Timescaled monitoring to manage venous leg ulcers and chronic oedema

Venous leg ulcers, chronic oedema and lymphoedema are lifelong conditions that cause great distress to individuals due to physical symptoms and often poor mental health associated with social isolation and depression (Jones et al, 2006). Time and resources spent on managing chronic wounds place an economic burden on healthcare providers, particularly with an anticipated increase in an ageing population and diminishing numbers of those providing long-term care. This is highlighted in the joint report by the Royal College of Nursing and The Queen's Nursing Institute (QNI), which has indicated a 43% decline in district nurses over the last 10 years (Fanning, 2019). Worryingly, these figures are likely to have declined further with the QNI recording district nurse workloads far exceeding capacity of services (Penfold, 2020). Resources are further challenged if wounds remain unhealed, with costs calculated at 1.35% higher than that of healed wounds (Guest et al, 2017); furthermore, wounds failing to heal at 4 weeks have been predicted to remain unhealed after 8 additional weeks of treatment (Cardinal et al, 2008). The national cost of treating a venous leg ulcer was estimated at £102 million, with an annual cost at £4787.70 per person (Urwin, 2022). The human costs are even greater, with patients often facing a lifetime of discomfort due to low awareness of venous disease, despite epidemiological studies. In a study of 561 patients, Carradice at al (2011) have raised concerns about demonstrable mortality from venous disease and finding impairment with venous ulceration to be comparable to that of persons with cardiac failure and chronic lung disease.

Therefore, this article will focus on clinical monitoring with simple timescaled measurements by all care providers, including patients and non-healthcare professionals to ensure timely interventions and appropriate care at each stage.

Wound healing and chronicity: why is monitoring important?

Unlike acute wounds, chronic wounds do not follow a straightforward trajectory along predicted timescales but remain in the inflammatory phase. This results in harmful inflammation, excess exudate and the formation of devitalised tissue that could contribute to infection and delayed healing. Wounds that fail to heal within anticipated timescales, including factors such as vascular aetiologies, general condition of the patient and comorbidities, should be reviewed and if necessary, referred for specialist management. The National Institute for Health Care and Excellence (NICE) set out guidelines for immediate referrals. If improvements do not occur, subsequent referrals are recommended, highlighting the importance of constant vigilance (NICE, 2023). Leg ulcers remain the most problematic of wound types, as indicated by an international survey recording nursing practice and wound types of 1057 wounds. The most frequently observed hard-to-heal wounds were leg ulcers at 44.4%. Of these, 43.7% improved at 6 weeks and 35.5% remained unhealed after 12 months. Data collected from five centres in the UK included 296 wounds (Milne et al, 2020).

Table 1 describes the challenges and anticipated timescales.

Vascular assessment

Vascular flow is measured by non-specialists using patient reporting, general health, Doppler ultrasound and simple toe pressures or capillary refilling, the normal being less than 3 seconds when the skin is pressed. Guidelines recommend a 3 monthly assessment, although an 88 patient study over 24 months found that most patients with an ankle-brachial pressure index (ABPI) of greater than 1.0 and no risk factors are unlikely to change over time. However, those with two or more risk factors sch as diabetes, dampened doppler sounds and an initial reading of less than 1.0 should be reassessed within 3 months (Pankhurst, 2004). Rest pain and intermittent claudication when walking are useful indicators of significant arterial impairment that might require specialist advice with compression therapy.

Signs and symptoms are manifested as visible or palpable skin changes distinctive of venous and arterial disorders. Arterial disorders are characterised by pale, shiny, hairless skin that turns dusky when the leg is dependent. Often present are thickened toenails and deep punched out ulcers. On the other hand, venous disorders present with lipodermatosclerosis, a collection of symptoms that include atrophie blanche, hyperpigmentation, ankle flare and induration with accompanying varicose eczema, itching, leg and foot oedema that resolve with elevation and respond well to compression.

