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WOUND CARE

Leg ulceration is a common condition seen in 1–3 per 1,000 of the UK population

and 1% of people in the UK will have a leg ulcer at some stage of their life (Callam, 1992; Scottish Intercollegiate Guidelines Network [SIGN], 2010). Similarly, the treatment of venous leg ulcers accounts for about 1% of the health budget in Western healthcare systems — a substantial outlay every year (Pascarella and Shortell, 2015). While leg ulcers are rarely found in people below the age of 45, the prevalence increases with age and can rise to 20 per 1,000 for people over the age of 80 (Royal College of Nursing [RCN], 1998; Dutch College of General Practitioners, 2004).

A leg ulcer is defined as an open wound on the leg that takes longer than 4–6 weeks to heal. Most leg ulcers will be caused by underlying venous problems and valve incompetence in the lower leg. Some ulcers (about 20%) might be caused by arterial disease (Adeyi et al, 2009) and this can be checked by performing an ankle brachial pressure

How to improve the community care of leg ulcer patients

index (ABPI) Doppler test. Ulceration has been shown to be more common in women (Moffatt et al, 2004; Vowden and Vowden, 2009), and although there is no link between ulceration and socioeconomic status, people with ulcers from more deprived backgrounds often take longer to heal (Callam et al, 1988).

Compared to other wound types, leg ulcers take a long time to heal anyway and even then about two-thirds of healed ulcers will recur (Morris and Sander, 2007). This can have a profound effect on people’s quality of life.

CARE OF LEG ULCERS IN THE COMMUNITY Community nurses spend about 25–50% of their time treating leg ulcers (Simon et al, 2004), and, as the population is generally becoming older, this number is set to increase, particularly as the risk of ulceration increases with age (Franks and Moffatt, 2007).

People generally are living with chronic illness and complex health conditions for much longer than they used to mainly because of medical

innovations and improved health care — this places a burden on already over-stretched community nursing teams. Similarly, changes in lifestyle and diet has meant an increase in obesity and reduced mobility among the population, which are also risk factors for ulcer formation and chronic illness.

Recent government plans for heath care have included a shift in care away from the hospital model into the community and there is an increasing emphasis on community nurses providing care to people in their own homes (Department of Health [DH], 2013). In the future, up to 80% of leg ulcers will be treated in the community (SIGN, 2010), some in nurse-led specialist clinics and others in projects such as Lindsay Leg Clubs, which act as an adjunct to community care and which are successful in providing a model of care where the patient, their peer group and clinicians work in partnership to achieve good leg care at drop-in clubs.

WHAT CAUSES LEG ULCERS?

Chronic venous insufficiency Chronic venous insufficiency occurs when the veins become weakened and are unable to maintain blood flow to the heart. The valves in the veins that usually ensure that the blood only flows in one direction can become damaged over time, allowing blood to flow backwards in the veins (reflux), particularly in the lower leg which is the furthest point from the heart and requires more pressure to pump the blood back to the upper body.

AetiologyChronic venous insufficiency can be an inherited condition and will most often be seen in older people, with more women then men having the

Deborah Simon, tissue viability lead, 5 Boroughs NHS Foundation Trust, Knowsley

Venous leg ulcers make up a considerable part of the community nurse’s workload and the gold standard treatment is multilayered compression bandaging applied to cleansed and debrided lower limbs. The author of this piece looks at the background to leg ulcer development; as well as how to assess patients and the principles of prevention. This article also examines the KTwo® bandaging system (Urgo Medical), which has a built-in pressure indicator to ensure that application is both consistent and effective. The make-up of the two-layer system makes it as effective as four-layer systems without the associated bulk, which means that patients find it easier to wear.

KEYWORDS: Wound care Compression Leg ulcers Oedema

Deborah Simon

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COMPRESSION Treatment of venous and mixed aetiology leg ulcers, venous oedema and lymphoedema

2 DYNAMIC LAYERS WORKING IN HARMONY

Thanks to its unique "PresSure System" and its 2 dynamic layers, ensures consistent application of the recommended therapeutic

pressure of 40 mmHg*, without over pressure and slippage1.

