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232 ASSESSMENT OF LEG ULCERATION
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important to check any known allergies and consider food allergies,
as some dressings have food products within them such as shellsh
and ovine products. Allergies such as latex and lanolin may also have
an inuence on the choice of treatment.
Diet andNutritional Status
Individuals who are overweight are just as likely to be malnourished
as those who are slight in build. Highly exuding wounds result in a
loss of protein that is essential for cell regeneration. Having a wellbalanced diet is a key factor to consider in wound healing (Hess2020).
The prevalence of venous leg ulcers (VLUs) is signicantly higher in
patients who have obesity compared to patients who do not (Danielsson etal.2002; Van Rij etal.2008). A high body mass index (BMI)
will add extra pressure on the venous system and increase the risk of
valvular incompetence (Atkin 2019). Additional intra- abdominal
pressure in patients with a BMI >40 or >35 (with obesity- related
complications) can hinder venous and lymphatic drainage and a
high BMI can increase the risk of varicose veins (Iannuzzi etal.2002).
Obesity can result in a reduction of mobility, increased aggravation of
limited joint and ankle mobility (Belczak etal.2021) and a sedentary
lifestyle. People who are suering from active ulceration are more
likely to be obese (Carruthers etal.2014). Discuss diet and signpost
to a dietician where appropriate.
Sleep Pattern andBehaviour
The importance of discussing sleep behaviour and asking the direct
question ‘Where do you sleep at night?’ is fundamental to the success of the treatment and an important discussion point within the
assessment. If the individual does not sleep in a bed at night, this
results in an increase in dependent oedema. Riser recliner chairs do
have some benets and are useful during the day to raise the feet
intermittently. However, most of these chairs, unless they lay at, do
not elevate the legs suciently for eective venous return and some
dependent oedema is likely to remain. It is recommended that
patients should aim to raise their legs approximately 15cm (6in.)
from the bed to reduce oedema (Vascular Society for Great Britain
and Ireland2023).
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Smoking
Smokers have an increased risk of cardiovascular disease. Smoking
damages the lining of the arteries, including the coronary arteries.
The damage encourages the build- up of fatty materials in arteries,
which can lead to MI and stroke. Smoking causes vasoconstriction,
which leads to hypoxia. Neutrophils and monocytes (cells that help
prevent infection) are reduced, as is collagen, which means that there
is less tensile wound strength and a delay in wound healing due to
the reduction of oxygenated blood essential for tissue repair (Wang
etal.2021).
Pain
Ask the person about the pain they feel. Pain associated with venous
insuciency occurs after standing or sitting for long periods of time.
Does the pain improve when the legs are elevated? If there is pain or
discomfort lying down at night, consider restless leg syndrome or
intermittent claudication (Collares and Faintuch 2017). See Chapter6 for a more detailed exploration of pain and its impact.
Stress
Stress in both family and work environments may worsen prognosis
and accelerate the progression of coronary heart disease and atherosclerosis in women (Wang etal.2006).
Alcoholism
Alcohol can increase the risk of arterial disease by narrowing the
arteries and reducing blood ow. Alcohol works as a vasoconstrictor,
causing veins to tighten and constrict (Kawano2010).
Mobility
Studies show that regular exercise protects against the development of
VLUs (Wittens etal.2015; Smith etal.2018). The calf muscle pump
function is reduced in patients with VLUs and non- functioning of the
calf muscle pump in permanent immobility leads to an outow
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234 ASSESSMENT OF LEG ULCERATION
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disorder, which may result in oedema and skin changes (Suehiro
et al. 2014). Co- morbidities resulting in reduced mobility that are
found to be associated with VLUs include rheumatic diseases, PAD
and neuropathy (Seitz et al.2010; Matic etal. 2016). Note that any
limb deformity including of the foot is especially important in patients
who have rheumatoid arthritis or diabetes, for instance Charcot’s foot.
Assess ankle mobility and action of the calf musclepump to aid in
venous return (Chapter4 explores the biomechanicalfundamentals).
Quality ofLife
Consider whether the person has any symptoms that aect their
quality of life (NICE 2023). Concerns could include malodour,
exudate, nding appropriate footwear and social isolation.
Loneliness andIsolation
Leg ulceration can be lonely and isolating. Malodour or poor exudate
management can add to this signicantly, as can diculty nding
appropriate footwear. Signpost patients to support services such as
Lindsay Leg Clubs (www.legclub.org). Leg Clubs were initially set up
in 1995 to oer community- focused support to patients in a social
non- medical environment. Healthcare professionals work in
collaboration with volunteers to support health promotion. The
social aspect of meeting others with the same condition can prevent
social isolation and support integration into their local community.
However, it is worthy of note that not all areas of the UK have Leg
Clubs. Legs Matters (https://legsmatter.org) is an organisation that
provides advice on leg care and foot health that is accessible for
patients and healthcare professionals.
