Post on 17-May-2018
transcript
The Impact
• Quality of life
• Pain
• Loss of earnings
• Visits to clinics
• Time/waiting
• Isolation
• Reduced mobility
• Community support
Heinen, M., Persoon, A., van de Kerkhol, P., Otero, M. & van Achterberg. (2006). Ulcer-related problems and health care needs in patients with venous leg ulceration: A descriptive, cross-sectional study. International Journal of Nursing Studies.44. 1296-1303
The Impact
• Dressings and bandages
• Nursing time
• Doctors time
• Medication costs
• Financial support eg W&I
• Admissions to hospital
EWMA Position Document: Hard-to-heal wounds: a holistic approach.London. MEP Ltd. 2008.
Leg Ulcer Prevalence
• Australia - 3 per 1000 adult population • NZ - 2.48 per 1000 adult population • Risk increases over the age of 65 • Venous leg ulcer recurrence between 22-69% • 80% venous ulcers
• Majority managed in community • 50% Community Nurses practice
Trans-Tasman Collaboration
• Increase awareness
• Optimize prevention, assessment, management
• Dissemination best practice
• Simplify clinical decision making
Australian and New Zealand clinical Practice Guideline for the Prevention and Management of Venous Ulcers. 2011
Guideline Development Process
• National Health & Medical Research Council • Endorsed by NZGG • Robust process • Grading of evidence A,B,C,D and CBE • Practice points • Lack of evidence not lack of effect • Further reading: Barker, J (2010) Developing
clinical practice guidelines for prevention and management of venous leg ulcers. Wound Practice and Research, 18(2), 62-71
National Health and Medical research Council. How to put the evidence into practice: Implementation and dissemination strategies. Canberra. 2000
Preventing Initial Occurrence VLU
• DVT prophylaxis
• Early detection & management DVT
• Access venous & phlebology intervention
• Compression hosiery
Assessment: History
VLU risk – familial, DVT/PE, leg trauma, ↓ mobility, VV’s, obesity, multiple pregnancies
Ulcer history - duration, past treatment, recurrence
Nutrition - nutritional intake, BMI, weight changes
Assessment: History
Pain assessment
Mobility – foot/calf muscle pump
Psychosocial/QoL - impact to patient
CEAP Clinical Classification assessing venous disease
CEAP Clinical Eitiology, Anatomy, Physioloy
C0 No sign of venous disease
C1 Telangiectasias (spider veins) or reticular veins (small dilated torturous veins)
C2 Varicose veins
C3 Presence of oedema
C4a Eczema or pigmentation
C4b Lipodermatosclerosis or atrophie blanche
C5 Evidence of a healed venous leg ulcer
C6 Active venous leg ulcer
Antignaini, P. (2009). The CEAP classification and its evolution. EWMA Journal, 9(1), 19-24.
Investigations
• Blood pressure
• ABPI
• TBPI
• Duplex ultrasound
• Blood screen
• Microbiology
• 10gram monofilament screen
When to Refer to a Specialist
• Diagnostic uncertainty • Atypical ulcer characteristics/location • Suspicion of malignancy • Treatment underlying condition eg vasculitis • ABPI ↓0.8 or ↑1.2 • Failed to heal in 12/52 despite compression • Recurrence • Antibiotic-resistant ulcers • Uncontrolled pain • Unresolved eczema
Patient Education Provide appropriate education on condition/management
• Explanation
• Informed choice
• Consistent message
• Regular reinforcement
Psychological Support Psychological support an essential component
• Include patient in developing plan of care
• Information on progress
• QoL scales may be used
Exercise Progressive resistance exercise improve calf function
• Weight bearing foot and ankle exercises
• Gait analysis
• Consider referral to physiotherapy
• Elevation level of heart when sitting
Manage Surrounding Skin Treat eczema/impaired skin promptly
• Differentiate eczema, sensitivity, infection
• Barrier preparations
• Topical steroids
• Zinc impregnated bandages
Antimicrobial Treatment
• Cadexomer iodine
• Topical silver
• Topical honey
• Other topical antimicrobials
• Topical antibiotics
• Systemic antibiotics
Compression Therapy when no contraindications apply compression therapy to promote healing in VLU (Grade B)
Considerations:
• Shape and size leg
• Patient tolerance
• Clinician experience
• Environment
• Application/removal
• Access
• Other co-morbidities
• Patient activity
• Cost
Inappropriate compression hosiery can result
in damage and possible amputation
Achilles tendon
Tibial crest
Ankle joint
Compression Hosiery
Nelson, E., Bell-Sayer, S. & Cullum, N. (2000). Compression for preventing recurrence of venous ulcers. (Review). The Cochrance Database of Systematic Reviews, Issue 4.
Patient education is crucial to compliance and effectively wearing hosiery
Monitor Progress
• Reduce by ≥ 25% in 4 weeks
• Heal within 12 weeks
• Comfort and tolerance
• Maintaining their plan of care
• Identify and manage issues
NZ Implementation Strategy
• Venous Leg Ulcer Advisory Group
• Strategic leadership in the implementation of the guidelines
• Multidisciplinary representation
• Publications
• Education
• Leg Ulcer Pathway
References Antignaini, P. (2009). The CEAP classification and its evolution. EWMA Journal, 9(1), 19-24. Australian and New Zealand clinical Practice Guideline for the Prevention and Management of Venous Ulcers. 2011 Barker, J (2010) Developing clinical practice guidelines for prevention and management of venous leg ulcers. Wound
Practice and Research, 18(2), 62-71 EWMA Position Document: Hard-to-heal wounds: a holistic approach.London. MEP Ltd. 2008. Heinen, M., Persoon, A., van de Kerkhol, P., Otero, M. & van Achterberg. (2006). Ulcer-related problems and health care
needs in patients with venous leg ulceration: A descriptive, cross-sectional study. International Journal of Nursing Studies.44. 1296-1303
National Health and Medical research Council. How to put the evidence into practice: Implementation and
dissemination strategies. Canberra. 2000 Nelson, E., Bell-Sayer, S. & Cullum, N. (2000). Compression for preventing recurrence of venous ulcers. (Review). The
Cochrance Database of Systematic Reviews, Issue 4. Nelson E, Cullum N & Jones J. Wenous leg ulcers. British Medical Journal (Clinical Research Edition) 2006;172(11):1447-
1452. Walker N, Vandal A, Holden J et al. Does capture-recapture analysis provide more reliable estimates at the incidence
and prevalence of leg ulcers in the community. Australia and New Zealand Journal of Public Health 2002;26:451-5