Reduced is available for patients with mixed aetiology leg ulcers or those intolerant to full compression and donates 20mmHg*

is available in a Latex Free version and 2 ankle sizes (18-25 cm and 25-32 cm) to be adapted to all of patients.

Two dynamic layers:• "Gold Standard" effi cacy2

• Improves patient comfort and concordance3

• Easy application with consistent pressures4

• Contraindications: arterial conditions (arterial or predominantly arterial ulcers ; known or suspected arterial disease). Ankle Brachial Pressure Index (ABPI) <0.8 for KTwo or <0.6 for KTwo Reduced. Patients suffering from diabetic microangiopathy, ischaemic phlebitis (phlegmatia coerulea dolens), septic thrombosis. Ulceration caused by infection. Allergy to any of the components, in particular latex for the "non-latex free" version.*average donated pressure at the ankle. Please read the product pack insert carefully before use.

References: 1Junger, M. et al. Comparison of interface pressure of three different bandage systems used on healthy volunteers. J Wound Care 2009; 18(20). 2Lazareth, et al. Evaluation of the effi cacy and safety of KTwo® versus Profore compression systems in the treatment of venous leg ulcers. Journal of Wound Care (2012); 21(11). 3Benigni, J-P. et al. Effi cacy, safety & acceptability of KTwo® for venous leg ulcers. J Wound Care (2007); 16(9). 4Hanna, R. et al. A comparison of interface pressure of three compression bandage systems. Br. J Nursing (2008) Tissue Viability Supplement; 17(20).

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patient can be advised to help their leg ulcer to heal and prevent its recurrence. Good nutrition, eating plenty of fruit and vegetables, maintaining a healthy weight and not smoking may all be of benefit. Maintaining or increasing mobility should also be advised and patients who spend a lot of time in chairs can be shown how to exercise their calf muscles. Elevating the lower leg is advised along with avoiding sleeping in a chair. Continuing to wear compression therapy will also help to prevent recurrence (Ashby et al, 2014).

MULTICOMPONENT COMPRESSION SYSTEMS

Multicomponent compression bandages have been shown to be more effective than single-layer bandages (O’Meara et al, 2012). KTwo® (Urgo Medical) has two components — KTech and KPress — that work together to improve blood flow in the patient’s lower limb.

KTech KTech is an inelastic bandage that provides compression while also protecting the lower leg. It has approximately 75% extensibility and combines viscose and polyester wadding with a polyamide and elastane knitted layer. It has a high working pressure and low resting pressure, which creates a massaging effect to help reduce levels of oedema (Benigni et al, 2007).

KPress KPress is an elastic, cohesive bandage that delivers the additional pressure required for correct therapeutic compression and maintains resting pressure, while keeping the system in place. It is made of acrylic, polyamide, elastane and low levels of natural latex (there is also a non-latex version for people with allergies).

The system provides sustained graduated compression for up to seven days, which saves on nursing time spent reapplying compression bandaging.

This system is available in different sizes that can be chosen according to the size of the patient’s ankle. In

WOUND CARE

MANAGING LEG ULCERS IN THE COMMUNITY

The gold standard treatment for venous leg ulcers is multilayered compression bandaging applied to cleansed and debrided legs. A thorough assessment of the ulcer will help in the choice of wound care needed and will depend on exudate levels and the presence of infection. It is important to manage any distressing symptoms that are affecting the patient’s life.

The wound should be cleansed and debrided if necessary and then dressed with an appropriate product. SIGN (2010) recommends washing with tap water and drying carefully and this is supported by a Cochrane review into irrigation (Fernandez and Griffiths, 2012). A low-adherent dressing should be chosen, applied and changed in accordance with the exudate volume being produced by the wound.

The National Institute for Health and Care Excellence [NICE] (2015) recommended that after measuring the person’s ankle circumference below the knee, graduated multilayer high compression bandaging should be applied with four- or three-layer bandaging for less mobile patients and two-layer bandaging for mobile patients. There are also two-layer systems that can be used in place of multilayer bandaging and which are suitable for use on both mobile and immobile patients (see below).

The highest pressure is applied at the ankle and assists the blood flow back up the leg and on to the heart. Compression should be avoided if there is an ABPI reading of less than 0.8 or there is evidence of cellulitis, deep vein thrombosis (DVT) or phlebitis.

