Lower Limb and Leg Ulcer Assessment and Management

Lower Limb and Leg Ulcer Assessment and Management is an indispensable resource for practitioners in primary and secondary care, offering a practical and accessible guide to treating and managing leg ulcers.

This comprehensive text challenges the misconception that leg ulcers are invariably chronic. In practice, proactive management will prevent the harm associated with sub-optimal management. Insights are provided into lower limb assessment, early intervention for ulcer prevention, ulcer types and their causes, along with the influence that swelling and biomechanical changes have on the lower limb. The authors draw on international best practice guidance on lymphoedema, wound pain, wound bed preparation, compression therapy, psychological impact, and evidence-based care to enhance leg ulcer management.

Each chapter aims to facilitate reader comprehension and promote productive patient discussions, empowering healthcare professionals to collaborate with patients and improve leg ulcer management rapidly and effectively.

This multi-disciplinary resource covers:

Normal venous, arterial, and lymphatic function in the lower legLeg ulceration due to venous hypertension, peripheral arterial disease, and lymphoedemaLeg ulcers of unusual aetiology, addressing autoimmune and inflammatory disorders such as pyoderma gangrenosum, rheumatoid arthritis, scleroderma, sickle cell, and moreMusculoskeletal changes in the lower limb, assessment, and management to enhance mobility and calf-muscle functionClinical management, with topics like wound management, stages of wound healing, exudate management, holistic assessment including vascular assessment, compression therapy, and Laplaces lawPain management with an emphasis on understanding the complexities and features that exacerbate or diminish the pain responseThe personalisation of care, understanding of social determinants of health, and the role of supportive self-management in lifelong management

For professionals seeking evidence-informed approaches to delivering exceptional care,Lower Limb and Leg Ulcer Assessment and Management is an essential companion on the journey to understanding and managing leg ulcers effectively.

Aby Mitchell,Senior Lecturer in Nurse Education, Adult Nursing Department, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London. Abys clinical experience spans across burns and plastics, primary care, and physical health in community mental health. Aby is a registered specialist practitioner in district nursing and has an MSc in Advanced Practice (healthcare education). Aby is committed to improving patient care through nurse education.

Georgina Ritchie,Executive Director and Director of Education at Accelerate. Georgina brings over two decades of experience in clinical practice and education. Her journey from military nursing in the British Army to leadership roles in the NHS and academia has honed her expertise in community and district nursing. Georgina is a registered community specialist practitioner and a V300 non-medical prescriber, holding an MEd, with a passion for empowering confident clinical practice through education.

Alison Hopkins MBE,Executive Director and CEO at Accelerate. With over three decades of experience in wound care, Alison established the leg ulcer service at Tower Hamlets District Nursing Service in 1989, beginning a life-long passion for compression therapy and community transformation. In 2019 Alison was awarded an MBE for services to nursing and wound care and holds an MSc in Psychology and Health. In addition to overseeing Accelerate, she continues to contribute to academic journals, and speak at conferences, always seeking to challenge the status quo so that excellent wound and lymphoedema care becomes the norm.

List of Contributors xiii

Foreword xv

Preface xvii

Acknowledgements xx

Introduction 1Alison Hopkins and Joseph Montgomery

The Wound Care Burden 1

The Cost of Sub-Optimal Wound Care 3

Classification of Dressing Products 4

Dressing Product Analysis 6

Online Non Prescription Services 7

Conclusion 9

References 9

Chapter 1 Aetiology 11Aby Mitchell

Normal Venous Function 11

Veins in Action 16

Blood Pressure in Veins and Capillaries 17

Venous Disease 18

Pathophysiology of Chronic Venous Disease 19

Theories of Tissue Damage 21

Chronic Venous Insufficiency 23

Risk Factors for Venous Insufficiency 24

Arterial Disease 24

The Skin 33

Wound Healing 35

Phases of Wound Healing 36

Conclusion 39

References 39

Chapter 2 Lymphoedema and Chronic Swelling 43Caitriona ONeill and Rhodri Harris

Function of the Lymphatic System 43

Prevalence and Key Facts 48

Causes of and Risk Factors 52

Assessment, Diagnosis and Staging 55

Management Challenges 66

Lymphovenous Disease 68

Treatment 74

Compression Therapy and Assessment Considerations 76

Adjunct Treatment Modalities 79

Surgery 82

Palliative Care 83

Lipoedema 87

Summary 97

References 97

Chapter 3 Atypical Causes of Leg Ulceration 106Sarah Bradbury and Kirsten Mahoney

