Lower Limb and Leg Ulcer Assessment and Management E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 718

Veröffentlichungsjahr: 2024

Beschreibung

Lower Limb and Leg Ulcer Assessment and Management Lower Limb and Leg Ulcer Assessment and Management is an indispensable resource for practitioners in primary and secondary care, offering a practical and accessible guide to treating and managing leg ulcers. This comprehensive text challenges the misconception that leg ulcers are invariably 'chronic'. In practice, proactive management will prevent the harm associated with sub-optimal management. Insights are provided into lower limb assessment, early intervention for ulcer prevention, ulcer types and their causes, along with the influence that swelling and biomechanical changes have on the lower limb. The authors draw on international best practice guidance on lymphoedema, wound pain, wound bed preparation, compression therapy, psychological impact, and evidence-based care to enhance leg ulcer management. Each chapter aims to facilitate reader comprehension and promote productive patient discussions, empowering healthcare professionals to collaborate with patients and improve leg ulcer management rapidly and effectively. This multi-disciplinary resource covers: * Normal venous, arterial, and lymphatic function in the lower leg * Leg ulceration due to venous hypertension, peripheral arterial disease, and lymphoedema * Leg ulcers of unusual aetiology, addressing autoimmune and inflammatory disorders such as pyoderma gangrenosum, rheumatoid arthritis, scleroderma, sickle cell, and more * Musculoskeletal changes in the lower limb, assessment, and management to enhance mobility and calf-muscle function * Clinical management, with topics like wound management, stages of wound healing, exudate management, holistic assessment including vascular assessment, compression therapy, and Laplace's law * Pain management with an emphasis on understanding the complexities and features that exacerbate or diminish the pain response * The personalisation of care, understanding of social determinants of health, and the role of supportive self-management in lifelong management For professionals seeking evidence-informed approaches to delivering exceptional care, Lower Limb and Leg Ulcer Assessment and Management is an essential companion on the journey to understanding and managing leg ulcers effectively.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

Dedication

List of Contributors

Foreword

Preface

Acknowledgements

Introduction

THE WOUND CARE BURDEN

THE COST OF SUB‐OPTIMAL WOUND CARE

CLASSIFICATION OF DRESSING PRODUCTS

DRESSING PRODUCT ANALYSIS

ONLINE NON PRESCRIPTION SERVICES

CONCLUSION

REFERENCES

CHAPTER 1: Aetiology

NORMAL VENOUS FUNCTION

VEINS IN ACTION

BLOOD PRESSURE IN VEINS AND CAPILLARIES

VENOUS DISEASE

PATHOPHYSIOLOGY OF CHRONIC VENOUS DISEASE

THEORIES OF TISSUE DAMAGE

CHRONIC VENOUS INSUFFICIENCY

RISK FACTORS FOR VENOUS INSUFFICIENCY

ARTERIAL DISEASE

THE SKIN

WOUND HEALING

PHASES OF WOUND HEALING

CONCLUSION

REFERENCES

CHAPTER 2: Lymphoedema and Chronic Swelling

FUNCTION OF THE LYMPHATIC SYSTEM

PREVALENCE AND KEY FACTS

CAUSES OF AND RISK FACTORS

ASSESSMENT, DIAGNOSIS AND STAGING

MANAGEMENT CHALLENGES

LYMPHOVENOUS DISEASE

TREATMENT

COMPRESSION THERAPY AND ASSESSMENT CONSIDERATIONS

ADJUNCT TREATMENT MODALITIES

SURGERY

PALLIATIVE CARE

LIPOEDEMA

SUMMARY

REFERENCES

CHAPTER 3: Atypical Causes of Leg Ulceration

INFLAMMATORY/AUTOIMMUNE DISORDERS

METABOLIC DISORDERS

MALIGNANT/NEOPLASTIC WOUNDS

DRUG‐INDUCED LEG ULCERS

EROSIVE PUSTULAR DERMATOSIS

INFECTIVE CONDITIONS

CONCLUSION

REFERENCES

CHAPTER 4: Musculoskeletal Factors in Leg Ulcers: Assessment and Management

RISK FACTORS

LOWER LIMB VENO‐MUSCULAR PUMPS

ANKLE JOINT ASSESSMENT

HOLISTIC HISTORY TAKING RELATING TO FACTORS THAT INFLUENCE BIOMECHANICAL LOWER LIMB FUNCTION

MANAGEMENT

REDUCING FALLS RISK

ALLIED HEALTH PROFESSIONALS AS PART OF THE MULTIDISCIPLINARY TEAM

CONCLUSION

REFERENCES

CHAPTER 5: Assessment of Leg Ulceration

ASSESSMENT

HISTORY TAKING

EXAMINATION

ARTERIAL DISEASE

WOUND ASSESSMENT

SKIN ASSESSMENT

DIAGNOSTIC ASSESSMENT

HOW TO PERFORM A HANDHELD DOPPLER

RED FLAGS FOR THE URGENT TREATMENT OF PATIENTS WITH VENOUS LEG ULCERS

REASSESSMENT AND RECURRENCE

CONCLUSION

REFERENCES

CHAPTER 6: Holistic Management of Pain

THE PAIN EXPERIENCE

THEORIES OF PAIN

CAUSES OF PAIN

TYPES OF PAIN

PAIN CYCLES: NEVER‐ENDING PAIN

IMPACT OF PAIN ON PEOPLE'S LIVES

CAUSES OF PAIN

PAIN MANAGEMENT SOLUTIONS: ASSESSMENT

MANAGING PAIN

CONCLUSION

REFERENCES

CHAPTER 7: Personalised Care in Leg Ulceration

THE WIDER OR SOCIAL DETERMINANTS OF HEALTH

WIDER DETERMINANTS OF ENGAGEMENT WITH TREATMENT

MAKING EFFECTIVE CHANGE

WHAT INFLUENCES PRACTITIONERS' DECISION‐MAKING IN LEG ULCER MANAGEMENT?

THE INFLUENCE OF CONFIDENCE, COURAGE AND COMPETENCE

A PROBLEMATIC CULTURE WITHIN LEG ULCER MANAGEMENT

CHALLENGING NON‐COMPLIANCE

UNDERSTANDING THE LIVED EXPERIENCE

SUPPORT PERSONAL HEALTH MANAGEMENT THROUGH PATIENT ACTIVATION

PATIENT ACTIVATION MEASURE

SHARED DECISION‐MAKING

SOCIAL PRESCRIBING

MOTIVATIONAL INTERVIEWING

SUPPORTING SELF‐MANAGEMENT

LEGS MATTER COALITION: RAISING AWARENESS OF LOWER LIMB CONDITIONS

PEER SUPPORT GROUPS

USING POSITIVE LANGUAGE TO PROMOTE A POSITIVE CULTURE

CONCLUSION

REFERENCES

CHAPTER 8: Clinical Managementof the Lower Limb

THE CASE FOR EARLY INTERVENTION

CLINICAL MANAGEMENT

WHAT IS COMPRESSION THERAPY AND HOW DOES IT WORK?

