Abstract. Venous leg ulcers are a major health issue in terms of financial burden to the NHS, nurses' input, and physical, psychological and social impact to the ...
Venous leg ulcers and the impact of compression bandaging Marie Todd
Abstract
Venous leg ulcers are a major health issue in terms of financial burden to the NHS, nurses’ input, and physical, psychological and social impact to the patient. The best practice management of leg ulcers is the application of high compression, which is a complex task and requires substantial skill and knowledge. Healing and recurrence rates are poor in some cases and this adds to the physical and psychosocial impact, as well as the financial burden. Many of the sequelae of ulceration hinder patients’ ability to tolerate treatment. Nurses must acknowledge the difficulties patients face and become skilled in holistic assessment, care planning and the delivery of patient-focused best practice. Key words: Venous leg ulcers n Compression bandaging n 4-layer bandaging n Holistic assessment
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he prevalence of chronic venous ulceration in the UK is estimated to be between 0.1% and 3% and this increases with age (Callam, 1985; Callam et al, 1987; Baker et al, 1991; Agren and Gottrup, 2007). Approximately 1% of the population will develop leg ulceration in their lifetime (Callam, 1992). The clinical picture of chronic venous ulceration is one of cyclical healing and recurrence (Scottish Intercollegiate Guidelines Network (SIGN), 2010). Three-month healing rates of 69-74% have been reported in patients undergoing four-layer bandaging carried out in specialist clinics compared to approximately 20% for those being managed in more traditional settings (Blair, et al, 1988; Moffatt et al, 1992; Simon et al, 1996). Poorer healing and higher recurrence rates are found in patients from the most deprived areas (Callam et al, 1988). Many patients have other co-morbidities which compound the problem, for example obesity, diabetes, arthritis (Callamet al,1987; Anderson, 2011). The chronicity of venous leg ulcers in terms of healing rates, duration of ulcers, and recurrence rates means that treatment of this health issue is estimated to cost the NHS £400 million per year, and accounts for 13% of all district nursing visits (Value for Money Unit, 1992; Simon et al, 2004). The long-term physical, psychological and social costs to the patients are just as staggering (Persoon et al, 2004). Marie Todd is a Clinical Nurse Specialist in Lymphoedema, Specialist Lymphoedema Service, NHS Greater Glasgow and Clyde Accepted for publication: October 2011
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Pathophysiology The pressure of venous blood flow is far less than arterial flow. This means that, especially in the lower limbs, there is hardly enough pressure to compensate for the gravitational force. Backflow into the distal veins is prevented by the presence of uni-directional valves in the lumen of many of the veins, especially in the limbs. In the legs, the valves are operated mainly by the action of the calf muscle. As skeletal muscles contract, they squeeze the veins passing through them which increases the venous blood pressure. This causes the valves to open and the increased pressure forces the blood forward proximally. Relaxation of the muscles causes the valves to close and backflow is prevented. When prolonged periods of standing or immobility occurs, there is little calf muscle pump activity. This causes pooling in the distal veins which leads to venous hypertension and inefficient valvular action. Chronic venous insufficiency ensues. In some patients, the muscular activity is normal but hereditary or ageing factors affect the valves in the deep, superficial or perforating veins, rendering them incompetent. This causes pooling in the distal veins and venous hypertension. Chronic pooling in the veins causes over-stretching and loss of elasticity, which results in the development of varicose veins. Superficial veins are more vulnerable than deeper veins because of the lack of surrounding muscular support.Venous hypertension results in localized oedema which traps leukocytes in the tissues. The leukocytes release oxygen-free radicals (unstable molecules often produced in wounds that attach healthy tissue) and other toxins which cause tissue damage that eventually results in the development of fibrosis, inflammation and ulceration (Tortora and Grabowski, 2000; Foldi et al, 2003).