Family/Carer Support
Discuss long- term support with the patient. This could be a relative,
carer, friend or neighbour who may be willing to support with the
application and removal of compression hosiery or wraps. Attendance allowance is not means tested and patients should be signposted
to apply for this if help with personal care is required.
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Assessment of Leg Ulceration 235
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Employment
Ask the patient what they do for work. People who have occupations
that require prolonged standing are more are risk of developing
venous disease (Atkin2019). The sustained pressure of standing for
long periods of time is thought to lead to venous distention and
secondary valvular incompetence (Nicholls2005).
Psychological Status
Assess the patient’s psychological status. There is increasing
recognition of the role that psychological status plays in the
development and outcomes of chronic disease (Moatt etal.2009).
The nature of leg ulceration can aect the most important spheres
of human life: physical, psychosocial and emotional. Leg ulcers are
accompanied by numerous symptoms, including pain, pruritus,
joint deformation, swelling, discharge and unpleasant odour.
These symptoms can diminish quality of life (QoL) by restricting
physical activities, inuencing mobility, causing sleeplessness,
depressing mood, limiting professional, social and familial
relationships and leading to nancial diculties (Platsidaki
etal.2017). Family members can experience a signicant impact
on their lives too. This impact depends on the duration and the
severity of the disease, the treatment that is followed and, above
all, the relationship with the patient. Patients with leg ulcers
demonstrate higher anxiety levels in comparison with healthy
people (Platsidaki et al. 2017). This could be explained by the
associated stressors of living with leg ulcers, which lead to negative
emotions and anxiety. Understanding the person’s emotional state
of mind can determine their ability to engage with the assessment
and management process, which is particularly important for longterm conditions (Table5.1). See Chapter7 for a greater exploration
of the impact on QoL and further discussion of self- care,
personalisation and psychosocial support.
Good history taking in leg ulcer management can provide healthcare practitioners with the essential information required to ensure
that care is eective and patient centred based on individual values,
beliefs and expectations.
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TABLE5.1 Psychological assessment.
Mental
health history
Current
mental health
Clinical depression Is the patient currently or have they in the past
Anxiety Does the patient appear anxious?
Belief systems What are the patient’s belief systems around
Has the patient been detained under the Mental
Health Act?
Do they have capacity and ability to answer
questions during the assessment?
Is there a risk of selfA patient’s ability to engage may be aected by
their understanding and capacity, which are
fundamental to gaining a therapeutic
relationship with the healthcare provider
(Wounds UK2019b).
It is also important to remember that just because
someone is making a decision that the
professional feels is clinically unwise, this does
not mean they do not have capacity, and it is
their right to do so if they have capacity.
Is the patient at risk?
Do they require an advocate or an assessment to
review their mental capacity?
been diagnosed with depression?
Is this exacerbated by the patient’s current
mental state?
Research suggests that there is a direct association
between having a leg ulcer and depression
(Upton etal.2014). This may be inuenced by
changes in their daily activities of living
(Platsidaki etal.2017).
Are there any areas of particular concern?
Anxiety can be raised, with consequent inability to
work and feelings of inadequacy to care for and
provide for the family (Platsidaki etal.2017).
medical management and selfWhat is their understanding of how the wound
will heal?
A study by Walburn etal. (2017) found that there
was an association between slower healing leg
ulcers and patients who had negative beliefs and
perceptions about the ability to heal the ulcer.
harm?
management?
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Assessment of Leg Ulceration 237
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TABLE5.1 (Continued)
Understanding own
health needs
Expectations What is the patient’s expectation (hopes and fears)
Motivation How motivated is the patient towards treatment
Perception of and
living with an
ulcer– body
image challenges
Loss of status,
self- esteem and
independence
Psychological
assessment–
dependence on
nursing services
Does the patient understand the nature of leg
ulceration and what they can do to help
themselves?
Supported self-
be encouraged following a mental capacity
assessment.
How is the patient currently managing anxiety
around their health or current problem?
Additional mental health support may be
appropriate.
of this assessment?
It is important to identify small goals that are
achievable.
It is important to work collaboratively with the
patient and build trust.
Patients tend to have fewer symptoms of their
condition and have higher satisfaction with the
treatment they receive if they have trust in the
healthcare professional delivering their care
(Birkhäuer etal.2017).
and lifestyle change?
Motivation is an inherent part of the healing process.
How is having a leg ulcer aecting the patient’s
image, hobbies and social life?
selfSalomé etal. (2016) found that patients with leg
ulcers had negative feelings about their bodies
with low self- esteem.
Is the patient dependent on others to support
them with daily activities?
Have they lost their independence, which can lead
to a loss of self- esteem?
The symptoms associated with leg ulcers, e.g.
pain, malodour and exudate, can reduce
functionality and culminate in a feeling of low
self- esteem (Salomé2020).