ANTI‐INFLAMMATORY ACTION OF COMPRESSION THERAPY

CAUTIONS AND CONTRAINDICATIONS

CONSIDERING AND COMMENCING TREATMENT

LOCATION OF THE ULCERATION

COMPRESSION OF THE FOOT

INTERMITTENT PNEUMATIC COMPRESSION

WOUND BED PREPARATION AND CLINICAL MANAGEMENT

CONCLUSION

REFERENCES

CHAPTER 9: Lifelong Management

FACTORS INFLUENCING VENOUS ULCER RECURRENCE

HOLISTIC REASSESSMENT INCLUDING ANKLE BRACHIAL PRESSURE INDEX

ENDOVENOUS ABLATION

COMPRESSION THERAPY SYSTEMS

ASSESSING FOR COMPRESSION HOSIERY

CHOOSING AND PRESCRIBING HOSIERY

OTHER CONSIDERATIONS WHEN CHOOSING A COMPRESSION THERAPY SYSTEM

EMPOWERING PATIENTS' SELF‐MANAGEMENT FOR LEG ULCER PREVENTION

KNOWLEDGE, STAFF AND TRAINING

PUBLIC HEALTH

PATIENT SATISFACTION AND QUALITY OF LIFE

LEG ULCER PATHWAYS

CONCLUSION

REFERENCES

Index

End User License Agreement

List of Tables

Introduction

TABLE I.1 Data for insight into the use of healthcare resources.

TABLE I.2 Tips on how practitioners can develop good resource management pra...

TABLE I.3 Product classification.

Chapter 1

TABLE 1.1 Mechanisms of action.

TABLE 1.2 Disease pathology.

TABLE 1.3 Features of venous ulcers.

TABLE 1.4 Risk factors for venous insufficiency.

TABLE 1.5 Basic clinical descriptors of arterial leg ulcers.

TABLE 1.6 Functions of arteries in the leg.

TABLE 1.7 Risk factors for venous and arterial disease.

TABLE 1.8 Phases of wound healing.

Chapter 2

TABLE 2.1 Anatomy of the lymphatic system.

TABLE 2.2 Types of lymphoedema.

TABLE 2.3 Obstructive and non‐obstructive causes of lymphoedema.

TABLE 2.4 Risk factors for lymphoedema.

TABLE 2.5 Underlying causes of swelling.

TABLE 2.6 Common factors that will influence and contribute to the oedema....

TABLE 2.7 Medical history to support diagnosis of lymphoedema.

TABLE 2.8 Unilateral or bilateral lower limb swelling.

TABLE 2.9 Screening and investigations.

TABLE 2.10 Physical examination of the skin and tissues.

TABLE 2.11 Stages of lymphoedema.

TABLE 2.12 Psychosocial impacts of lymphoedema.

TABLE 2.13 How can the complexities be addressed for a better system – what...

TABLE 2.14 Signs that the patient might be at increased risk of lymphorrhoe...

TABLE 2.15 Differential diagnosis of red legs.

TABLE 2.16 Treatment for red legs.

TABLE 2.17 Lymphoedema patient education overview.

TABLE 2.18 Compression assessment considerations for lymphoedema.

TABLE 2.19 Requirements for self‐lymphatic drainage (SLD).

TABLE 2.20 Contraindications to intermittent pneumatic compression.

TABLE 2.21 End‐of‐life diseases associated with lymphoedema.

TABLE 2.22 Key differences between lipoedema, lymphoedema and obesity.

TABLE 2.23 Classification of lipoedema based on anatomy.

TABLE 2.24 Classification of lipoedema according to disease progression.

Chapter 3

TABLE 3.1 Typical clinical presentation of pyoderma gangrenosum (PG).

TABLE 3.2 Diagnostic tool for pyoderma gangrenosum.

TABLE 3.3 Some common forms of vasculitis.

TABLE 3.4 Co‐morbidities and risk factors for leg ulceration in rheumatoid ...

TABLE 3.5 The American College of Rheumatology and European League Against ...

TABLE 3.6 Key risk factors and presentation of basal cell carcinoma (BCC), ...

TABLE 3.7 Weighted seven‐point checklist.

TABLE 3.8 Common drugs that may cause cutaneous atypical wounds and conside...

TABLE 3.9 Aspects of drug‐taking history that can be included in the assess...

TABLE 3.10 Possible differential diagnoses of erosive pustular dermatosis....

TABLE 3.11 Suggested contents of self‐harm rescue pack.

Chapter 4

TABLE 4.1 Biomechanical risk factors that may contribute to developing a ve...

TABLE 4.2 Important questions to ask about injury history.

TABLE 4.3 Reasons for falling.

TABLE 4.4 Spatial and temporal parameters.

TABLE 4.5 Examples of screening tools for falls.

Chapter 5

TABLE 5.1 Psychological assessment.

TABLE 5.2 The CEAP standard for identifying venous disease.

TABLE 5.3 Identifying arterial disease in the lower limb.

TABLE 5.4 The 6 Ps of peripheral arterial disease (PAD).

TABLE 5.5 Intrinsic and extrinsic factors that affect wound healing.

TABLE 5.6 TIMES wound assessment.

TABLE 5.7 Descriptions of exudates and their significance.

TABLE 5.8 Skin assessment.

TABLE 5.9 Presenting conditions that may lead to inaccurate Doppler results....

TABLE 5.10 Ankle brachial pressure index (ABPI) indicators for compression ...

Chapter 6

TABLE 6.1 Gate theory and influences.

TABLE 6.2 Impact of pain on the person.

TABLE 6.3 Leg ulcer types.

TABLE 6.4 Assessment scales.

TABLE 6.5 Key messages that will make a difference to patients.

Chapter 7

TABLE 7.1 The social, environmental and cultural context of health.

TABLE 7.2 Examples of the wider determinants of health that affect leg ulce...

TABLE 7.3 Examples of the inextricable links between the social determinant...

TABLE 7.4 Examples of how public help interventions could prevent lower lim...

TABLE 7.5 Five key areas of public health practice for the lower limb.

TABLE 7.6 Applying the cycle of change to support people with leg ulceratio...

TABLE 7.7 Common views of leg ulcer management.

TABLE 7.8 System delays that will have impacts on patient outcomes.

TABLE 7.9 The rationale for patient activation.