Skin carePeople with chronic venous insufficiency or leg ulcers should be advised to look after their skin and to apply emollients to stop the skin drying out and breaking down (SIGN, 2010).

PreventionThere are a number of ways that a

condition. Height can also have an influence, with taller people being more susceptible. Obesity is a risk factor, as is working in jobs that require standing for long periods of time (Medline Plus, 2015).

SymptomsSymptoms of chronic venous insufficiency include: Oedema and swelling Skin changes including fibrosis

and lipodermatosclerosis Hyperpigmentation where the

skin colour darkens Ulceration Extreme skin dryness Atrophie blanche (Bradbury et

al, 2009).

HOW TO ASSESS LEG ULCERS

A thorough assessment of the patient’s ulceration is important when choosing between management options, particularly as compression is contraindicated if there is any arterial involvement. It is essential to test the patient’s ankle brachial pressure index using Doppler ultrasound in order to rule out arterial disease.

A full history should be taken and any comorbidities noted. The ulcer should be examined for signs of infection and photographs taken, if the patient consents, as this can be a good way to monitor any changes. The ulcer should be measured and attention paid to the colour and consistency of any exudate. Any odour should also be noted.

It is important to record the size and depth of the wound and document the condition of the wound bed and note any signs of healing. The patient should be asked about the effect the ulcer is having on their daily life and about the pain levels they are experiencing in relation to the ulcer.

Risk factors and comorbidities that could have an impact on the ulcer’s healing ability, such as obesity, immobility or diabetes should be assessed and treatment, advice or appropriate referrals made to help tackle these underlying factors (SIGN, 2010).

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WOUND CARE

CASE STUDY

This 73-year-old woman was referred to the author’s leg ulcer clinic with a non-healing wound to her lower leg which had developed six months previously (Figure 1). She had been redressing the wound herself until an infection led to a GP visit at which she was referred to the leg ulcer clinic. She had undergone compression therapy on a previous venous ulcer but had found it bulky as well as difficult to wear shoes with. Apart from the leg ulcer she generally enjoyed good health and was not taking any medication apart from paracetamol for pain in and around the leg ulcer.

At the review visit, the author completed the leg ulcer pathway, which confirmed that the aetiology remained venous. The ulcer itself was superficial but the surface exhibited a fine layer of slough and the exudate volume was high. The different treatment options were discussed with the patient and she declined multilayer compression bandaging because, although it was comfortable, she was unable to get her shoes on and felt self-conscious going out in them. Compression hosiery was also considered to be too painful

Figure 1.The patient’s lower limb leg ulcer before treatment began.

to apply and the levels of exudate too high. However, after the author had showed her some images of the KTwo system in place, the patient agreed that this would be the best option.

The author applied the KTwo compression bandage appropriate for an ankle circumference of 25–32cm with a low-adherent primary dressing. Staff at the clinic regularly use this dressing combination as they find it easy to

Figure 2.The patient’s lower limb at week seven of the treatment.

apply and they can have confidence that they have achieved the correct pressure because of KTwo’s pressure indicator guide. The patient found the bandages very comfortable and after two weeks no longer needed any analgaesia. She found her shoes were easy to get on and was able to carry on her day-to-day activities without anyone noticing the bandages. The ulcer made excellent progress (Figure 2), and the leg was healed at 10 weeks.

a study on the ease of application of this two-layer system, it was found that the optimum level of pressure can be achieved first time and in fact was more accurate when compared with nurses’ routine application of another compression system (Hanna et al, 2008). This consistency can be maintained by the entire care team because of ease of application, helping continuity of care. The same trial showed that 85% of nurses achieved the recommended pressure of 30–50mmHg on first application of KTwo and the mean pressure of 40mmHg did not change between applications.

KTwo has been shown to be as effective as other compression systems, and it performed well in one 12-week randomised controlled trial, producing complete wound healing in 44% of cases compared with 39% in an established four-layer compression system (Lazareth et al, 2012). The study also found that 20% of the patients using the four-layer system experienced pain compared

with only 10% of the KTwo patients, while the KTwo compression system was also found to be easier to apply.

