Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD)

1. Prior to treatment, assess causative and contributive factors and significant signs and symptoms to differentiate among the types of lower-extremity wounds, which have different etiologies and treatment requirements, in order to establish an appropriate treatment plan.

2. Review and document the relevant health history.

3. Assess the risks and contributing factors for developing LEVD such as family history, female sex, pregnancy, older age, tobacco use, systemic inflammation, obesity, comorbid conditions (cardiovascular disease), venous thromboembolism/ deep vein thrombosis (VTE/DVT), excessive sitting or standing, physical inactivity, trauma, injection drug use, impaired calf muscle function, and impaired ankle range of motion.

4. Assess the risks and contributing factors for developing a VLU, which are similar to those for LEVD: previous leg surgery, previous VLU, obesity, family history, venous reflux, VTE/DVT, physical inactivity, older age (>50 years), female sex, multiple pregnancies, and prolonged sitting or standing.

5. Assess for specific triggers associated with development of VLUs: cellulitis, penetrating injury/trauma, dry skin and itching, contact allergic dermatitis, rapid onset of leg edema, burns, and insect bites.

6. Assess the history of present and prior leg ulcers: previous treatments and tolerance (eg, medications and compression), ulcer recurrences, unusual or atypical presentations of ulcers, and/or surgical interventions or biopsies.

7. Assess for lower-extremity symptoms associated with LEVD: pain, sleep disturbances, and leg symptoms (ie, itching, heaviness, tightening, swelling, and aching).

8. Assess quality of life using valid/reliable instruments such as the Venous Insufficiency Epidemiologic and Economic Study (VEINES/QOL/Sym), Aberdeen Varicose Vein Questionnaire, and the Chronic Venous Insufficiency Quality of Life Questionnaire; and repeat the assessment on a regular basis.

9. Assess self-efficacy using a validated instrument such as the Venous Leg Ulcer Self-Efficacy Tool to determine the patient’s perception of his/her ability to perform self-management.

10. Assess the nutritional status of the patient including intake and the availability and ability to obtain adequate food.

11. Assess biomarkers associated with risks of LEVD as appropriate: C-reactive protein, fibrinogen, interleukin-10, and interleukin-8.

12. Conduct a physical examination of the lower leg:

• Inspect the lower extremity for skin changes including hemosiderosis/hemosiderin staining, venous eczema/ dermatitis, hyperpigmentation, atrophie blanche, varicose veins, ankle flaring, scarring from previous ulcers, and lipodermatosclerosis.
• Determine the type and characteristics of lower-extremity edema to differentiate the clinical presentation of edema due to LEVD from other conditions such as lymphedema and lipedema, which may be misdiagnosed.
• Determine perfusion status:

−−Assess skin temperature (cool skin), capillary and venous refill, paresthesia, and color changes of the skin with elevation or dependency of the limb.
−−Determine presence or absence of pedal pulses. Palpate both dorsalis pedis and posterior tibial pulses of each lower extremity. Presence of palpable pulses does not rule out lower-extremity arterial disease; nor does absence of pulses indicate arterial disease, especially, in the presence of edema.
−−Perform a screening ABI to identify/rule out arterial insufficiency.

• Recheck the ABI periodically (every 3 months) for patients with nonhealing, lower-extremity ulcers.

13. Classify the clinical manifestations of LEVD according to the “C” component of the basic Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification.

14. Determine and document the characteristics of the wound and periwound at each dressing change: location; size and shape; wound edges; wound bed; exudate; condition of periwound skin; and absence/presence of odor, bleeding, and complications (eg, cellulitis and eczema/dermatitis).

15. Monitor the healing status of the wound at least weekly: Measure the percentage change in ulcer area to assess healing and determine whether adjunctive therapies are warranted for ulcers that do not heal or show significant healing within 4 weeks of appropriate treatment.

16. Measure the ankle and calf circumference on a weekly basis to determine the effectiveness of treatments (eg, compression therapy, leg elevation, and exercise) to reduce edema.

17. Identify factors that may impede wound healing: location, long duration, large size of the wound, comorbid conditions, suspected biofilm, inflammation, infection, lack of adherence to prevention and treatment programs (especially compression therapy), psychosocial factors including depression and social isolation, and use of medications such as steroids or long-term topical or systemic antibiotics.

