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CHAPTER
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9
Lifelong Management
JANE HARRY
ower limb wounds represent an important public health problem
L
for people with ulceration, the health system and society in general. This leads to a heavy burden in terms of time and costs for health
services, and it does not end once the ulcer is healed. Harding etal.
(2015) estimated that 69% of patients with a venous leg ulcer have a
recurrence within one year of healing (around 7/10 patients). The
wound care burden was highlighted across the United Kingdom by
the publication of the Guest data in 2015, which showed the signicant burden that wounds pose on the NHS and how clinicians were
failing to conduct holistic assessments of wounds. Guest etal. (2015)
identied that only 16% of patients were having a full ankle brachial
pressure index (ABPI) assessment and that wound care spend was
the equivalent to 5% of the total NHS spend. A more recent study
identied that only 15% of patients with a lower limb wound had an
ABPI measurement documented on their records (Guest etal.2020).
In cases where patients do not have an ABPI obtained and recorded
treatment and healing delays are likely to be seen, which in turn
leads to increased costs for the NHS, a pull on clinical resources, and
a greater burden and chronicity of these wounds (NHS England2017).
With wound care in the six top spending categories for the NHS
and leg ulceration spend being twice as much as any other type of
wound, Guest etal. (2020) equated this to the highest spend within
wound care and went on to highlight that this problem needs to be
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
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addressed. The coronavirus pandemic has brought new issues in caring for patients generally, with long- term conditions and leg ulcer
management a particular concern. Guest and Fuller (2023) further
stated that healing rates of venous leg ulcers in 2020–2021 decreased
by 16% and 42%, respectively, compared with 2019, and time to heal
increased by >85%. The number of communityclinician visits decreased by >50% in both years and >35% fewer
patients were referred to a specialist. Guest and Fuller (2023) also
reported that in 2020 and 2021 up to 20% of patients were prescribed
dressings without compression, compared to 5% in 2019. There
was a signicant trend towards decreasing wound care through
thepandemic, which went outside the boundaries of good care. The
pandemic also led to unprecedented challenges in delivering wound
care and held back the national improvement work of the National
Wound Care Strategy Programme (NWCSP) (Adderley 2020).
Atthesame time, some barriers that once limited patients have been
lifted through the use of supported self- care and telemedicine
(Schoeld2021), but supported self- care is not an option for everyone.
Due to the nature of the underlying disease process, it is common
for patients to go through a cyclical process of periods of being healed
followed by periods of ulceration and tissue breakdown. The risk of
this may increase as the patient ages and their co- morbidities worsen.
However, this is an unnecessary cycle if practitioners prevent this
reoccurrence through proactive lifelong management. To do this it is
important to diagnose the underlying disease and identify the person’s
needs in terms of prevention of reoccurrence, which is supported by
practitioners building sustainable relationships with the patient during diagnosis, treatment and post ulceration (Wounds UK2022).
The risk of reoccurrence and the need to manage an increasing
population of people requiring lifelong management will continue to
increase as the general population ages: the number of people over
85will increase from 1.7million people (2.5% of the UK population)
to 3.1million people (4.3% of the UK population) by 2045 (Oce for
National Statistics 2022), further increasing the public health burden. Overall primary prevention and treating the underlying venous
disease prior to any occurrence of leg ulceration will lead in the long
term to a lower rate of leg ulceration and therefore a lower impact on
people, the health service and the health economy (Wounds UK2022).
It is a common misconception that people with venous leg ulcers
cannot be healed. Myths need to be addressed and awareness raised
based face- to- face
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Lifelong Management 407
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within the nursing profession and the public. As healthcare professionals we have an opportunity to transform and change perspectives
and shape leg ulcer care and well leg management in the future
(Atkin etal.2021). Once the ulcer is healed the maintenance stage
should commence; this is just as important as the diagnosis and treatment phase. Education with people who have lower limb problems
should start from the very rst contact with them about how to manage their condition and equip them with the knowledge and tools of
how to prevent further breakdown. Laying the foundations for
supported self- care or fully independent self- care and management
at the start is key to maintaining well legs in the future. People should
be encouraged to see compression and well leg management as a lifelong commitment, and this is how we as practitioners and the wider
healthcare community should see it also. Chapter7 explores personalised care in more detail.