IndicationsKTwo can be used for patients with an ankle circumference of up to 32cm and can provide 40mmHg pressure for venous leg ulcers. KTwo Reduced offers 20mmHg pressure for mixed aetiology ulcers. There is also an option for patients with oedema who require full leg bandaging. Patients with latex allergies can use the latex-free system. In addition to measuring the ankle circumference to choose the appropriate KTwo kit, the instruction leaflet must be read to ensure correct application — with the 18–25cm kit, both bandages are applied in a spiral with 50% overlap; with the 25–32cm kit, both bandages are applied in a spiral with a two-thirds overlap. This is essential to ensure the therapeutic levels of compression are achieved.

The PresSure SystemThe KTwo compression bandage

system incorporates the PresSure System, which is designed to help clinicians achieve optimal levels of compression consistently.

Each bandage has a pressure indicator which shows whether the bandage has been applied correctly and is delivering the correct level of pressure. The kits are printed with a series of ovals that become circles when the bandage has been correctly applied. Similarly, when the bandage is being wrapped around the lower leg, the pressure indicator guides the clinician as to the correct overlap.

Reasons to choose KTwo in the communityCompression therapy needs to remain effective over a sustained period of time and deliver a consistent level of compression all the time it is worn. Compression therapy is also affected by non-concordance from patients who find it too uncomfortable or even painful to wear.

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between 0.6–0.8. The KTwo range is also contraindicated for known or suspected arterial disease, diabetic micro-angiopathy and ischaemic phlebitis (Young et al, 2013).

CONCLUSION

Venous leg ulcers make up a considerable part of a community nurse’s workload. New ways to treat them effectively, which also help to prevent recurrence, should always be considered.

The KTwo system has been shown to be effective in the treatment of patients with leg ulcers and its built-in pressure indicator ensures that application is both consistent and effective. The make-up of the two-layer system means that it as effective as four-layer systems without the associated bulk, which means that patients find it easier to wear. JCN

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Adeyi A, Muzerengi S, Gupta I (2009)

Leg ulcers in older people: a review of

management. Br J Med Pract 2(3): 21–28

Ashby R, Gabe R, Ali S, et al (2014) VenUS

IV (Venous leg Ulcer Study IV) —

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Benigni JP, Lazareth I, Parpex P, et al (2007)

Efficacy, safety and acceptability of a new

two-layer bandage system for venous leg

ulcers. J Wound Care 16: 385–90

Bradbury A, Lambert A, McLafferty R, Ruckley

C (2009) Chronic insufficiency presentation

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Callam (1992) Prevalence of chronic leg

ulceration and severe chronic venous

disease in western countries. Phlebology

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Callam MJ, Harper DR, Dale JJ, Ruckley

CV (1988) Chronic leg ulceration: socio-

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Venous leg ulcer. Available online: www.

hovumc.nl/docs/int/guidelines/Venous%20

However, as the KTwo system is comfortable and less bulky than four-layer systems, a greater percentage of patients may continue to wear the system day and night — one study found that 95% of patients wore the system throughout the day, while 92% continued to wear it at night (Benigini et al, 2007). It was also considered cooler to wear, which helps to reduce night pain. The system also helped with patients’ everyday mobility as the lack of bulk lets them wear their own footwear along with the compression system.

The first layer of the KTwo system also has increased absorbency meaning that it can be used without additional dressings underneath — this cuts down on bulk and increases patient comfort. There is also reduced slippage as the system is kept in place effectively by the outer layer.

The fact that the system is easy to apply and provides consistent pressure for sustained periods of time is useful for community nurses with heavy caseloads, reducing the amount of patient visits without compromising the quality of the therapy. One case study also showed the system to be a cost-effective alternative to other compression bandage systems (Thompson and Steventon, 2010). The ease of application may also facilitate a greater level of self-care, with patients and carers able to reapply the system in between nurse visits.

To summarise, the benefits of the KTwo system include: The pressure indicator ensures

that the pressure is consistently achieved even with minimal training

It can provide sustained pressure for up to a week

It produces good healing results that rival four-layer systems without being bulky

It is comfortable, day and night and can be worn with the patient’s normal footwear.

ContraindicationsKTwo is contraindicated for patients with ABPI less than 0.8 because of the possibility of arterial involvement. However, KTwo Reduced can be used for people with an APBI

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