Assess the patient’s level of dependence on
nursing services.
Patients may suer from social isolation, malodour
or wound exudate leakage (Platsidaki etal.2017).
management (NHS2020) should
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(Continued)
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TABLE5.1 (Continued)
Quality of life Assess the patient’s quality of life with the use of a
validated tool, e.g. the Quality of Life Wound
Checklist (Green etal.2018).
Concordance,
adherence and
ability to tolerate treatment
A patient may choose not to adhere to a plan of
care for a variety of reasons, especially if
incorrect compression is applied and is not
eective, or feels uncomfortable.
Ensure that treatment planning is patient centred
and that patients are empowered to become
active participants in their own care.
The care plan should respond to the patient’s
individual needs, values and preferences.
EXAMINATION
Practitioners who manage people with leg ulceration need to be
competent in recognising clinical signs and symptoms of PAD and
chronic venous insuciency (CVI). CEAP is a standardised
classication system based on the current understanding of venous
pathology, signs, symptoms and manifestations of the disease
process (Lurie etal. 2020). The issues of concern are categorised
as follows:
Clinical presentation
Etiology
Abnormalities found
Pathophysiology of the problem encountered
The clinical presentation classication is divided into six
categories and further subdivisions (Table 5.2). Determination of
CEAP classication requires an interprofessional team of health
professionals, specialists and assessors (Zegarra and Tadi2022).
A comprehensive assessment of the limb is vital to identify early
indications of venous disease, assess for the presence of arterial
disease, and strategies to maintain the patient’s QoL and reduce the
prevalence of ulceration or adverse limb events (Tummala and
Scherbel2018).
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TABLE5.2 The CEAP standard foridentifying venous disease.
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Category Description
C0 No visible or palpable signs of
venous disease. This category is
often overlooked– however, early
intervention at this stage can
have excellent results. Patients
report tired, heavy legs.
C1 Telangiectasis or spider veins are
dilated venules or arterioles
measuring less than 1.0 mm in
diameter (Figure5.1).
This section has been subdivided into two categories:
Patients with venous symptoms and no signs of venous disease, with reux or
obstruction identied during routine investigations.
Patients with venous symptoms, no venous signs and no pathological ndings.
FIGURE5.1 Signs of telangiectasis.
Telangiectasis can appear anywhere on the lower extremities (Thomson2016), but
quite often in the thigh region caused by dilation of the capillaries just under the
surface of the skin. Reticular veins have a diameter of less than 3 mm. These are
often tortuous and located in the subdermal or subcutaneous tissue (Eklof
etal.2004) and are the rst visible signs of venous problems.
(Continued)
TABLE5.2 (Continued)
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Category Description
C2 Varicose veins.
Swollen or enlarged veins.
Varicose veins are a signicant indicator of chronic venous insuciency (CVI)
aecting an estimated 30% of the population (this is considered to be
underreported) (Onida and Davies2016). For this category, these are
subcutaneous, dilated and tortuous veins measuring more than 3 mm in
diameter when the patient is in a standing position (Collares and
Faintuch2017). Varicose veins are caused by damage to the valves that prevent
the backow of blood from the deep to the supercial venous system. Venous
valve damage is serious enough that backow and blood pooling cause vein
walls to stretch beyond repair. This makes it increasingly dicult for the venous
system to pump blood back to the heart. Varicose veins can change in severity
from mild to moderate and may be bumpy in appearance, ranging from reddish
to purple or blue in colour (Figure5.2).
FIGURE5.2 Signs of enlarged veins.
C2r Recurrent varicose veins. The incidence of recurrent varicose veins after surgery is reported to be between
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20% and 80% (Winterborn etal.2004; Blomgren etal.2004).
C3 Oedema.
Swelling for more than 3 months in
duration, which mostly involves
the toes and feet and can extend up
into the thigh. Less likely to resolve
on limb elevation and skin changes
indicative of lymphoedema are
likely to follow (see Chapter2).
C4 Changes in skin and subcutaneous
tissue secondary to
venous disease.
In CVI this tends to be pitting oedema (excess uid in the body, causing swelling
when under pressure and the skin remains indented), which gets worse during
the day and is resolved partially when the patient goes to bed at night. This
should not be confused with cardiac or renal oedema, which is nonOther symptoms of cardiac and renal oedema include shortness of breath,
bilateral oedema, fatigue, urine retention and oedema extending to other parts
of the body.
Often associated with changes that cause discomfort, pain, sleep disturbances,
absenteeism in the workplace, disability and deteriorated quality of life
( Ruggiero etal.2016).
pitting.
FIGURE5.3 Signs of hyperpigmentation, staining and hyperkeratosis.
Courtesy of Accelerate / Andrew Joyce.
(Continued)
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