FACTORS INFLUENCING VENOUS
ULCER RECURRENCE
There are many factors that can inuence if a person’s leg ulcer will
recur and when. It is not just the person’s medical conditions that
inuence this, but also their commitment and ability to maintain a
well leg. In some cases recurrence is due to ceasing compression
hosiery or not getting new hosiery when it is damaged, leading to
insucient levels of compression on the limb to reverse venous
hypertension and support the veins leading to tissue breakdown.
Other causes of recurrence could be new trauma to the limb; uncontrolled venous disease such as varicose eczema, leading to skin irritation; and patients with urinary incontinence, who may develop
severe dermatitis leading to ulceration (Moat et al. 2009).
Practitioners may also bear responsibility here: evidence suggests
that there are gaps in knowledge about compression hosiery (Heyer
etal.2017: Gong etal. 2020) within clinical practice, with a heavy
reliance on o- the- shelf and British Standard hosiery due to a lack of
knowledge about bespoke hosiery, which is necessary for many people who have had ulceration and/or chronic oedema and altered leg
shape. Education for healthcare professionals is discussed in more
detail later in this chapter. Healthcare professionals need to work
together with patients to overcome recurrence, heal the ulcer again
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and educate the person in the self- care methods they can use to prevent further disease progression and recurrence of future ulcerations.
Recurrence inPatients withPeripheral Arterial Disease
Patients with an established arterial component to their ulceration
should have a reassessment every three months, or more frequently
if there are any changes in the patient’s symptoms (such as new pain
in the foot, arch or toes, or rapid deterioration of the ulcer), as this
could indicate that the peripheral circulation is deteriorating and
may require a change in the treatment regimen or onward specialist
referral (Wounds UK2015). Chapter5 explores assessment of arterial factors in more detail.
Prevention ofRecurrence inPatients withHealed
VenousUlceration
It is important to implement an agreed and ongoing self- management
plan with the patient, including movement/exercise and a skincare
regimen (Wounds UK2022). People need to be supported in developing their knowledge so that they understand that prevention of
breakdown of a healed ulceration is a lifelong commitment.
Education with this group of people should start from the rst contact when they present with ulceration to a healthcare professional
and be revisited regularly during treatment.
When the venous leg ulcer is healed, it is important that the
underlying problem that caused the wound to develop in the rst
instance is addressed– venous hypertension. In order to manage this,
ongoing compression therapy is required to reduce the venous pressure and hypertension. Patients should be given an explanation of
venous hypertension and understand the role of compression therapy in healing ulcers and then maintaining skin integrity; this helps
to prevent recurrence of the venous leg ulceration and reduce the
nursing workload (Wounds UK 2022). The National Institute for
Health and Care Excellence (NICE2021) states that patients should
be oered the strongest compression that they can tolerate and apply.
To prevent recurrence, compression hosiery should be prescribed
(following a holistic assessment including ABPI) British Standard
hosiery if no oedema is present, or the European class hosiery if
oedema is present. Consider a referral to vascular services to assess
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Lifelong Management 409
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the need for venous intervention to reduce the risk of recurrence
(NICE2020; Wounds UK2022).
The guidelines suggest that compression hosiery is the rst option
for the maintenance phase (NICE2020), but there are other options:
Compression hosiery kits, also known as leg ulcer hosiery kits,
which have two layers of hosiery to achieve approximately
40 mmHg. These can also be used while the patient has active
ulceration, and this is now suggested as rst- line treatment
where possible (Wounds UK2022). The VenUS IV study (Ashby
et al.2014) found that patients who became used to wearing
hosiery as an ulcer treatment would be more likely to wear it as a
maintenance treatment after healing– appropriate ongoing compression therefore makes recurrence less likely.
Adjustable compression wraps use Velcro® to make it easier for
patients or their carers to apply compression themselves at home,
once a trained practitioner has assessed and measured the limb,
prescribed the most appropriate wrap, and given the patient/carer
instruction in how to apply and wash it. Wraps can be used in either
the intensive or maintenance stages of lymphoedema treatment.
