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surrounding environment and prevents loss of water, reduces chemical exposure and protects against micro- organisms. During the ageing process physiological changes occur, including decreased collagen
production, decreased blood circulation, decreased fat content and
loss of rete ridges. In intrinsic ageing theory it is suggested that the
reparability of the DNA decreases, which in turn leads to the formation of wrinkles, acne, eczema and psoriasis (Putri etal.2021). There
are also factors that aect the role of the skin in intrinsic ageing, such
as ethnicity, anatomical variations and hormonal changes. The epidermis thins over time at the dermoanocytes and Langerhans cells also decrease in number over time.
The dermis reduces in thickness as the patient ages, synthesis of collagen and elastin bres reduces and there is a decrease in the number
of blood vessels. The distribution and volume of fat change in the
hypodermis of the skin. There is also a decrease in melanin, the number of sweat glands and sebum production falls (Putri et al.2021).
Understanding this is critical within a programme of reassessment in
lifelong conditions, as the acceptability or impact of garments and
their properties may change.
The use of emollients to promote skin barrier function is critical
in the prevention of recurrence of leg ulceration. Emollients help to
restore the function of the skin, reduce itching and skin breakdown
and increase the level of hydration. Emollients work in one of two
ways and this depends on their constituents. The rst traps moisture
into the skin, which has been shown to slow the evaporation of water;
the second actively draws down moisture into the stratum corneum
from the dermis through the eects of humectants (Moncrie
etal.2015). Humectants either mimic or comprise the same molecule as the natural moisturising factors within the skin, such as urea,
glycerol or isopropyl myristate (Moncrie etal.2015).
In patients with previous leg ulceration, it is essential that a good
daily skincare regime- washing, cleansing and emollient application,
is embedded in to daily life to reduce the risk of further breakdown.
Patients should be taught the correct way to apply emollient in order
to prevent folliculitis, and the importance of applying the emollient
daily and checking for any changes in their skin. Emollients also pay
a key part in the prevention of skin tears (Bale etal.2004).
At every appointment with the patient, note any skin changes as
this may indicate progression of the venous or lymphatic disease process, and educate your patient on what healthy skin is and when to
report changes to a healthcare professional. It is important that the
epidermal junction and the mel-
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practitioner and the patient know how to identify skin changes and
early detection can prevent tissue breakdown. The practitioner
should be able to identify and treat the following: breaks in the skin,
signs of trauma, signs of infection, rashes, pressure damage, varicose
eczema, contact dermatitis and fungal infections such as tinea pedis.
Particular attention should be paid to any skin folds and between the
toes for fungal infection.
Precautions should be taken with regard to skincare under compression therapy garments and bandaging systems. The practitioner
needs to identify if the skin is already fragile– skincare needs to form
part of the holistic assessment and be included in the treatment planning for the patient.
Patients should be given tools and knowledge of ways to maintain skin integrity, signs and symptoms of skin breakdown and what
to look out for, and when to seek help of a practitioner.
Complete emollient therapy should be recommended and
encouraged in all patients– this is dened as everything that goes on
the skin being emollient based and all soaps replaced with emollient
wash products. This includes a combination of wash and leave-
on
products like creams and ointments. It is also important that patients
are given instructions on application methods: emollients should
always be applied in a downward direction or the direction of hair
growth (Wounds UK 2018).
Patients should use emollients as part of treatment planning to
aid in moisture management and should be encouraged to use emollients instead of soap for cleansing as part of their daily self- care
regime (daily for humectant- containing emollients, twice daily for all
other emollients) (Wounds UK2018).
A benet of emollients is that they moisturise the skin while
cleansing it, rather than decreasing the moisture within it and prevent the skin from drying. Some emollients are buered so they
maintain normal skin pH. Evidence has also shown that emollients
can accelerate regeneration of the skin barrier function and reduce
dryness. Most lipid- rich emollients restore the skin barrier rapidly
(Held etal.2001; Moncrie etal.2015).
Emollients come in many forms and the one selected must be
acceptable to the patient as this will help with concordance with the
care regime. These preparations include ointments, creams, lotions,
gels and sprays. Most of the greasiest preparations contain paran.
There is a Medicines Healthcare Regulatory Agency (2020) alert for
products containing soft white paran at a content above 50% due to
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safety concerns raised by the creams having contact with dressings,
clothing and bedding, as they are highly ammable. This needs to be
a consideration when treatment planning for patients who smoke or
are on home oxygen.
Ensure that patients have adequate emollient and soap substitute prescribed. Also if patients are prone to skin breakdown, look at
the materials used in the hosiery, as it may be that the patient needs
a cotton rich bonded garment or skin-
Tips for good skincare can be summarised as follows (Wounds
UK2015,2021):
Ensure that the legs are dry before putting on medical compres-
sion hosiery.