Skin

Hyperkeratosis and dry skin

Visual signs and patient-reported symptoms should be managed with emollients depending on levels of dryness. Hyperkeratosis is a build-up of dry scaly skin and often product residue (Figure 1). If left untreated, it can have a detrimental effect on wound healing by inhibiting diagnosis, presenting a focus for infection, reducing absorption of emollients and causing discomfort and pain to the patient. Additionally, it can cause damage to deeper tissues by creating pressure points under compression that may lead to patients not wishing to wear compression (Whitaker, 2016).

Maceration and excoriation

Moisture-associated dermatitis can occur when corrosive bodily fluids such urine or sweat, or the overspill of exudate from wounds or lymphorrhoea remain unchecked on the skin. A Wet Legs Pathway has been devised to advise on monitoring and managing excess fluid on the skin and in wounds associated with venous disease, ensuring optimal use of wound dressings and compression (Thomas and Morgan, 2021).

Mechanical skin stripping and sensitivity to adhesives

If compression is contraindicated, dressing retention may be problematic. Dressing adhesives that are too harsh may cause skin stripping; similarly, they may cause skin damage through slippage if they are not strong enough to hold heavy dressings in place. Sensitivity to dressings or devices can often be confused with cellulitis and infection. However, sensitivity reaction may be recognised by clearly defined demarcation at the dressing edges and the disappearance of redness when the allergen is removed. The British Lymphology Society has devised a Red Legs Pathway to guide practice, reducing inappropriate referrals or unnecessary antibiotic usage (Elwell, 2020).

Venous leg ulcers

Simple wound measurements that utilise tape measures, rulers, tracing and photography are effective to assess the linear extent of the wound, while probes may be required to determine depth and undermining. As the shape of a wound can appear to change with positioning of the leg, it is important to try to standardise measuring techniques at each assessment. Devitalised tissue in wounds have been described as black, green or yellow according to a colour continuum, progressing to the red and pink stages of granulation and epithelialisation following debridement. Hampton (2019) advised that venous leg ulcers were most likely to be yellow, green or red, becoming black if infection is present. Considerations for debridement are tissue type, skill of the practitioner, pain associated with treatment and management of coexisting factors such as exudate, wound friability, infection and periwound condition. Timescales of management depend on the type of tissue, underlying pathologies and method of removal. Effective debridement with mechanical methods such as sharp debridement by a specialist or with a debridement pad should take minutes, and autolysis with dressings can be achieved within 2–3 weeks, bearing in mind that this process can increase fluid production that is usually managed by the dressing (Strohal et al, 2013).

Chronic wounds contain protease-laden exudate that can be profuse and difficult to manage, becoming easily infected, malodorous and delaying healing. Observation of volume, type, colour, viscosity, trigger factors and cause determines the most appropriate type of dressing and compression (World Union of Wound Healing Societies (WUWHS), 2007). The easiest method of monitoring is frequency of dressing change, strike through and the type of dressing that is required to manage levels of fluid while preventing the wound from drying out.

If left unchecked, exudate can increase and become infected with multiple organisms often creating biofilm formation, which in turn increases excess fluid. Chronic wounds are usually contaminated or colonised, requiring little extra management.

However, this can progress to critical colonisation, and localised infection requiring antimicrobials and in more serious cases, systemic or spreading infection, that would require antibiotics to eliminate pathogens. Pathogens have distinctive odours and colours that are often visible in dressings that have been removed (Figure 2). A simple four-stage categorisation based on visual signs and healing helps to identify severity and progressing of the wound infection (European Wound Management Association (EWMA), 2006). The periwound area will appear red and inflamed, and patients will experience higher levels of pain. Infected wound tissue is usually bright or dark red, friable and sometimes has thin strips of bridging tissue or unhealed areas underneath superficial epithelium that has covered the wound.

