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2011 Assessment Flowchart Vlu
2011 Assessment Flowchart Vlu
Patient presents with an ulceration on the lower leg Patient assessed as having a venous ulcer on the lower leg
1 Patient’s clinical history (page 20) Comprehensive assessment of the patient (page 20)
• Provide appropriate PAIN MANAGEMENT (page 28)
• medications • quality of life
•
1
venous disease varicose veins
• family history of leg ulceration • phlebitis
• psychosocial • nutrition
• decreased calf muscle pump • obesity
• comorbidities • pain Provide patient EDUCATION (Grade C, page 30)
HISTORY
function
• number of • Leg elevation • Compression therapy including use and care of hosiery
• surgery or trauma of affected pregnancies
Patient’s leg ulcer history (page 20)
• Nutrition • Exercise
leg
• previous or
• the duration of the current ulcer
• chest pain or pulmonary current DVT • previous ulcers and the time they have taken to heal
embolism
THE PATIENT
• prolonged standing or sitting
• time spent free of ulcers Provide access to appropriate PSYCHOSOCIAL support (page 31)
• strategies used to manage previous ulcers
Recommend ELEVATION of the lower limb to reduce oedema (Grade C, page 32)
Venous characteristics (page 22) Arterial characteristics
Associated changes in the leg Associated changes in the leg
PROGRESSIVE RESISTANCE EXERCISE to improve calf muscle function (Grade C, page 33)
• Firm (“brawny”) oedema • Oedema may be observed if infection present
• Haemosiderin deposit (reddish brown • Thin, shiny skin often with minimal hair growth
pigmentation)
• Leg shape is often straight with minimal shape
Encourage optimal NUTRITION AND HYDRATION to assist healing (page 34)
• Lipodermatosclerosis (skin hard and woody)
• Limb cool to touch
• Evidence of healed ulcers
•
• Dilated and torturous superficial veins
Elevated toes/leg become pale, dependent rub (+ve Beurger’s
test) 2 Prepare the surrounding skin:
• Hair is evident • Weak or absent pedal or leg pulses
• CLEANSE the leg at dressing changes (page 35)
• Atrophie blanche (white areas of intact skin) Ulcer location/characteristics
• MAINTAIN SKIN INTEGRITY of surrounding leg skin (page 36)
AND WOUND
Venous eczema (dry or wet itchy scaly skin)
• Altered shape – inverted “champagne
• Poorly perfused wound bed
bottle” • Necrotic tissue that may be tenacious (difficult to remove)
Wound bed preparation:
• Ankle flare (distended veins in foot arch or • Minimal wound exudate unless infected
ankle region) • CLEANSE the ulcer at dressing changes (page 35)
• Leaking oedema may result in maceration,
• Prone to infection • Consider DEBRIDEMENT of non-viable tissue (Grade C, page 37)
pruritis and scale
Pain • Consider treating CLINICAL INFECTION (page 38–47)
• Limb may be warm – heat and/or itch • Claudication or rest pain, may be worse at night or if leg is • Select appropriate PRIMARY DRESSING (Grade B, page 47)
elevated
Ulcer location and characteristics
• Anterior to medial malleolus
• Pretibial area (lower third of leg) Atypical ulcer characteristics
•
3 Graduated compression therapy (Grade B, page 53)
• Shallow with ragged, irregular edges None or minimal venous and arterial ulcers characteristics In the absence of arterial disease or diabetes mellitus
• Ruddy granulation tissue • Pain is extreme aim for > 30 mmHg (elastic) or high stiffness system (inelastic)
COMPRESSION
• Caution: Compression should be applied by a trained health professional
• Wound exudate moderate to high Oedema
and according to manufacturer’s guidelines
• May be odorous • Ulcer has an unusual appearance or atypical distribution
Pain • Suspicion of malignancy
• Patients receiving compression therapy should be MONITORED CLOSELY to ensure they
Varying from nil, to mild or extreme • Deterioration in ulcer or necrotic tissue present
• are able to tolerate compression and to monitor signs of healing
May be relieved by elevation of leg • Ulcer that has not healed in three months
Non-invasive diagnostic tests may be ordered: (page 24) Invasive diagnostic tests may be ordered:
INVESTIGATIONS
•
•
Pedal and leg pulses • Arterial and/or venous duplex scanning
(page 24)
• Blood profiles 4 Review and consider referral (page 26)
ABPI • Photoplethysmography
•
• TBPI • TCPO2
Wound tissue biopsy Ulcers not reduced in size by 25% in four weeks or failing to heal in
• • MRI
REVIEW
12 weeks should be considered for specialist referral
X-ray • Pulse oximetry
• Wound swab
professional of the Venous Measure and fit compression hosiery providing 18–40 mmHg (Grade B, page 62)
DIAGNOSIS
ulcer
(page 26)
ABPI 0.8–1.2 or
RECURRENCE
Characteristics of venous aetiology Ongoing encouragement should be given related to exercise, leg elevation and nutrition
PREVENT