TABLE 7.10 Patient activation scoring in the patient activation measure....

TABLE 7.11 The benefits of supported self‐management.

TABLE 7.12 Characteristics of people with leg ulcers who are deemed suitable...

TABLE 7.13 Negative terminology

TABLE 7.14 Using positive descriptors to generate action and confidence.

Chapter 8

TABLE 8.1 Tools in the toolbox.

TABLE 8.2 Lower limb management plan.

TABLE 8.3 Medications that can cause or exacerbate swelling in the ankle an...

TABLE 8.4 The three key steps to good skincare.

TABLE 8.5 The threefold approach to exudate management.

TABLE 8.6 Contraindications and cautions in compression therapy.

TABLE 8.7 Subdivision of venous pathologies.

TABLE 8.8 What does compression therapy do?

TABLE 8.9 The different doses of compression therapy.

TABLE 8.10 Four areas to consider when understanding doses of compression t...

TABLE 8.11 Laplace's law explained.

TABLE 8.12 How compression reduces the inflammatory response in the lower l...

TABLE 8.13 Signs of inflammation before ulceration may have occurred.

TABLE 8.14 Advantages of compression hosiery kits.

TABLE 8.15 Ankle circumference.

TABLE 8.16 Different types of bandages.

TABLE 8.17 Monitoring whether therapy is working.

TABLE 8.18 Types of ulceration for which intermittent pneumatic compression...

TABLE 8.19 Indications and contraindications for intermittent pneumatic com...

TABLE 8.20 Three steps to wound bed preparation.

Chapter 9

TABLE 9.1 Risk stratification for reassessment.

TABLE 9.2 Lifelong compression.

TABLE 9.3 Key steps to consider when assessing for compression hosiery.

TABLE 9.4 Difference between British, French and German Standard hosiery cl...

TABLE 9.5 Treatments for venous insufficiency and oedema.

TABLE 9.6 Location for leg measurement for leg compression hosiery.

TABLE 9.7 Quick guide for good medical compression hosiery fit.

TABLE 9.8 Dos and don'ts of compression hosiery.

TABLE 9.9 Main examples of hosiery application aids – (BPS‐Compression...

TABLE 9.10 Supported self‐management.

TABLE 9.11 Tips for patient education and involvement.

TABLE 9.12 Structure of the core capabilities framework.

List of Illustrations

Introduction

FIGURE I.1 Typical annual spend across wound management classifications.

Chapter 1

FIGURE 1.1 Transportation of blood around the body. Peate (2021) / John wile...

FIGURE 1.2 Blood flow from capillaries to venules. Peate (2021) / John wiley...

FIGURE 1.3 One‐way bicuspid valves.

FIGURE 1.4 The venous system of the leg.

FIGURE 1.5 (a, b) Varicose veins.

FIGURE 1.6 DVT, deep vein thrombosis; MMP, matrix metalloproteinase.

FIGURE 1.7 Consequences of glycocalyx and endothelium changes in venules and...

FIGURE 1.8 Fibrin cuff theory.

FIGURE 1.9 Layers of the arteries and veins.

FIGURE 1.10 The layers of the skin.

Chapter 2

FIGURE 2.1 Lymphatics in humans. The system consists of serially connected n...

FIGURE 2.2 Lymphatic vessels. (a) Initial lymphatic capillaries are blind‐en...

FIGURE 2.3 Stemmer sign.

FIGURE 2.4 Type III, Stage 2 lipoedema, anterior view. Note the excess tissu...

FIGURE 2.5 Same patient as in Figure 2.4, posterior view. Note the stance an...

FIGURE 2.6 Close‐up anterior view of ankles to demonstrate ‘cuff’ phenomenon...

FIGURE 2.7 Posterior view of the patient in Figure 2.6.

FIGURE 2.8 Type III late stage 2 with chronic oedema of lower legs and feet,...

FIGURE 2.9 Same patient as figure 2.8, lateral view. The ‘hood’ of excess ti...

FIGURE 2.10 Same patient as figures 2.8 and 2.9, posterior view.

Chapter 3

FIGURE 3.1 Typical presentation of PG with violaceous (purple border).

FIGURE 3.2 Cribriform scar.

FIGURE 3.3 Typical presentation of vasculitis.

FIGURE 3.4 Punched‐out ulceration to the foot with visible foot deformity du...

FIGURE 3.5 Ulceration associated with systemic scleroderma with visible skin...

FIGURE 3.6 Calcium deposits in the wound bed related to calcinosis cutis and...

FIGURE 3.7 (a, b) Sickle cell ulceration.

FIGURE 3.8 Reddened plaques to the pretibial region associated with necrobio...

FIGURE 3.9 Ulcerated necrobiosis lipoidica.

FIGURE 3.10 (a) Martorell's ulceration to the lower limb with typical dry ne...

FIGURE 3.11 Dusky, mottled skin seen in early stages of calciphylaxis.

FIGURE 3.12 Necrotic lesion from calciphylaxis.

FIGURE 3.13 Basal cell carcinoma presenting as a leg ulcer – note the raised...

FIGURE 3.14 Amelanotic malignant melanoma disguised as a diabetic foot ulcer...

FIGURE 3.15 (a, b) Marjolin's ulcer – SCC transformation in a leg ulcer orig...

FIGURE 3.16 Pustules and crusted areas to surrounding skin.

FIGURE 3.17 Leg wounds due to self‐harm with continual gouging/scratching of...

FIGURE 3.18 Ecthyma gangrenosum on the lower leg with multiple, painful ulce...

FIGURE 3.19 Cutaneous leishmaniasis.

FIGURE 3.20 Leg ulcer associated with Hansen disease – note the areas of une...

FIGURE 3.21 Buruli ulcer with typical necrosis and undermining edge.

Chapter 4

FIGURE 4.1 Biomechanical factors that influence venous leg ulceration.

FIGURE 4.2 (a) Universal and (b) digital goniometers.

FIGURE 4.3 The gait cycle.

FIGURE 4.4 Seated ankle joint exercises with a TheraBand.

FIGURE 4.5 Tips on choosing footwear.

FIGURE 4.6 Darco healing sandal.

FIGURE 4.7 (a) Off‐the‐shelf functional foot orthoses. (b) Fully custom‐made...

Chapter 5

FIGURE 5.1 Signs of telangiectasis.

FIGURE 5.2 Signs of enlarged veins.

FIGURE 5.3 Signs of hyperpigmentation, staining and hyperkeratosis.

FIGURE 5.4 Varicose eczema.

FIGURE 5.5 Atrophie blanche.

FIGURE 5.6 Lipodermatosclerosis and venous staining.

FIGURE 5.7 Signs of ankle flare.

FIGURE 5.8 Arterial ulceration.

