These should not be compressed.

Vasculitic ulcers are often necrotic in nature, extremely painful and occasionally will have a blue line around the margins of the wound. These should not be compressed.

Diabetic foot ulcers (Figure 5)<h2>Figure 5: Diabetic foot ulcer</h2><p><img src="https://pcnr.co.uk/images/184_diabetic-foot.jpg"></p> should not be compressed.

Onward referral

There can be no excuse for patients not being given the opportunity to have compression therapy. If the nurse is still unable to make a decision on which compression or how to compress, then they must refer onward to a Tissue Viability Nurse. This is clearly outlined in the Nursing and Midwifery Council ‘The Code: Standards of conduct, performance and ethics for nurses and midwives’. Point 28 states: “You must make a referral to another practitioner when it is in the best interests of someone in your care” [7]<h2>Reference 7</h2><p>Nursing & Midwifery Council. (2014) The Code: Standards of conduct, performance and ethics for nurses and midwives. Available at: <a href="http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/">http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/</a></p> .

The representatives of all of the companies involved in selling compression will always offer education to all involved which can be over a lunch time, so that time constraints are not affected.

Conclusion

Patients with venous leg ulcers must be given the opportunity of compression in order to regain a better quality of life and the ability to provide that quality of life is largely in the hands of nurses who lack confidence in their competencies. It is vital to understand the importance of compression and, if all that is holding up the healing of these terrible afflictions is lack of education due to time constraints and lack of finance, then a simpler method of treatment must be identified. Some compression is always preferable to no compression and if a simple method of treating venous leg ulcers does exist then we must provide the means for patients to receive the most appropriate care that is possible even if it is the simple way.

Given the difference compression can make to a patient’s quality of life, neglecting to offer this treatment modality is unacceptable.