The impact of living with a leg ulcer The presence of a leg ulcer has a devastating impact on a patient’s quality of life. Studies have identified many physical, psychological and social effects of ulceration (Persoon et al, 2004; Briggs and Fleming, 2007; Palfreyman, 2008). The main categories of physical symptoms reported are pain, odour, itch, leakage, and infection (Briggs and Fleming, 2007). Pain is the most frequently cited symptom among venous leg ulcer sufferers at 80% (Palfreyman, 2008). Pain may be associated with wound cleansing, dressing and compression bandaging (Briggs and Closs, 2006). Briggs and Closs (2006) found pain was reported in 22% of wound cleansing episodes, application and removal of most primary wound dressings and 50% of patients receiving compression bandaging. Pain caused by compression bandaging has been reported to be more severe in the first week and reduces in subsequent weeks during
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CLINICAL healing (Franks et al, 1994; Brereton et al, 1997; Briggs and Closs, 2006). Pain is a recurring feature in non-concordance with compression bandaging (Edwards, 2003). Briggs and Fleming (2007) found that 43.5% of venous leg ulcer patients reported symptoms indicative of neuropathic pain. These patients have higher daily pain scores and reduced healing rates at 6 months than those patients with no neuropathic pain symptoms.There is the possibility of patients experiencing both nociceptive and neuropathic pain which can make assessment and management of pain more difficult (Mangwendeza, 2002). Health professionals dealing with pain in patients must, therefore, be skilled and knowledgeable in recognizing pain, being able to differentiate the type(s) of pain, and developing an appropriate management strategy (Beldon, 2009). Odour and leakage are responsible for making patients feel unclean and embarrassed, and reducing opportunities for social interaction (Persoon et al, 2004; Briggs and Fleming, 2007). Patients find itch similarly distressing as wound leakage (Briggs and Fleming, 2007). Sleep disturbance occurs often as a result of pain, but wet bed clothes from wound leakage can compound the problem (Persoon et al, 2004). Reduced mobility is also frequently reported and is associated with pain, wound dressings, swelling, leakage and inability to wear appropriate footwear (Persoon et al, 2004). Some patients refrain from standing or walking as a result (Krasner, 1998). The negative effects of leg ulcers on mood and feelings include depression, fear, reduced willpower and self-esteem, loss of control, and feelings of helplessness and hopelessness (Charles 1995; Douglas, 2001; Briggs and Fleming, 2007). Social isolation, reduced employment prospects and loneliness can also result from the occurrence of leg ulcers (Briggs and Fleming, 2007), and it would seem that each individual aspect of ulceration has a compounding effect on the other aspects, for example, pain reduces mobility which causes social isolation which adds to the psychological problems of depression. Patients also cite the management of the ulceration as having an intolerable effect on their lives because of the pain and effects on mobility, footwear, etc. (Persoon et al, 2004).
Healing and recurrence rates Leg ulcers are a chronic problem. The average duration is 6-9 months (range: 4 weeks - 72 years) (Briggs and Closs, 2003). It has been estimated that 60% of ulcers are present for more than 6 months and 33% for more than 1 year (Harrison et al, 2001). A further 20% of ulcers are present for more than 5 years (Price and Harding, 1996). Specialist clinics (run by nurses who have undergone specialist training in the assessment and management of patients with leg ulcers) have achieved 3-month healing rates of 69-74% compared to approximately 20-34% in traditional treatment centres (carried out by district or practice room nurses in GP practices or patients’ homes) (Blair et al, 1988; Moffatt et al, 1992; Simon et al, 1996; Morrell et al, 1998). However, healing rates can be improved if guidelines are implemented when delivering care (Royal College of Nursing, 2006). Healing rates are improved in specialist centres because of the increased level of expertise and propensity to adopt best
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practice. For example, 81% of patients receive compression bandaging at specialists centres compared to 42% being treated at home (Simon et al, 1996). In patients where healing is achieved, there are 12-month recurrence rates of 26-69% (Harrison et al, 2001; Nelson et al, 2006).This means that many patients will have to endure ulceration for the better remainder of their lives. Poor compliance with followon compression hosiery or application of an inadequate class of compression hosiery results in higher risk of recurrence (Callam et al, 1987). This gloomy picture compounds the physical, psychological and social impact of ulceration. It has been postulated that patients do not comply with treatment or deliberately interfere with treatment to delay the healing of the ulcer in an attempt to prolong contact with their nurses for social contact and support (Brown, 2005). However, this has been refuted by Charles (2010) who found that patients do not consider nurses as a source of social contact but see them as a ‘service contact’.
Factors related to poor healing rates There are several factors that affect the healing of leg ulcers with compression bandaging. Patients who have larger ulcers and ulcers of longer duration are at risk for not healing (Fletcher et al, 1997; Margolis et al, 1999). Other factors include increasing age (Skene et al, 1992), previous venous stripping and the presence of fibrin on more than 50% of the ulcer surface (Margolis et al, 1999), ulceration >2 cm in depth, BMI >33, reduced walking (