FIGURE 5.9 Skin tone tool.

FIGURE 5.10 Repair and regeneration.

FIGURE 5.11 Infection and inflammation of the tissue.

FIGURE 5.12 Epithelial wound edges.

FIGURE 5.13 Applying the sphygmomanometer cuff.

FIGURE 5.14 Arterial pulses of the foot.

FIGURE 5.15 Lower limb cuff position.

FIGURE 5.16 Waveforms. (a) Triphasic; (b) biphasic; (c) monophasic.

Chapter 7

FIGURE 7.1 The wider or social determinants of health.

FIGURE 7.2 A framework on which to base confident and competent leg ulcer pr...

Chapter 8

FIGURE 8.1 Recognition of leg ulceration as a symptom of a long‐term conditi...

FIGURE 8.2 Compression hosiery kit.

FIGURE 8.3 Compression hosiery wrap.

FIGURE 8.4 Inelastic bandage.

FIGURE 8.5 Elastic bandage.

FIGURE 8.6 Compression hosiery stockings.

FIGURE 8.7 Static stiffness for elastic and inelastic bandages.

FIGURE 8.8 Laplace's law.

FIGURE 8.9 Tubular stockinette.

FIGURE 8.10 The wadding layer is applied to protect the bony prominences on ...

FIGURE 8.11 The wadding layer.

FIGURE 8.12 Inelastic bandage.

FIGURE 8.13 Applying an inelastic bandage.

Chapter 9

FIGURE 9.1 Sites to measure limb circumference for compression hosiery.

FIGURE 9.2 The core capabilities framework tiers (NWCSP 2021).

FIGURE 9.3 Plan–Do–Study–Act (PDSA) cycle.

Guide

Cover Page

Table of Contents

Title Page

Copyright Page

Dedication

List of Contributors

Foreword

Preface

Acknowledgements

Introduction

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Lower Limb and Leg Ulcer Assessment and Management

Edited by

ABY MITCHELL

GEORGINA RITCHIE

ALISON HOPKINS

This edition first published 2024© 2024 John Wiley & Sons Ltd

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In remembrance of Hugo

Professor Hugo Partsch, 1938–2023

Doctor, researcher, scientist

A humble and generous mentor

Founder of the International Compression Club

Who ignited for many a lifelong fascination with compression therapy

Thank you

List of Contributors

Sarah Bradbury RN, BSc(Hons), MScClinical Research DirectorWelsh Wounds Innovation CentrePontyclun, UK

Rona Frances Campbell Podiatrist, BSc(Hons), MScClinical Lead Podiatry & BiomechanicsAccelerate CICLondon, UK

Deborah Chester‐Bessell Nurse BSc(Hons)Learning and Teaching FellowUniversity of SalfordSalford, UK

Rhodri Harris RN, BSc, LTA Cert (Lip)Advanced LymphoedemaSpecialist NurseAccelerate CICLondon, UK

Jane Harry RN, Dip Nurs, BSc, MScTissue Viability Specialist Service Team LeaderBerkshire Healthcare Foundation TrustWokingham, UK

Juliet Herbert RN, DipHEAdvanced LymphoedemaSpecialist NurseAccelerate CICLondon, UK

Alison Hopkins MBE RN FQNI MScChief ExecutiveAccelerate CICLondon, UK

Gabriela Korn RGN, MScAdvanced Specialist Wound Care NurseAccelerate CICLondon, UK

Kirsten Mahoney RGN, BSc, MSc, IPSenior Tissue Viability Nurse andClinical Operational Programme Improvement LeadWelsh Wounds Innovation CentrePontyclun, UK

Aby Mitchell RGN, MSc, PG Cert, BA, FHEASenior Lecturer in Nursing EducationKing’s College LondonLondon, UK

Joseph MontgomeryCustomer Services LeadAccelerate CICLondon, UK

Caitriona O’Neill RGNDirector of Clinical Services and LymphoedemaAccelerate CICLondon, UK

Georgina Ritchie RN, DN, QN, MEd, FHEADirector of EducationAccelerate CICLondon, UK

Charlotte Smith RN, SCPHN, MEdSenior Lecturer and Healthy University AdvisorFaculty of Health and WellbeingUniversity of Central LancashirePreston, UK

Heidi Sandoz RN, BScTissue Viability Clinical Nurse Specialist Lead NurseHertfordshire Community NHS TrustWelwyn Garden City, UK

Karen Staines RN, QN, BScDirector of Research and Wound CareAccelerate CICLondon, UK

Hayley Turner‐Dobbin RN, QN, MScClinical Delivery LeadAccelerate CICLondon, UK

Fran Worboys RGN, BSc, Dip Nurs, Dip HEConsultant Clinical Nurse Specialist in Tissue ViabilityAccelerate CICLondon, UK

Foreword

Wound care is predominantly a nursing issue. It is a vital and highly skilled field of nursing practice that is routinely delivered in the community, every day of the year, to hundreds of thousands of individuals in homes and clinics, where it is unseen and rarely celebrated.

This book lifts the veil on the management of leg ulcers, with evidence‐informed approaches to providing excellent care. It is written by a team of experts for nurses, principally for the district nursing service, but it will also be highly beneficial to all nurses working in general practice, in care homes and in domiciliary care where they are also responsible for leg ulcer care.

Nurses ensure that care is personalised to the individual they are caring for and this book provides a framework for practice that recognises the holistic, person‐centred nature of nursing assessments and nursing work. It brings together a guide to practice along with the supporting evidence, to enable learning and critical thinking on assessment techniques, diagnosis, selection of the most appropriate intervention, evaluation, potential referral and review.

Nurses providing care for people in a home environment know that it is not only expert skills that are needed to provide the most appropriate care for the leg ulcer, but also seeing the person in the context of the environment in which they live. In addition to undertaking a physical assessment of the wound and surrounding skin condition to ensure that the most appropriate therapeutic intervention is prescribed, nurses observe mobility, continence, hydration, nutritional status, levels of self‐care and the warmth and living conditions of the home, including the potential for personal care and elevation of legs as required.

With highly developed skills in communication and personalised care, nurses provide the most appropriate therapeutic intervention as part of a shared decision‐making process, considering the person's lifestyle, employment status and psychological and social situation. This is complex work – and nurses make it look easy, all the while utilising skills of critical thinking and holistic assessment to determine the best approach for leg ulcer care to propose to the individual. They also know when to refer to the multidisciplinary team for additional assessment, with an understanding of the benefits of working in a wider team of clinical professionals.