As the wound passes successfully through the phases of healing, paler pink, less vascular tissue with epithelial cells appear at the edges to achieve closure. Often, small islands of epithelial tissue are apparent in the centre of the wound and these are sometimes mistaken for slough. EWMA (2006) recommends that dressings are selected at each stage to manage excess fluid, address local infection and create a moist wound healing environment. If the wound shows no sign of healing after 7–10 days, reassessment should consider a change of treatment or specialist referrals (EWMA 2006), as factors such as ischaemia or other uncontrolled underlying conditions could delay healing.

Pain and quality of life

Pain is a subjective symptom closely linked with physiological responses, particularly inflammation and wound healing (Solowiej et al, 2009). It is largely dependent on patient reporting, although physical symptoms and vital signs provide good data, particularly for patients who are unable to communicate or reluctant to discuss pain. The Visual Analogue Scale records levels from 0–10, where 0 is no pain and 10 is the worst pain ever. Non-verbal methods include the Wong–Baker Faces Pain Rating Scale, with a series of faces that are sad or happy (Wong and Baker, 2001). Pain types will dictate treatment. For example, itching may require topical steroids, neuropathic pain is treated with specific drugs and nociceptive pain is managed with dressings, compression and a scale of analgesia according to severity and patient tolerance. Changes in types and levels of analgesia or sedation are good indicators of treatment efficacy (Armitage, 2004). Functionality such as mobility impairment or the inability to perform everyday tasks will usually alert a person that their condition may be deteriorating.

Mobility and functionality

Inactivity is detrimental to oedema formation due to gravity affecting venous flow. Weight gain associated with immobility contributes to oedema formation, leading to a cycle that may need to be carefully monitored and investigated to identify causes of restricted activity (Muldoon, 2013). Walking remains a powerful form of exercise to activate the foot pump for venous return and may be measured using simple gait analysis through observation. The validated Timed Up and Go Test (Podsiadlo et al, 1991), which has been successfully used by physiotherapists managing patients with oedema and venous leg ulcers (Bock et al, 2022) could be adapted to a less formal method, whereby the time taken by the patient to answer the door compared to a previous visit is recorded by the district nurse. Properly fitting footwear, supportive yet non-bulky compression and patient education for good foot and ankle mobility should be assessed regularly to adjust treatment.

Limb and oedema

Poor venous return, venous hypertension and reduced mobility contribute to oedema formation that impacts on wound healing and quality of life. The validated International Society of Lymphology (ISL) and the Clinical Etiological Anatomic Pathophysiologic (CEAP) (Carradice, 2011) scoring systems are useful staging to identify severity and tissue type that aid assessment, clinical decision-making and monitoring. Chronic oedema secondary to venous disorders is generally managed in the community with compression, which remains one of the mainstays of management for venous and lymphatic disorders. Pressure and stiffness are key components of effective yet tolerable compression delivered by devices that incorporate various technologies (Partsch and Mortimer, 2015).

Compression and self-care

Once safety to compress is established according to the vascular and holistic assessment, the choice of compression and frequency of change are determined by the presence of wounds, limb shape, size, skin folds, tissue density and by assessing self-care ability and wearer tolerability.

In the intensive stage, day and night compression bandages and adjustable wraps provide easily removable options when frequent inspection, personal hygiene, skin and wound care may be necessary. This may be daily, 2–3 times weekly, reducing to weekly as the condition improves. Tissue density can be measured by non-specialists using the pitting test that records rebound time of tissue when fingertip pressure is applied or when patients report changes such as heaviness, discomfort and mobility issues that often precede visible changes. Useful markers of effective compression are tissue softening, shape changes, volume reduction, and transient guttering and pruning once compression has been removed (Figure 3). Bandage damage is easily identified by horizontal marks and tissue breaks, particularly at joints or folds. Compression should feel supportive yet comfortable, without allowing excess ballooning of swelling. Anticipated timescales for oedema reduction are 2–4 weeks with bandages, wraps or garments and moving to hosiery for maintenance, bearing in mind that recurrence may likely necessitate a return to intensive management (Mortimer and Levine, 2017).