Inflammatory/Autoimmune Disorders 107

Metabolic Disorders 134

Malignant/Neoplastic Wounds 145

Drug- Induced Leg Ulcers 155

Erosive Pustular Dermatosis 161

Infective Conditions 172

Conclusion 176

References 177

Chapter 4 Musculoskeletal Factors in Leg Ulcers: Assessment and Management 188Rona Frances Campbell

Risk Factors 190

Lower Limb Veno-Muscular Pumps 192

Ankle Joint Assessment 196

Holistic History Taking Relating to Factors that Influence Biomechanical Lower Limb Function 198

Management 205

Reducing Falls Risk 216

Allied Health Professionals as Part of the Multidisciplinary Team 218

Conclusion 218

References 219

Chapter 5 Assessment of Leg Ulceration 226Karen Staines and Aby Mitchell

Assessment 227

History Taking 227

Examination 238

Arterial Disease 248

Wound Assessment 252

Skin Assessment 263

Diagnostic Assessment 265

How to Perform a Handheld Doppler 268

Red Flags for the Urgent Treatment of Patients with Venous Leg Ulcers 276

Reassessment and Recurrence 276

Conclusion 276

References 277

Chapter 6 Holistic Management of Pain 285Fran Worboys and Alison Hopkins

The Pain Experience 285

Theories of Pain 287

Causes of Pain 292

Types of Pain 293

Pain Cycles: Never- Ending Pain 295

Impact of Pain on Peoples Lives 296

Causes of Pain 296

Pain Management Solutions: Assessment 298

Managing Pain 303

Conclusion 312

References 312

Chapter 7 Personalised Care in Leg Ulceration 318Alison Hopkins and Charlotte Smith

The Wider or Social Determinants of Health 319

Wider Determinants of Engagement with Treatment 324

Making Effective Change 326

What Influences Practitioners Decision-Making in Leg Ulcer Management? 329

The influence of Confidence, Courage and Competence 330

A Problematic Culture Within Leg Ulcer Management 332

Challenging Non- compliance 335

Understanding the Lived Experience 338

Support Personal Health Management Through Patient Activation 339

Patient Activation Measure 340

Shared Decision- Making 340

Social Prescribing 342

Motivational Interviewing 342

Supporting Self- Management 343

Legs Matter Coalition: Raising Awareness of Lower Limb Conditions 345

Peer Support Groups 345

Using Positive Language to Promote a Positive Culture 346

Conclusion 347

References 348

Chapter 8 Clinical Management of the Lower Limb 353Georgina Ritchie

The Case for Early Intervention 360

Clinical Management 360

What Is Compression Therapy and How Does it Work? 372

Anti- inflammatory Action of Compression Therapy 381

Cautions and Contraindications 384

Considering and Commencing Treatment 386

Location of the Ulceration 396

Compression of the Foot 396

Intermittent Pneumatic Compression 397

Wound Bed Preparation and Clinical Management 398

Conclusion 400

References 400

Chapter 9 Lifelong Management 405Jane Harry

Factors Influencing Venous Ulcer Recurrence 407

Holistic Reassessment Including Ankle Brachial Pressure Index 409

Endovenous Ablation 411

Compression Therapy Systems 411

Assessing for Compression Hosiery 413

Choosing and Prescribing Hosiery 415

Other Considerations when Choosing a Compression Therapy System 423

Empowering Patients Self- Management for Leg Ulcer Prevention 434

Knowledge, Staff and Training 439

Public Health 441

Patient Satisfaction and Quality of Life 450

Leg Ulcer Pathways 450

Conclusion 451

References 452

Index 457