This perfectly formed reference, provided as a very practical pocketbook to accompany the nurse in practice, challenges the reader to think differently about leg ulcer care. The text changes the narrative about leg ulcer healing and prevention, with references to causing harm to the very people being cared for through inappropriate interventions or sub‐therapeutic ‘doses’ of compression therapy. It places the person being cared for at the centre and provides an accessible and supportive reference for all nurses in clinical practice delivering leg ulcer care for the communities they serve.

The development of this book by United Kingdom experts in the field of leg ulcer management is timely, with the National Wound Care Strategy Programme (NWCSP) in England having been published in 2018 and the learning from this continuing to be rolled out. The book brings into sharp focus a world in which leg ulcer management can be rapidly and radically improved through education and the application of best practice.

My congratulations to every member of the Accelerate CIC team, the Welsh Wounds Innovation Centre, King's College London and the nurses working in the National Health Service who have contributed their expertise to this book. I very much look forward to seeing the tangible impact flowing through the nurses working in the community setting, and most importantly to the individuals they care for.

Dr Crystal Oldman CBE RN RHV EdD MSc MA FRCN

Chief Executive of The Queens Nursing Institute

Preface

Often people peruse a book with the question ‘Is this for me?’ So what is your purpose in picking up this book? What are you hoping to gain or change? You certainly must have an interest in leg ulcers, otherwise you would not have sought out or reached for this book.

Simply because of that interest, the authors are interested in you, in your ambition and in what changes you want to be part of. This book has been written with you in mind. You are likely a community nurse or therapist who wants to manage people with lower limb conditions more effectively, and perhaps you would like to place a greater emphasis on partnership working with your patients and colleagues. With our collaborative experience and clinical expertise, gained in the classroom and in the mentoring of specialists, our aim is to help you increase your knowledge and skill set so that you can improve the lives of your patients and bring about the change the healthcare system and our citizens deserve.

Lower limb management is not just for nurses; it needs to involve multidisciplinary teams. There is certainly a groundswell of change being advocated in the world of leg ulcer management and the authors are keen to support this. Improving understanding and developing specialist skills require teamwork, so Accelerate CIC has partnered with key allies in the NHS, King's College London and the Welsh Wounds Innovation Centre to write this book. This has been an exciting collaboration to be part of.

As I write this preface, I am reminded that this is my 35th year of a focus on improving the lives of people with leg ulcers. It is exciting to see recent developments and the establishment of the National Wound Care Strategy. There is a growing body of evidence about the costs of wound care for both people and the health economy; there is a recognition of the drain that unhealed leg ulcers are on our resources and lives. I do believe we are making national progress. Yet the story underpinning leg ulcer management can sometimes feel as if nothing has changed since I started my journey in 1989. The health system continues to perpetuate avoidable patient harm through system paralysis and a lack of understanding of the extent of the damage to patients and clinicians.

And this harm is avoidable. The system must focus on developing skilled practitioners, optimising compression therapy, safeguarding escalation to specialist practitioners and ensuring that access for biomechanical assessment is addressed. If not, then our patients may well continue to suffer life‐changing events, potentially leading to sepsis and even death. This is completely unnecessary, and we do not need more research to tell us what to do to prevent this or how to improve the lives of our citizens. The resources used to prop up a poor system are costly to all.

Unfortunately we have a narrative that reinforces a negative view of people with leg ulcers. I have witnessed 35 years of a damaging story, a powerful and influential narrative that has led to an acceptance of chronicity and to delays in treatment, allowing non‐healing wounds to hit crisis point with inadequate resources to manage them. This false narrative says that leg ulcers are inevitably ‘chronic’, that it is the non‐compliance of patients that hinders healing and that nurses should be afraid of doing harm by using compression. Products have been adapted to reflect this false narrative; there has been a growth in sub‐optimal compression devices alongside hundreds of unnecessary wound dressings designed to promote the healing that has so far eluded us.

Meanwhile the prevalence of non‐healing persists and grows, using up 50% of community nursing workload. This all‐pervasive story hinders the healing of lower limb wounds and is the reason behind the writing of this book. The book aims to bring together the multidisciplinary knowledge and insight required to effectively manage lower limb conditions, and it aims to support you, the practitioner, in developing the courage you need to counter this pervasive narrative. Together we can indeed improve lower limb management by simply using our skills and knowledge.

This level of understanding is necessary to create confidence in your growing expertise. It will enable you to have good conversations with your patients and to consider the next steps in partnership with them. The language this book promotes should give you clarity, confidence and courage alongside professional humility – recognising that we have much to learn from our patients. This book will hopefully assist in growing your resolution to deliver the expert compassionate care required alongside confidence to challenge the system. Your expanding knowledge will enable you to act as an advocate for your patients and your colleagues, and to champion an improved health system.

I want to give my heartfelt thanks to all the contributors for their time freely given. I feel privileged and blessed to have been part of this book. A very special thanks need to be offered to my fellow editors, Georgina Ritchie and Aby Mitchell; the book simply would not have been published without their tireless support, energy and enthusiasm.

Alison Hopkins MBE RN FQNI MSc

Acknowledgements

Thank you to Accelerate CIC members and patients.

A heartfelt thanks to members of Accelerate CIC who provided unwavering support throughout the writing of this book.

A special thank you to the Accelerate CIC patients who were brave and kind enough to allow us to photograph and share pictures of their wounds and lower limbs. Without their contribution, learning and understanding lower limb management would not be possible.

The editors of this book wish to thank the contributors for their input into the writing of this book.

Juliet Herbert

Hayley Turner‐Dobbin

Gabriela Korn

Heidi Sandoz

Deborah Chester‐Bessell

Introduction

ALISON HOPKINS AND JOSEPH MONTGOMERY

In order to understand the placement of and need for this textbook, it is critical that practitioners understand the resources being used in the management of the lower limb. In order to improve outcomes for patients, we need to critically appraise the resources being used, the waste in the health system and where to focus our attention. Resource management is also part of excellent system management. Unfortunately the collection and analysis of system and patient data concerning those with wounds are not routinely accessible and providers often have to rely on the data of others or studies to make conclusions about their local provision. This has created much paralysis in our commissioning landscape. However, there is some local data that can be accessed and this introduction sets the scene and clarifies the role the insights can play in improving care delivery. Dressing spend will reduce when best practice is utilised and wound chronicity avoided. Thus clinical improvements as a result of increasing readers' knowledge and skills in leg ulcer management will create a profound and positive impact on the health economy.