Changing to hosiery is an important milestone and garments should be chosen with the patient according to lifestyle, preference, ability and their condition. Generally, British Standard hosiery with a circular knit and lower profile may be more comfortable for patients to initially manage mild symptoms such as varicose veins or prevention of recurrence following healing. Stiffer, flat knit garments address skin folds, shape distortion and dense oedema. Correct measuring and fitting of hosiery are essential, reviewing and changing every 6 months to ensure that it still fits well for comfort and foot mobility (Figure 4). If swelling has reduced, the hosiery will become loose and baggy. On the other hand, if hosiery has been washed too many times or exceeded the manufacturer's wear time, the patient should be remeasured and prescribed new hosiery. In some cases, the patient might not fit into off-the-shelf hosiery and would need to wear made-to-measure garments.

Often, restrictions on social activities, cosmetic appearance, pain or the inability to apply compression garments may be resolved by reviewing management and changing the regime. For example, the use of application aids to don and doff stockings or choosing open toed stockings. Heat and pruritis have been cited as reasons why patients will not wear their hosiery even in cooler climates (Jungbeck et al, 2002; Weller at al, 2021). Technologies such as Tactel^® Climate Effect microfibre yarn mixtures are incorporated into made-to-measure, circular knit hosiery, which are available on prescription. They wick moisture away from the skin for cooling and comfort.

Discussion

The power of patient reporting for monitoring progress should not be underestimated, as individuals living with a chronic condition often have extensive knowledge of how their bodies function and a vested interest in resolving distressing and painful conditions. Interestingly, studies show a correlation between visible signs, symptoms and impact on lifestyle requiring listening to the effect on patients and early intervention with compression. Discussing progress with the patient provides a valuable platform for a patient-clinician partnership, although in some cases, such as failure to heal through malignancy, these discussions may be confusing and distressing until the root cause has been identified. Similarly, keeping a pain diary can be counterproductive if patients become anxious and too focused on their pain. However, for most patients, this partnership fosters a sense of empowerment, boosting confidence and morale, while promoting concordance with management through ownership. This is essential when transitions are made from clinical care to self-care with ongoing monitoring to ensure a powershift and more appropriate long-term management with compression hosiery.

Sharing experiences with multidisciplinary practitioners such as dermatologists and physiotherapists is a valuable source of information alongside structured learning at educational events using guidelines and published research. Guidelines are underpinned by clinical evidence as demonstrated by Charles (2002) in a randomised controlled study of 65 patients with venous leg ulcers using the visual analog scale and the McGill Pain Questionnaire (Melzack, 2005). Following 2 weeks of effective compression with short stretch bandaging, a 70% reduction in pain was reported, where patients had previously described their pain as throbbing, sharp, itchy, sore and tender (Charles, 2002).

Conclusion

Regular reassessment and monitoring are essential to ensure treatment success and timely intervention, working with all clinical partners, including the patient so that they can receive the right treatment at the right time and for the right length of time. Knowledge of anticipated timescales and the ability to adapt treatment plans prevent unwarranted delays in healing, reducing human and financial costs of managing chronic leg wounds.

Key points

• Reassessment and intervention within anticipated timescales are essential to prevent unnecessary chronicity and discomfort
• Delays in wound healing and oedema resolution increase human and financial costs
• Management can be aided by an effective clinician-patient partnership
• Compression is a balance between clinical effectiveness and tolerability
• Self-monitoring and self-care for long-term conditions empower individuals and encourage concordance.

CPD reflective questions

• Does your practice include all aspects of reassessment for changes in vascular status, skin, wounds and oedema according to anticipated timescales?
• What wound factors are associated with delayed healing?
• How could you improve concordance and self-care for patients with active and healed venous leg ulcers?
• When would you expect to see reduction in oedema and a stabilised limb to progress from clinician-managed compression therapy to self-care with compression hosiery?
• Which methods could be employed to reassess and monitor changes in pain, personal living, mobility and functionality?