Avoid applying skincare products (e.g. emollients, topical steroids)
just before application of hosiery as this can make application of
the garment harder. Applying skincare products 20 minutes prior
to the application of hosiery can reduce the diculty. Or apply
skincare products in the evening, after removing hosiery for bed.
Check skin daily (or as often as possible) for changes, including
on the legs, toes/nails and interdigital spaces.
Check for any breaks in the skin, any signs of athlete’s foot (tinea
pedis), varicose eczema or red leg syndrome, and signs of cellulitis.
Hosiery should be applied rst thing in the morning, when
oedema is at its lowest level, to help prevent skin damage and
oedema in the tissues.
Gently elevate the legs when resting to reduce pooling of oedema
that can result in skin damage (high elevation not necessary).
Keep physical activity to the fullest extent possible, depending
on each patient’s specic situation. Follow guidance for ankle
exercises for chronic venous insuciency, chronic oedema and
lymphoedema as far as possible. Give information sheets of exercises to patients as an aid.
friendly undergarments.
EMPOWERING PATIENTS’ SELF- MANAGEMENT
FORLEG ULCER PREVENTION
As healthcare professionals we need to encourage patients to achieve
positive outcomes, which includes engagement with the patient,
family and carers to be involved in their care to a level suitable for
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their capacity and capability. This is why it is essential that the healthcare professional considers the patient’s views, priorities and expectations around their care (Wounds UK 2022). Promoting
self-
management for patients is part of the NHS Long Term Plan’s
Comprehensive Model for Personalised Care to make personalised
care standard across the health and care system (NHS England2020).
See Chapter7 for further exploration.
One of the roles of the healthcare professional is to help patients
tolerate compression; most patients can tolerate it more easily when
the correct type and size of hosiery have been selected in partnership
with them. Labelling a patient as non- compliant, or non- concordant
is dismissive to the patient and must be avoided (Wounds UK2022).
A recent study also showed that patients’ individual factors were
rarely considered when prescribing compression hosiery garments
(Schwann- Schreiber et al. 2018). Healthcare practitioners need to
understand from patients their concerns over leg management and
what their goal for treatment is, and to work with the patient to
achieve this many dierent treatment options and garments may
need to be discussed with the patient in order to nd an acceptable
solution. If patients are to have any faith in and be commitment to a
treatment plan, they need to feel that they are part of the planning
stage and feel listened to. It is unhelpful to label patients as intentionally non- adherent (Green and Jester2009); instead, healthcare professionals should work with patients to understand their concerns
and their goals for treatment and ongoing management.
Improving patient engagement with personalised prevention
methods is benecial to both the patient, the healthcare professional
and the wider health service (Table9.10). We must understand what
the patient knows about the condition of their leg in order to be able
to provide the correct information to them so they can make an
informed choice about their care going forward. Healthcare professionals need to use language that resonates with the patient and back
up the discussion with written information so that the patient may
consider everything in their own time and revisit the information for
clarication. Table9.11 oers suggestions for how to educate and
involve patients in their care.
It is acceptable to discuss, compromise and plan with patients.
This will help to build trust in the healthcare professional–patient
relationship over time, which in turn will help the patient to approach
the healthcare professional with questions and seek help when
needed. During appointments with patients explore other treatment
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TABLE 9.10 Supported self- management.
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Assess the patient’s capacity and capability.
Assess their willingness/desire to participate in supported selfAssess whether there are any safeguarding issues.
Talk to them about previous experiences of supported self- management.
Before encouraging supported self-
informed of the following information:
Treatment plan, practicalities of wound care and using compression
garments, and use of emollients in the form of a care contract or leg
ulcer/well leg passport.
Hand washing and limb hygiene.
Reasons for treatment.
Signs of deterioration and improvement.
Signs and symptoms of infection.
Contact details of who to contact if the patients is concerned.
When self-supported management may not be appropriate for people
with venous leg ulceration.
Safeguarding issues (e.g. mental health patients in the community
living alone.
Patients who do not or struggle to understand.
Patients who are not able to tolerate compression therapy (once they are
supported to tolerate compression, they could be more involved in self
management).
Patients who have dexterity problems who are unable to apply the
hosiery themselves even with an aid and have no support network to
help them.
Where hygiene levels are not appropriate.
Where they have problems accessing required products.
management, ensure the patient is
management.
Review every four
NWCSP (2023) recommendations.
or
Remeasure and replace hosiery according to manufacturer’s guidelines,
usually every three months for British Standard Hosiery and six months
for European Standard Hosiery (Wounds UK2021).