THE WOUND CARE BURDEN

During 2017 and 2018 it was estimated that more than one million people in the United Kingdom had an active ulcer on the lower limb (Guest et al. 2020). This equates to 2% of the population and is a 37% increase from the prevalence data recorded in 2012 (Guest et al. 2020). More than 50% of these patients were recorded as having venous leg ulceration and approximately 36% of all lower limb wounds did not have a documented diagnosis. This lack of accurate diagnosis indicates that a significant proportion of the population is likely to experience delayed wound healing associated with the absence of effective treatment. The cost of lower limb ulceration cannot be underestimated, as experiencing a leg ulcer is known to be associated with a negative effect on the biopsychological, spiritual and socioeconomic aspects of patients' health, well‐being and quality of life.

Treatment and management of leg ulcers are expensive, and the financial costs of wounds overall are well documented. Approximately £8.3 billion per year are spent on wound management, of which £2.7 billion is associated with managing healed wounds and £5.6 billion is associated with managing unhealed wounds (Guest et al. 2020). In terms of practitioner time, this equates to 54.4 million district or community nurse visits per year, 28.1 million practice nurse appointments and 53.6 million healthcare support worker visits (Guest et al. 2020). It is estimated that 50% of community nursing caseloads is attributed to lower limb wounds (Hopkins and Samuriwo 2022). Missing from the picture is health economics data about the amount of money and time spent by patients, their families and support networks in managing their wounds.

For practitioners this so‐called ‘big data’ can feel disconnected from day‐to‐day practice, but effective resource management is an area that practitioners can influence, through learning about local needs and patterns, choosing the right management plan, analysing and understanding available data and working effectively to be aware of sustainability. Front‐line healthcare practitioners are well positioned to make a difference in resource management and environmental sustainability (Ritchie 2019) for the benefit of the local health economy.

Effective management of resources, whether that is clinical consumables, human time or a commitment to environmental sustainability, has the potential to underpin effective leg ulcer management. When managing resources for the population of citizens who have wounds, it is necessary to be cognisant of the resources being used, those that are obvious and measurable, as well as where we are data poor. This is an important area for practitioners to appreciate and lead on, whatever level of change they are attempting to create, from developing a basic business case to those who wish to promote system‐level change. Table I.1 highlights areas of data that could support a strategy to improve resource management.

TABLE I.1 Data for insight into the use of healthcare resources.

Understanding the burden on the local workforce such as frequency of dressing and nursing activity per week.

The dressing spend per resident for the borough and comparing to others.

Identifying unwarranted variation such as use of compression therapy or antimicrobials across teams.

Identifying the types of wounds on the caseload and proportion of bilateral leg ulcers.

Obtaining data on urgent admissions for cellulitis and the impact of unmanaged oedema.

THE COST OF SUB‐OPTIMAL WOUND CARE

Dressing prescription costs are a known resource within community services alongside the awareness that waste is prevalent and there is a chronic lack of adherence to formularies. This brings an opportunity for cost control and reduction often led by medicines management teams. Less known or understood is the extent of time spent on delivering wound care; this has been reviewed in some studies (Guest et al. 2020; Hopkins and Samuriwo 2022) but it is rare for an area to know accurately how many hours of practitioner time are spent on care delivery. This prevents the development of a comprehensive workforce strategy that will utilise an effective skill mix for the successful management of patient need.

The successful management of lower leg wounds and lymphoedema is very dependent on the skillful use of dressings, compression bandages and compression garments. When evidence based care is utilised for people with leg ulcers, this has a positive effect on spend and patient outcomes, as well as practitioner time. Hopkins and Samuwiro (2022) found that more nursing time was spent on lower limb management when compression was not used; non‐use of compression increased nursing activity by 37%. Analysis of the usage and costs of dressings, compression bandages and compression garments bring insights to direct care delivery at the front line, as well as improving the system‐wide population health management. Yet the insightful management of dressings and bandages as a critical resource remains a rarity in resource management.

Collecting local data on practitioner time, dressing and bandage usage and unplanned admissions remains a difficult task but can provide profound insights into the evidence of sub‐optimal care and unwarranted variation. Persuading commissioners of the worth of investment remains problematic and hence the need for the National Wound Care Strategy to provide a framework for evidence production and business cases. While data may be lacking, enthusiastic local leaders can help commissioners or nursing leaders make system‐changing decisions. Table I.2 offers some tips for how practitioners can develop good resource management practices.

TABLE I.2 Tips on how practitioners can develop good resource management practices.

Identify a person with sub‐optimal management of leg ulcers; explore the resources used in time and dressings, the number and costs of infections and admission. Describe an alternative journey for this person and identify the impact on cost reduction.

Use the insights developed through dressing analysis with terminology that targets the commissioners' understanding and focuses on population health, such as ‘unwarranted variation’, ‘inequity’, ‘sub‐optimal care’, ‘unplanned admission’.

Highlight the need for budget holders to invest in robust, high‐quality education, rejecting a ‘see one, do one’ approach to lower limb management that perpetuates the cycle of sub‐optimal care and ineffective resource management.

Look at your caseload of all those with lower leg wounds of all types. Establish how many are using compression therapy and whether this is optimal.

CLASSIFICATION OF DRESSING PRODUCTS

Dressings are classified according to their primary purpose, with the exception of some antimicrobial products. Categorising products, as in Table I.3, is beneficial when reviewing the use of dressings and spending attributed to them. This method provides a quick overview of the most‐used or highest‐spending products and brings insight at a glance, while highlighting where further analysis is needed.

TABLE I.3 Product classification.

Classification

Generic examples

Absorbent

Hydrofibre, supra‐absorbents

Antimicrobial

Products with Ag (silver) layer or specific antimicrobial properties

Bandage

Crepe or retention bandage

Compression bandage systems

Individual bandages, multicomponent kits, hosiery kits

Debridement

Skin or wound cleansing wipes or pads, often with microfibres

Dressing packs

Including gloves and aprons to aid good infection control practices

Film

Film only

Foam

Adhesive or non‐adhesive hydrophilic polyurethane foams

Gauze

Packs of simple gauze

Hydrocolloid

Hydrocolloid of various thicknesses

Hydrogel

Debriding gel

Irrigation

Saline and other wound cleansers

Non‐adherent

Wound contact layers

Negative pressure wound therapy

Various manufacturers

Other (consumables)

Forceps, scissors, probes

Paste bandage

Impregnated bandages or tubular bandages

Pressure‐offloading devices

Footwear

Simple dressings

Non‐adherent pads with adhesive tape or film

Tubular bandage

Used under bandages

Wadding

Sub‐bandage wadding

Hosiery/wraps

Hosiery, split into garments and wraps and by compression class

Displaying spend and usage in this manner to those using the scheme can stimulate conversation and debate about what this means for them and how their clinical decisions are shaping their dressing and bandage spend.

DRESSING PRODUCT ANALYSIS

Top 10 Dressing Products

An example of a typical annual spend in dressings across the classifications can be seen in Figure I.1.

FIGURE I.1 Typical annual spend across wound management classifications.