18. Identify, monitor, and document pain in the lower-extremity and/or wound pain using a valid and reliable pain scale to determine the following: onset; duration; location; exacerbating and alleviating factors; use and response to analgesics; severity/intensity (mild to severe); characteristics of leg pain (eg, variability; stinging, throbbing, cramping, or sharp/shooting; leg heaviness and achiness; and worsens with prolonged leg dependency); and changes or alterations in pain, which may indicate a change in healing status or disease.

19. Differentiate venous claudication from arterial, ischemic claudication:

20. Evaluate laboratory parameters such as albumin, prealbumin, hemoglobin, hematocrit, homocysteine, hemoglobin A1c (HbgA1c), prothrombin time, and inflammatory biomarkers (eg, C-reactive protein and fibrinogen) to establish potential for healing.

21. Identify factors that are associated with VLU recurrence: long duration of a VLU, decreased physical activity, lack of leg elevation, not wearing compression, high body mass index, malnutrition, depression, low self-efficacy, and presence of comorbid conditions and other general risks for LEVD and VLUs.

22. Refer patients as indicated for further evaluation and diagnostic testing to determine the severity of LEVD with vascular studies such as a venous duplex ultrasound, which is the most reliable noninvasive test to diagnose anatomical and hemodynamic abnormalities, reflux, or obstruction in any venous segment (superficial and deep).

23. Refer patients with the following conditions for further evaluation and treatment: cellulitis, VTE/DVT, variceal bleeds, intractable pain, eczema/dermatitis that is unresponsive to appropriate topical therapy and/or short-term topical steroids, and ulcers that are atypical in appearance or unresponsive to 4 weeks of appropriate therapies.

24. Encourage patients to undertake a program of physical activity to strengthen the calf muscle and increase ankle range of motion.

25. Recommend patients with varicosities wear compression stockings, manage their weight, engage in physical activity such as walking and avoid wearing constricting garments and crossing legs to reduce the risk of VLUs.

26. Consider using the WOCN Society’s algorithm, Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus- Based Algorithm for Care Across the Continuum (http:// vlu.wocn.org/#home), to identify the appropriate type and level of compression for adults.

27. Screen patients for arterial disease with a Doppler measurement of the ABI by suitably trained staff prior to the use of compression.

28. Educate individuals with sufficient blood flow (ABI ≥0.80) to use the strongest compression they can apply or tolerate to prevent VLUs or reduce recurrence.

29. Consider light compression for individuals with LEVD and lipodermatosclerosis, who are unable to apply, tolerate, or afford the cost of high-level compression garments.

30. Have compression stockings fitted by trained personnel.

31. Closely supervise and monitor the use of reduced compression (23-30 mmHg) for individuals with mixed venous/ arterial insufficiency (ABI >0.50 to <0.80), which should be provided under the direction of wound care specialists.

32. Educate patients that compression must be worn every day for the prevention of venous edema and ulceration for all CEAP classifications, and for prevention of VLU recurrence.

33. Avoid compression if ABI is less than 0.50, the ankle pressure is less than 70 mmHg, or the toe pressure is less than 50 mmHg; and refer the patient for further evaluation and treatment.

34. Consider use of cryotherapy/cooling treatment to manage symptoms of LEVD.

37. Educate patient/caregivers about risk factors and triggers for developing VLUs and self-management strategies to minimize risks: using lifelong compression; daily leg elevation; weight management; engaging in daily physical activities; maintaining a well-balanced diet; avoiding trauma; seeking professional health care for signs of increased swelling, redness, pain, or skin breakdown in the lower extremity; abnormal sensations in the skin; and medication options.

38. Recommend patients with LEVD and lower-extremity ulcers seek care guided by a clinical wound expert.

65. Educate patients/caregivers about the risks, pathophysiology, disease process of LEVD, and the risks of VLUs and VLU recurrence.

66. Utilize varied educational approaches to teach patients’ self-management including individual education and counseling, print materials, and video programs.

67. Educate the patient and caregivers in measures/strategies for self-management to reduce risks, prevent and manage VLUs, prevent VLU recurrence, and promote overall health and wellness:

68. Teach patients to engage in regular and frequent exercise and physical activity, including home-based physical activity programs and resistance activities, to improve calf muscle pump function and reduce healing time.

69. Regularly assess and monitor patient adherence to recommendations; for problems or complications: use of compression and the condition of stockings or bandages/ wraps; functional abilities; activities of daily living; presence of depression, sleep disturbances, and other concomitant illnesses; pain; and use and response to prescribed and self-prescribed pharmacologic agents.