For the management of a venous leg ulcer and dressing it, the aim is to create optimum conditions for healing. Ensuring a good wound environment and managing oedema positively impact the wound-healing process. This is done by cleaning the wound thoroughly and using appropriate dressings and compression therapy. Understanding the patient’s history and any present comorbidity factors is vital for treatment and in understanding why the patient has an exuding wound. A hard-to-heal leg ulcer is, in itself, indicative of an underlying cause.
Venous leg ulcers are caused by venous insufficiency, which means the venous valves in the legs have been damaged and are not functioning normally. The venous valves are designed to help push blood and lymph around the body in a constantly circulating flow. Dysfunctional venous valves mean that a significant portion of fluid remains in the lower limbs, resulting in oedema – a swelling caused by fluid build-up. An international group of experts has recommendedSimplifying venous leg ulcer management: consensus recommendations. woundsinternational.com using compression therapy as far as possible to reduce the oedema.
Counteracting the oedema is the most critical aspect of treatment.
Compression therapy improves venous return, reduces swelling in the lower leg, and reduces leakage from the exuding wound. A reduction in wound exudate facilitates improved peri-wound skin condition. In addition, correct exudate management will extend dressing wear time and reduce nurse visits. There are currently several compression systems to choose from. Compression management includes long and short-stretch bandage systems and kits. The manufacturer’s instructions explain how the bandage is to be applied.
As well as compression using bandages, some solutions use adjustable compression. These take the form of compression stockings with a Velcro wrap system, which is adjusted to produce the required degree of compression. An inflatable boot may prove a valuable complement to other compression methods. With a holistic assessment, monitoring the reduction in oedema provides insight into the effectiveness of treating the venous leg ulcer.
Heavily exuding wounds can cause problems and be distressing for the patient. Exudate is a natural and vital part of a healthy wound-healing process. Exudate keeps the wound moist and contains nutrients, proteins and growth factors that promote healing and help to form new tissue. The objective is to create optimal moisture conditions – a healthy environment for the peri-wound skin to ensure it continues acting as a protective barrier.
The exudate in hard-to-heal wounds contains increased levels of inflammatory molecules, which keep the wound in the inflammation phase and can themselves cause more exudate to be produced. This can lead to an infection resulting in pain, discomfort, and a reduction in the patient’s quality of life, potentially delaying the wound healing process.
It is essential to remove excess exudate that may be present. Superabsorbent dressings are advised as they can lock the exudate within the dressing. This provides optimal moisture conditions and a healthy environment for the peri-wound skin.
When assessing and treating hard-to-heal venous leg ulcers, it is necessary to monitor the size and appearance of the wound area. Examining the wound’s edges and measuring its size indicates if healing is progressing. If the patient has an ulcer that produces excessive exudate, its edges and skin may be macerated. Clinical documentation is taken to record the wound and peri-wound skin progress. The wound edges can, for example, be described as rolling, punched-out, macerated or epithelialised. The nature of the wound area must be carefully described to determine whether the wound has a fibrin coating, is granulating or is necrotic. It may also be helpful to photograph the ulcer for documentation purposes.
Delayed wound healing usually occurs in the proliferation phase. Long-standing wounds have an increased risk of infection, enabling bacteria to proliferate. The bacteria thrive in moist conditions, and the more exudate and moisture in the wound, the more bacteria there will be. Bacteria are always present on the surface of a wound. Usually, these are bacteria from the skin and mucosal flora, such as staphylococci, enterococci and intestinal bacteria, but other bacteria may also be present. An infection can develop if the bacteria penetrate the wound deeper and multiply.
The patient will often experience the clinical signs of infection, i.e., an increase in pain, swelling, redness, and exudate, and the patient may also experience general malaise. However, it is worth remembering that people with diabetes can have reduced sensation and not exhibit pain (known as neuropathy). Redness, increased discharge from the wound, odour and swelling are other indications that a leg ulcer has become infected. Where infection is suspected, a clinical assessment must be performed to assess the need for antimicrobial wound dressings, antibiotic therapy, or wound swab for culture and sensitivity testing.
Cleaning the wound thoroughly when changing dressings is important to remove wound debris. Saline solution or tap water may be used to clean a wound. Local guidelines for wound cleansing techniques may also be advised, including the use of antimicrobial wash lotions. The wound usually has debris, e.g., fibrin and dried exudate. Such deposits can be removed through mechanical wound cleaning, for example, by using a gentle monofilament pad. For wound healing to progress, removing any devitilised tissue and wound debris is vital. Several debridement techniques can achieve this, including surgical, biological enzymatic, mechanical, and autolytic debridement. Debridement is a specialised technique and should always be performed by a licensed clinician qualified to practice this technique.
In conjunction with wound cleansing, debridement and chosen dressing, it is necessary also to consider suitable pain relief. A holistic assessment, including management of any pain the patient is experiencing via a validated pain scale, should also be noted. Before treating venous leg ulcers, an assessment of any pain, the patient experiences should be done using a validated pain scale. Based on clinical assessment, a qualified clinician may require and prescribe analgesia. Pain medication may be administered orally, by injection or be applied topically to the wound as a gel, spray or ointment. If using a spray, for example, this will take effect within 1-5 minutes.
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Dressing changes depend on several factors, including the amount of exudate present. Ulcers that produce excessive exudate or are infected require dressings to be changed more frequently. The nature of the wound also impacts the type of wound care products that will best promote healing and a successful long-term outcome.
A dressing that can manage exudate and facilitate wound healing leads to a reduced frequency of dressing changes. Dressing choice and absorption ability should ideally correspond with the treatment regime where compression therapy is part of the patient’s treatment plan.
A superabsorbent dressing is designed to work best with exuding wounds because the dressing absorbs and encapsulates the exudate, forming a gel inside the dressing’s core. Superabsorbent dressings that facilitates extended wear time benefits both patient and healthcare services. The dressing has properties that promote more rapid healing, which spares the patient uncertainty, time and pain. The dressing’s excellent absorptive capacity means fewer dressing changes, as the surface of the dressing remains dry. Dressings should reduce the risk of the peri-wound skin becoming macerated.
Superabsorbent dressings that encapsulate the exudate and keep the surface of the dressing dry are the ideal choice for use with compression therapy. The dressings come in various formats and sizes and all have great absorptive capacity. This makes it easy for the caregiver to choose a dressing suitable for a particular type and size of wound.
Dressing a wound is just one treatment measure in the lengthy process of treating a hard-to-heal ulcer, which can require lifelong follow-up care. If managed inappropriately, ulcers tend to reoccur. And can be resource dependent and problematic for the patient. Here you will find more information about how best to treat a venous leg ulcer to reduce the impact of hard-to-heal wounds.
This complete guide to leg ulcers will help you to understand various wounds, what distinguishes these, and how they can best be treated during and after the healing process.
Harding, K., et al. Simplifying venous leg ulcer management, Consensus recommendations. Wounds International, 2015, Available to download from www.woundsinternational.com
Höglin G, Freijd H. A cohort study to investigate the benefit of the use of DryMax Extra superabsorbent wound dressing on a population of wet wounds, 2011; Poster presentation, Harrogate.
Lindholm C. MD, professor, Sophiahemmet University, Stockholm, 2018, www.vardhandboken.se
Lindholm C. Sår. Uppl 4:2 Studentlitteratur AB, 2018