Foam, absorbent and antimicrobial dressings will normally feature within the first five highest‐spending classifications.

In areas where a dressings optimisation scheme is actively managed, the insights from the analysis should create a change in usage. A strategy for optimising dressings is linked to delivering evidence based care; effective management of oedema will see an increase in compression products and a reduction in use of bandages (crepe and retention). Monitoring product use across teams will also establish other areas of unwarranted variation.

Foam dressings combined with an online dressing optimisation system are often considered the first choice for even simple wounds as they are easy to use and comfortable. While they are essential for pressure ulcers, they are not always required for simple surgical or traumatic wounds. Encouraging a suitable switch to simple dressings such as non‐adherent pads with film or tape adhesive is cost effective.

Antimicrobial spending is excessive in the example in Figure I.1 and needs to be understood and reduced through a coordinated action plan that combines effective management of wounds with a local anti‐microbial strategy.

The use of absorbent dressing often benefits from greater exploration; excessive use, and certainly of the large sizes can point to inadequate lower limb management. Large absorbent dressings or pads are primarily used for lymphorrhoea or large bilateral leg ulcers; excessive use can suggest that oedema is not being addressed properly, especially if the analysis also demonstrates a high use of crepe in proportion to compression.

ONLINE NON PRESCRIPTION SERVICES

Prescribing is an essential component of effective clinical management in many areas of healthcare and non‐medical prescribing in particular has been demonstrated to have many positive outcomes for practitioners and patients (Nuttall and Rutt‐Howard 2019). The last 15 years have seen a number of online non prescription services developed by dressing manufacturers. Accelerate CIC has developed an independent online system that supports effective dressing optimisation through analysis and insight development; as an agnostic system there are no industry requirements for particular dressings to be present on the formulary allowing greater choice and control.Within leg ulcer management a dressing optimisation scheme (DOS) can be an effective way to deliver the insights required in order to manage resources successfully ensuring good prescribing practices that are not adversely affected by patient or colleague expectations, the organisational culture, as well as external influences such as pharmaceutical companies and the media (Ritchie 2019). While a dressing optimisation scheme does not eliminate the influences entirely, it can support their minimisation or regulation.

An online dressing optimisation system reduces waste. As the dressing or product is procured off prescription it is no longer the property of the patient but of the healthcare organisation. Therefore, a box could be opened and distributed across multiple patients or places of treatment. Additionally, as these items are owned by the local health organisation and fall under one budget for all services, if a dressing is no longer required or is likely to expire without being used, it can be utilised within the same organisation, infection control issues permitting. Orders made under the dressing optimisation scheme can also be returned to the supplier if they have not been opened and the account is credited. The system prevents people from continuing to collect or receive dressings direct to their homes without oversight. Regular reviews by a practitioner are completed to ensure that the patient's needs have not changed and that what they are using is still appropriate thereby preventing a wasteful build up of products in the home.

Access to dressings is managed through the agreed wound formulary, which is easily visible and accessible in the online system. Due to the ease of access it is critical that product sizes are restricted and products kept to a minimum; unusual products or sizes are restricted to a clinical lead or specialist nurse for authorisation and monitoring.

A benefit of an online non prescription service is that people with wounds do not pay for their dressings or compression garments via this system. This is significant for working adults and to those suffering due to the cost of living crisis. If the person is in supported self‐management, products are given to them as required.

Traditional prescriptions can create waste and delays in getting the right product to the right patient on time; delays in this system are common but rarely captured or monitored. An online system has far greater transparency allowing for monitoring and improvement processes. For practice nurses, leg ulcer clinics and nursing homes, delivery direct to the team is simple and easy to manage, although a storage area is required. For community nurses visiting people with wounds in their own homes, it is more difficult (Kilborn and Hopkins 2017); community nurses are required to provide dressings from the store or nursing base. The advantage is that nurses have what they need when they need it but they are required to be the provider of the dressings. Bringing clarity about the benefits and challenges at the outset of changing to an online system is critical so that expectations are clear. The savings through waste reduction and the insights into use should both contribute to a quality improvement programme and reduction in variation. The savings realised should be invested back into the system, through either additional nursing roles or specific equipment to improve service delivery.

The analysis that can be obtained from the dressing spend within a service or trust is often not understood or examined. The provision of insightful data can improve resource management and inform practice; linking this to population health management, reduction in variation and education of practitioners will deliver significant opportunities for the health of the system and for improvement in the lives of both people with wounds and practitioners. Significant savings can be made when the spend across the system is brought together and analysed.

CONCLUSION

This book will guide you through the physiology of the venous, arterial and lymphatic systems; the pathophysiology of lymphoedema, chronic oedema and lipoedema; lower limb and leg ulcer assessment; pain and clinical management; personalised care; and prevention of recurrence. The aim is to support clinicians in leg ulcer clinical decision‐making, inform practice and underpin the case for systemic change. Improved outcomes for patients can be evidenced within the data on dressings, compression and hosiery use.

REFERENCES

Guest, J., Fuller, G., and Vowden, P. (2020). Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from 2012/2013.

BMJ Open

10: e045253.

https://doi.org/10.1136/bmjopen‐2020‐045253

.

Hopkins, A. and Samuriwo, R. (2022). Comparison of compression therapy use, lower limb wound prevalence and nursing activity in England: a multisite audit.

Journal of Wound Care

31 (12): 1016–1028.

Kilborn, C. and Hopkins, A. (2017). Dressing optimisation strategy: meeting the needs of the patient and population.

Nurse Prescribing

14 (4): 188–191.

Nuttall, D. and Rutt‐Howard, J. (2019).

The Textbook of Non‐Medical Prescribing

, 3e. Chichester: Wiley‐Blackwell.

Ritchie, G. (2019). What nurses can do to combat the dangers of air pollution.

Journal of Community Nursing

33 (2): 10.

CHAPTER 1Aetiology

ABY MITCHELL

NORMAL VENOUS FUNCTION

The venous system is an important part of the circulatory system. The heart may be the principal organ that pumps blood around the body, but it is the vascular system that transports the blood throughout the system. Blood flows through arteries and arterioles transporting oxygen, nutrients and other substances essential for cellular metabolism and homeostatic regulation. Veins and venules are responsible for carrying deoxygenated (oxygen‐depleted) blood towards the heart. The exceptions to this are the pulmonary arteries (which carry deoxygenated blood) and the pulmonary veins (which carry oxygenated blood) (Blanchflower and Peate 2021). Capillaries are tiny blood vessels that form a delicate network near most parts of the body tissues and connect arteries and veins; they are unable to withstand high pressure. Their thin walls allow oxygen, nutrients, carbon dioxide and waste products to pass to and from tissue cells. Figure 1.1 illustrates blood flow, which is from the capillaries to the venules (Figure 1.2). Venules are porous and composed mainly of endothelium and fibroblast cells. Substances such as water, solutes and white blood cells are able to move in and out of the vessel in the extracellular fluid.