The advantage of a wrap is that after initial assessment and tting
by a qualied practitioner, the patient and/or their carer can be
taught to apply them easily at home when a nurse cannot be present.
Compression hosiery socks, stocking or tights, discussed later in
this chapter.
Both adjustable compression wraps and leg ulcer hosiery kits are
discussed in more detail in Chapter8. Before the correct tool from our
toolbox is chosen for treatment, it is rst important to undertake a holistic assessment to ensure that eective maintenance hosiery is selected.
HOLISTIC REASSESSMENT INCLUDING ANKLE
BRACHIALPRESSURE INDEX
Reassessments should be carried out:
For those who continue to have an ulceration.
For those who have healed and are in maintenance compression
therapy– well legs.
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410 LIFELONG MANAGEMENT
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TABLE 9.1
Annual No cellulitis
monthly History of lower leg infection, even if resolved
6-
3-
monthly History of diculty in tolerating treatment
N.B. Expedite a new assessment if there is increased oedema, lower leg pain or new
ulceration.
Source: Adapted from Wounds UK (2015).
Risk stratication forreassessment.
Limited or wellHealed ulcer (no recurrence in 12
Stable oedema
Able to tolerate treatment with no reported problems
with hosiery
Ankle brachial pressure index (ABPI) >0.9
Diagnosed with new disease/or new coHistory of recurrent lower limb problems
Multiple morbidities
Repeated poor t
Increasing or unmanaged oedema
Skin breakdown/ulceration
Rapidly changing medical condition (for example, the
person is having palliative or end- of- life care)
controlled co- morbidities
months)
morbidities
Assessments should take place as follows:
Reassessments should take place 3- , 6- or 12- monthly depending
on the risk factors for this individual patient (Wounds UK2015)
(see Table9.1).
Patients who have active ulceration should be assessed on a four-
weekly basis as a minimum to see if their symptoms/wounds are
improving with the current care plan and if this remains appropriate (Wounds UK2022).
If the leg ulcer has not healed after 12 weeks (Wounds UK 2022),
onward referral should be made to rule out another underlying
cause. All elements of the holistic assessment for leg ulceration
should be revisited at reassessment: history taking, medication
review, limb assessment, pain assessment and ABPI. Also,
patients should be asked if they have experienced any problems
since the last assessment, including with their hosiery.
See Chapter5 for a more detailed discussion on assessment for
acute ulceration.
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Lifelong Management 411
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Reassessment of the person, including ABPI assessment, should
occur for the rest of the person’s life; leg ulcer prevention is lifelong and
the schedule for this is based on the wound history and patient’s level
of cardiovascular risk (Wounds UK2022). Both legs should be assessed
for lower limb oedema/swelling and haemosiderin skin staining in all
at-
risk patients (Wounds UK 2022). If a patient has been diagnosed
with a venous leg ulcer in one leg that has healed, it is highly likely that
the venous disease aects both legs– therefore both legs should be
assessed and should receive compression therapy (Wounds UK2022).
To achieve good adherence to maintenance therapy, people need
an informed discussion with the practitioner about the implications
of compression hosiery for clothing, footwear, the likely restrictions
on travel and exercise, how to manage personal hygiene, skin care
and how to take care of the garments. Patients need to understand
that although bandages or a wrap may be required in the short term
only for intensive therapy, hosiery (or wraps) will be required to
maintain the good condition of the limb and prevent recurrence for a
long period into the future. A clear plan for maintenance therapy
should be agreed between the practitioner and the patient. The plan
needs to consider the patient’s aims for treatment, their life commitments and their ability to adhere to compression therapy, and the use
of suitable footwear and clothing that will enable them to have an
appropriate gait for optimal freedom and safety of movement.
Patients should also be supported to develop knowledge so that
they are able to be vigilant for any signs that they may need an assessment earlier than scheduled and that they have contact details for the
healthcare professional or service who would undertake the assessment (Wounds UK2022).
ENDOVENOUS ABLATION
All patients with venous insuciency should be considered for endovenous surgery, as outlined in Box9.1.
COMPRESSION THERAPY SYSTEMS
Compression is often a lifelong treatment for many individuals who
have a venous leg ulcer even after it has healed (Wounds UK2022).
The prescription of compression hosiery is advised to prevent leg
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