Oedema and the management of venous ulcers

Understanding venous leg ulcers

Venous leg ulcers are open lesions between the knee and the ankle joint, which occur in the presence of venous insufficiency. There are theories to explain the causes of venous insufficiency, which ultimately leads to venous hypertension and can result in leg ulceration. Although many patients present with evidence of venous hypertension, others do not, except for the manifestation of the ulcer. There are risk factors associated with venous insufficiency and a holistic approach must be taken in order to influence the management approach of venous leg ulceration. This article discusses venous insufficiency as a disease process, and explores the nursing assessment process, when assessing venous leg ulcers related to venous insufficiency.

Diagnosing and managing venous leg ulcers in patients in the community

Venous leg ulcers (VLUs) are a chronic condition affecting between 0.1% and 0.3% of the population in the UK. Healing rates are variable and recurrence rates are high. The diagnosis, assessment, and management of this patient group is primarily carried out in the community. Assessment of this patient group requires skill and competence to ensure a correct diagnosis is made. When carrying out the assessment, it is important to consider the patient's past medical history, medication, and allergies, as well as to record the ankle brachial pressure index (ABPI), pain level, palpation of pulses, and ankle joint movement, among other aspects of the assessment. VLUs heal with compression therapy, and practitioners should be knowledgeable about the various compression systems available in order to offer patients the most suitable and informed choices.

How echographic image analysis of venous oedema reveals the benefits of leg elevation

OBJECTIVE

Venous insufficiency, leading to venous oedema, is a key pathogenic factor for the non-healing of venous leg ulcers. This study aimed to evaluate the effects of leg elevation on venous oedema.

METHOD

Ten patients aged 44-89 years (median: 61) with leg oedema had high-frequency B-mode ultrasound scanning and digital image analysis before and after three to four hours of leg elevation. The echographic image analysis system was used, where oedema is represented by the hypoechogenic part of the image--that is, the total number or density of low echogenic pixels (LEPs) in a particular area.

RESULTS

Compared with pre-elevation, the volume of the lower leg decreased by 2.9% +/- 0.6 (138 cm3 +/- 39) after three to four hours' elevation (p < 0.05). After elevation, the LEPs in the upper, middle and lower sites of the limb decreased by 8.8%, 15.6% and 17.3% respectively, reaching statistical significance (p < 0.05) in the lower site. The ratio of LEPs in the upper and lower dermis in the upper, middle and lower sites decreased by 30.3%, 45.8% and 22.5% respectively. This was significant in both the middle and lower sites (p < 0.01). After elevation dermal thickness increased by 0.047 mm, 0.194 mm and 0.232 mm respectively. This change was statistically significant in the middle (p < 0.05) and lower sites of the limb (p < 0.01).

CONCLUSION

LEPs are a sensitive marker of dermal oedema and its effects. Leg elevation is extremely effective in reducing oedema, even if only for three to four hours.

Managing a necrotic heel pressure ulcer in the community

This care study considers the management of an elderly confused woman with a heel pressure ulcer. The care was complicated by clinical infection in the wound resulting in a high exudate level. Management of the infection led to side effects from systemic antibiotics and therefore topical antimicrobials were used. This highlighted the need to manage patients with wounds as individuals.

Medical pathology in patients with leg ulcers: a study carried out in a leg ulcer clinic in a day hospital for the elderly

This study was undertaken to see if the multiple pathology previously found in elderly patients with leg ulcers (other than the ulcer) differed in older and younger patients. A retrospective survey of the case notes of 42 consecutive patients (19 males, 23 females) admitted to a medically staffed leg ulcer clinic based in a geriatric day hospital was carried out. Twenty one patients were aged < or = 74 years (including seven aged < or = 59 years) and 21 aged > or = 75 years. Medical conditions known on referral and illnesses diagnosed during attendance were identified. The high incidence of disease in both age groups was identical, with 57% of patients with four or more diagnoses. No patient had no medical illness in addition to their ulcer. The commonest was cardiovascular disease followed by arthritis, obesity and endocrine disease. Nineteen per cent of all diagnoses were made at the clinic. Medical treatment, including drug reviews, in addition to compression bandaging and other local treatment, was found to be helpful for healing the ulcer. Medical input to leg ulcer clinics is therefore important.

Healing venous ulcers with cycloidal multidirectional vibration therapy

OBJECTIVE

This preliminary study combined compression bandaging with cycloidal vibration to determine whether this would enhance the rate of healing of venous leg ulceration.

METHOD

Twenty-one patients with venous ulceration were enrolled into a 12-week trial. The vibration device was used three times daily for 30 minutes on each occasion, along with compression bandaging.

RESULTS

Ulcers of 13 patients (62%) healed within 12 weeks. The remaining eight patients completed the 12-week study with a 31-90% reduction in ulcer size. A reduction in pain was observed in 17 out of 21 patients (81%). Ultrasound measurements showed reduced fluid content in the upper dermis in patients whose ulcers had healed and in others whose ulcers were improving.

CONCLUSION

This preliminary study shows that gentle cycloid vibration, combined with standard compression bandaging, enhances the healing rate of venous ulcers and helps to relieve pain.