FIGURE 1.1 Transportation of blood around the body. Peate (2021) / John wiley & Sons.

FIGURE 1.2 Blood flow from capillaries to venules. Peate (2021) / John wiley & Sons.

Venules unite to form veins. They contain three layers from the inside out:

Tunica interna

Tunica media

Tunica externa

The walls of veins are thinner compared to arteries and contain less elastic, collagenous tissue and smooth muscle. Veins have a larger lumen compared to arteries. Some veins, most commonly in the lower extremities, contain one‐way paired semilunar bicuspid valves. Their function is to prevent any backward reflux of blood towards the capillaries – allowing blood only to flow back towards the heart (Figure 1.3).

FIGURE 1.3 One‐way bicuspid valves.

The superficial venous system includes the great and lesser saphenous veins as well as the anterior, posterior and superficial accessory saphenous veins. Superficial leg veins run between the dermis and muscle fascia. The deep venous systems are located below the muscle facia and contain the femoral vein, the common femoral vein, the deep femoral vein and the popliteal vein, as well as the anterior and posterior tibial veins and the fibular veins. The two systems are linked by perforating veins that pass through the muscle fascia.

Veins in the leg are classified into three main categories:

The deep vein (can withstand high pressures during muscle contraction).

The superficial veins (not designed to withstand prolonged high pressures).

The perforator veins.

Lying deep in the muscles of each leg is a deep vein that runs the length of the leg. In the calf this is also known as the anterior tibial vein, in the knee the popliteal vein and in the thigh the femoral vein. These are all sections of the deep vein. In the groin, the deep vein joins the common iliac vein, which leads to the vena cava and eventually the heart (Figure 1.4).

FIGURE 1.4 The venous system of the leg.

There are numerous superficial veins that lie outside the muscle just below the skin. They comprise:

Long saphenous veins – originate from the medial malleolus (inner ankle) and empty into the femoral vein.

Short saphenous veins – run from the lateral malleolus (outer ankle) and empty into the popliteal vein.

There are also tributaries of these veins.

The perforator veins pass through the muscles, transporting blood from the superficial system into the deep vein. These are located at regular intervals along the leg and are particularly abundant in the ankle.

VEINS IN ACTION

The veins have an important job forcing blood upwards towards the heart against gravity. Table 1.1 depicts all the mechanisms of action that facilitate this.

TABLE 1.1 Mechanisms of action.

Source: Adapted from Moffatt et al. (2007).

Heart

The heart exerts a mild ‘pull’ on the veins due to the pressure gradient between the right atrium (pressure is around 0 mmHg) and the venous system. This is sufficient to produce some blood flow back to the heart when the person is horizontal, but insufficient in aiding venous return when upright

Veins

Dilate and contract

Respirator pump

Plays a limited role in venous return. During inspiration the diaphragm pushes against the abdomen, causing a rise in pressure in the intra‐abdominal veins. At the same time, the pressure in the thorax falls (pressure also falls in the intra‐thoracic veins and right atrium) and blood is drawn from the abdominal cavity into the thorax. The deeper the inspiration, the greater the venous return

Calf muscle and foot pumps

These are the most important mechanisms for aiding venous return. The foot pump (contraction of the plantar muscles during movement) squeezes and empties veins in the foot. During exercise, the calf muscle contracts, compressing the deep vein and forcing the displacement of blood. The one‐way valves prevent blood from refluxing, forcing the flow upwards against gravity. When the muscles relax the deep vein expands, which causes pressure to drop below that of the superficial veins. The resulting pressure gradient draws blood via the perforator veins from the superficial veins into the deep vein. As exercise continues, muscle contraction squeezes the refilled vein, forcing blood towards the heart. This is a continuous cycle

It is important to note that the effectiveness of the calf muscle and foot pumps depends on healthy one‐way valves and good ankle function/movement. Valve incompetence and limited ankle movement are major contributors to the development of venous disease and non‐healing leg ulceration (see Chapter 4).

BLOOD PRESSURE IN VEINS AND CAPILLARIES

Blood pressure in the capillary network is around 5–15 mmHg.

Blood pressure in veins fluctuates according to position and level of activity for each individual.

When a person is standing, venous pressure is equal to the weight of the volume of blood from the foot to the right side of the heart, which is about 80–100 mmHg. This falls to 10–20 mmHg when the calf muscle and foot pumps empty the veins during exercise.

The values in the perforating veins that connect the superficial veins to the deep veins prevent reflux. Pressure in the superficial veins remains low (Grey and Patel

2022

).

Venous blood pressure is reduced when the person lies horizontally.

VENOUS DISEASE

Venous disorders are thought to be a major cause of morbidity and decreased health‐related quality of life (White and Ryjewski 2005). Venous leg ulcers (VLUs) are typically long‐lasting, and there is a high risk of recurrence that can have a negative impact on a patient's quality of life (Green et al. 2014). VLUs arise from chronic venous insufficiency (CVI) in the lower limb. The prevalence of VLUs in adults over 18 years rose to 1 per 100 individuals in 2017/2018 (Guest et al. 2020). In the United Kingdom, complex wounds such as VLUs are mostly treated by community nursing teams (Urwin et al. 2022). The estimated national cost of treating a VLU in the United Kingdom is £102 million, with a per‐person annual cost of £4787.70 (Urwin et al. 2022). The average cost per person of treating a VLU is estimated at £166.39 (Urwin et al. 2022). The cost of managing an unhealed VLU is thought to be 4.5 times more than managing a healed VLU (£3000 per healed VLU and £135 000 per unhealed VLU) (Guest et al. 2018). Subsequent studies have identified a decrease in healing rates for VLUs in 2020 and 2021 by 16% and 42%, respectively, following the COVID‐19 pandemic (Guest and Fuller 2023). The pandemic appears to have had a deleterious impact on the health of patients with VLU (Guest and Fuller 2023).

Venous disease occurs when the calf muscle pump and foot muscle pumps are unable to effectively empty veins. This results in venous hypertension (increased pressure in the veins). This is often due to valve incompetence allowing blood to flow backwards (‘reflux’) towards capillaries as well as forwards towards the heart. Valve incompetence in the deep vein causes increased pressure on the valve below and the corresponding perforator vein valve. As a result, these valves also become incompetent, causing the superficial veins to varicose and leading to disease progression (Figure 1.5). The same effect happens whether the primary incompetence occurs in the perforator or superficial veins.