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CHAPTER

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Lifelong Management

JANE HARRY

ower limb wounds represent an important public health problem

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 etal. (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 signicant burden that wounds pose on the NHS and how clinicians were failing to conduct holistic assessments of wounds. Guest etal. (2015) identied 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 identied that only 15% of patients with a lower limb wound had an ABPI measurement documented on their records (Guest etal.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 England2017).

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 etal. (2020) equated this to the highest spend within wound care and went on to highlight that this problem needs to be

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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 signicant trend towards decreasing wound care through thepandemic, 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). Atthesame time, some barriers that once limited patients have been lifted through the use of supported self- care and telemedicine (Schoeld2021), 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 UK2022).

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 85will increase from 1.7million people (2.5% of the UK population) to 3.1million people (4.3% of the UK population) by 2045 (Oce 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 UK2022).

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 etal.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. Chapter7 explores personalised care in more detail.

FACTORS INFLUENCING VENOUS ULCER RECURRENCE

There are many factors that can inuence if a person’s leg ulcer will recur and when. It is not just the person’s medical conditions that inuence 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 insucient 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 (Moat et al. 2009). Practitioners may also bear responsibility here: evidence suggests that there are gaps in knowledge about compression hosiery (Heyer etal.2017: Gong etal. 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 inPatients withPeripheral 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 UK2015). Chapter5 explores assessment of arterial factors in more detail.

Prevention ofRecurrence inPatients withHealed VenousUlceration

It is important to implement an agreed and ongoing self- management plan with the patient, including movement/exercise and a skincare regimen (Wounds UK2022). 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 (NICE2021) states that patients should be oered 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 (NICE2020; Wounds UK2022).

The guidelines suggest that compression hosiery is the rst option

for the maintenance phase (NICE2020), 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 UK2022). 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 qualied 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 Chapter8. Before the correct tool from our toolbox is chosen for treatment, it is rst important to undertake a holistic assessment to ensure that eective maintenance hosiery is selected.

HOLISTIC REASSESSMENT INCLUDING ANKLE BRACHIALPRESSURE 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

monthly History of diculty 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 stratication forreassessment.

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 UK2015) (see Table9.1).

 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 UK2022).

 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 Chapter5 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 UK2022). 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 aects both legs– therefore both legs should be assessed and should receive compression therapy (Wounds UK2022).

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 UK2022).

ENDOVENOUS ABLATION

All patients with venous insuciency should be considered for endovenous surgery, as outlined in Box9.1.

COMPRESSION THERAPY SYSTEMS

Compression is often a lifelong treatment for many individuals who have a venous leg ulcer even after it has healed (Wounds UK2022). The prescription of compression hosiery is advised to prevent leg

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