When self-supported management may not be appropriate for people with
venous leg ulceration. Safeaguarding issues (eg mental health patients in
the community living alone. Patients who do not or struggle to understand. Patients who ae not able to tolerate compression therapy (once
they are supported to tolerate compression, they could be more involved
in self management). Patients who have dexterity problems who are
unable to apply the hosiery themselves even with an aid and have no
support network to help them. Where hygiene levels are not appropriate.
where they have problems accessing required products.
Source: Adapted from Wounds UK (2022).
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weeks if the patient has active ulceration in line with
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TABLE 9.11 Tips forpatient education andinvolvement.
Involve the patient in the decision- making process from the beginning.
Askthe patient what motivates them and what is important to them
to achieve?
Be aware that the patient’s view on supported self-
time continue to re-explore this during the patient’s journey.
Use positive language and avoid terms like non- concordant, non- adherent
and non-
Explain treatment and rationale at all stages, establishing patient’s and
carers’ long- term and short- term goals and experiences.
Use information leaets, online and resources, videos to help patients get
the information they need in a wat in which they can understand it to
help them make an informed choice.
Use telemedicine (e.g. online video calling, apps, smartphone support).
Suggest patient support groups where appropriate and where available.
Involve friends, family and carers where possible give them the information
if they are to be applying the compression hosiery for patients with
regards to application of the hosiery, how to care for the hosiery and
when to seek healthcare professionals advice.
Encourage continuity of care with consistent messages.
Source: Adapted from Wounds UK (2022).
compliant, tight (when talking about compression therapy)
care may change over
options that will aid in their tolerance of compression therapy
(Wounds UK2021):
Dierent hosiery options– another type of hosiery may be more
cosmetically appealing to the patient. They may have a special
event coming up, such as a family wedding, and they do not want
to wear bandages to the event, for example. Work with them to
nd a solution– maybe they could have hosiery for that event.
Skincare regimen: is the patient able to apply the emollient
independently? Do they need a family member’s help or a foam
application aid for its application?
Elevation: encourage the patient to elevate their legs every time
they sit down, whether to rest, to watch television or to read. All
elevation will help. Encourage activity, which could be getting up
and mobilising with their frame if housebound to encourage calf
muscle pump action. Even if they are unable to get up independently, they may be able to do simple leg and foot exercises whilst
sat in the chair.
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Encourage patients to have a healthy diet and support them to
make the correct choices talk to them about what food is important for wound healing. They may also need dietician review,
weight loss or bariatric service referral. Do they have support for
shopping if house bound?
When discussing compression therapy with patients, ask them to
consider the future with regard to their lower limb and discuss
the possible consequences of not wearing the compression therapy.
For example, what might happen if they chose not to wear it?
What could life be like in a few years’ time? Give the patient time
to consider what could happen.
Are there any support groups locally or nationally that the patient
can access Chapter 5 discusses the Lindsay Leg Club model in
more detail.
Brown (2013) identied some fundamental steps to support
people having compression therapy:
Ask the patient about their overall well- being.
The plan or treatment regime designed with the person should be
individualised and consider their wishes and concerns.
Listen to their concerns with regard to their leg care and the
issues they have identied as concerns. Try to address these
and include them in the patient’s prevention and management
plan going forward. Find out what the person’s expectations
are and what they want to achieve; this could be healing,
dry sheets in the morning if the exudate levels are high,
wearing regular- tting shoes or trousers again or gaining
greater mobility.
Make the person the centre of the process when assessing,
measuring and tting hosiery involve them in all decisions.
Ensure you oer the person a choice of hosiery to t their needs.
Take the patient’s feedback and use this to adapt their
treatment plans and the broader service being provided to
all patients.
Involved the wider multidisciplinary team to develop strong
patient pathways and referrals on to other services such as tissue
viability, dermatology and vascular as required.
There is more about personalised care in Chapter7.
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KNOWLEDGE, STAFF ANDTRAINING
Knowledge and training are essential for any clinical skill. If healthcare professionals are to choose the correct compression therapy
forpatients, they need to have the appropriate awareness and skills
inassessment, recognition, knowledge of products and correct application techniques, aids for application and personalised treatment
planning in order to provide safe and eective care for their patients.
They also need to have an understanding of the dierent types of
compression therapies and their uses in practice and the dierences
between them. This all needs to be considered in conjunction with
the requirements of the patient groups.
Historically, education around compression therapy has been
framed within the context of ‘training to deliver an intervention e.g.
application of a compression bandage. This approach to training has
contributed to the current situation within UK practice: sub-optimal
doses of compression leading to patients not having adequate levels of
compression, variations in practice across the UK, inappropriate selection and measurement of garments, and then blaming the person for
not ‘complying’ with the treatment plan oered. Practitioners deserve
good-quality education to help them develop knowledge about the
under pinning science and theory of compression therapy, followed
by support in clinical practice to grow condence and competency in
the art of measuring, selecting and applying the right treatments
together with the person who will be wearing them. Without robust
education that focuses on the art and science of the compression therapy, not just a task, practitioners will not be condent and courageous
in their practice and sub-optimal provision will continue, unabated.
The NWCSP introduced a core capabilities framework for wound
care in 2021 (Figure9.2) to address inequalities in wound care provision for patients; to enable care that is organised and research
informed; to achieve the best possible healing rates, better experience
of care for patients and greater cost eectiveness; and to prevent
wound incidence and recurrence in health and social care settings.
The framework is for a multiprofessional workforce working in
wound care and supports practitioners to develop and provide
evidence for their knowledge and skills and enables high standards
of practice (NWCSP2021).
The structure of the framework is broken down into 5 domains
with 12 core capabilities (Table9.12). The capabilities are numbered
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Capabilities that require a general knowledge and
understanding of wound care and the skills which
Capabilities that enable the provision of wound care
independently and with a degree of critical analysis
Capabilities that require a high degree of autonomy
wound care practice, enable innovative solutions to
enhance peoples experience and improve outcomes
support the provision of care.
and complex decision making, an ability to lead
Tier 1
Tier 2
Tier 3
Notes
• A practitioner may move between the
tiers depending on role, setting or
circumstance.
• Capabilities are cumulative, therefore
a practitioner working at tier 3 will be
able to demonstrate the capabilities
of tiers 1 and 2, as well as those of
tier 3.
• It’s important to note that the tiers do
not relate to specific roles or pay
grades.
• The framework is designed to cover
all health and social care settings.
• The framework does not replace local
arrangements for service provision,
for example in respect of referral
pathways and composition of
multi-disciplinary teams.
FIGURE 9.2 The core capabilities framework tiers (NWCSP2021).
Source: Reproduced with kind permission from Skills for Health and the
National Wound Care Strategy.
TABLE 9.12 Structure ofthe core capabilities framework.
Domain Domain title Topic/capabilities
A Underpinning principles 1. Underpinning principles
B Assessment, investigation
and diagnosis
C Wound care 1. Care planning
D Personalised care and
health promotion
1. Assessment and
investigations
2. Diagnosis
2. Wound care and
interventions
3. Referrals and collaborative
working
1. Communication
2. Personalised care
3. Prevention, health promotion
and improvement
E Leadership and
management, education
and research
Source: Adapted from National Wound Care Strategy Programme (2021).
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1. Leadership and management
2. Education and research
3. Audit and quality
improvement
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for ease of reference– this does not indicate a pathway for completion, or a prescribed pathway, process or hierarchy. The capabilities
are then divided into skills, knowledge and behaviours, which are
described for each of the tiers see Table 9.12 (NWCSP2021).
The core capabilities framework has been designed to identify
areas for personal development for healthcare practitioners to help
them build there skills for optimum care delivery; areas of service
development may also be identied during this process. Leg ulcer
prevention and management training combining the core capabilities should be available to all sta caring for patients with this condition. The training should include leg ulcer assessment, diagnosis and
management training based on local and national policies and procedures where the clinician is working. Training should also be provided in a variety of delivery methods to make it accessible for all:
taught inand assessments of clinical competencies in practice.
person sessions, online lectures, practice skills workshops
PUBLIC HEALTH
Since Lord Darzi published his report ‘High Quality Care for All’
(Department of Health and Social Care2008) and the High Impact
Actions (NHS Institute for Improvement and Innovation 2010),
tissue viability teams across the county have been tasked with
measuring the eectiveness of services. This can be dicult to measure as there are so many variances that aect healing rates. The NHS
Long Term Plan (2019) is committed to facilitating measurable
improvements in public health and reducing health equalities across
the country, minimising the impact of the burden of wounds to
healthcare in the future and improving care delivered to patients.
With this in mind, early prevention, presentation and assessment of
patients are key in preventing a further burden in years to come on
the health service and for services to meet demands in already struggling workforces. For this to be possible, patient education and selfcare are essential moving forward. See Chapter 7 for a greater
exploration of the determinants of health.
For some time the NHS has been encouraging patients to manage their own health and long- term conditions, including wounds.
This was a concept introduced by the introduction of The Five Year
Forward View (NHS England2014) and further supported as one of
the six elements of the personalised care plan in the NHS Long Term
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