- 1.3 or above may indicate arterial disease or calcification. Seek advice from tissue viability nurse
- 1.0-1.3 normal arterial flow. Regular compression is probably safe, if not otherwise contraindicated
- 0.8-1.0 Mild arterial disease, but sufficient for compression if not otherwise contraindicated
- 0.5-0.8 Moderate arterial insufficiency. Seek advice from tissue viability nurse; reduced compression may be appropriate following specialist advice
Tag Archives: tissue viability
In venous leg ulcers, the incompetency of venous valves means there may be backflow in the veins of the lower leg which results in venous hypertension. This can cause fluid to accumulate in the tissues, developing oedema.
Brown haemosiderin staining is caused by the breakdown of red blood cells which become trapped in the skin. Induration occurs from fibrosis of the subcutaneous layer which may result in a classic ‘champagne leg’. Other venous symptoms are varicose eczema, oedema, ankle flare (distended veins in medial ankle area) pain (with relief on elevating the limb), varicose veins, ulcers in gaiter or malleolus regions.
Risk factors of venous ulceration are: DVT, varicose veins, swollen oedematous legs, multiple pregnancies, lower leg fracture, thrombophlebitis, previous leg ulceration, previous vascular or orthopaedic surgery.
Arterial signs include: reduced or absent pedal pulses, history of intermittent claudication, reduced ABPI, deep punched out ulcers on toes, heels or foot, necrosis or gangrene, loss of hair to the limb, shiny, pale hairless skin on shin, dusky coloured foot, cool to touch, thickened toe nails, pain in feet and blanching when elevated, delayed capillary refill.
Risk factors for arterial ulcers include ischaemic heart disease, smoking, hypertension, diabetes mellitus, TIA/CVA, MI or angina, rheumatoid arthritis or previous arterial surgery.
Compression bandaging used in treatment of venous leg ulcers is designed to aid venous return. Laplace’s law is that the pressure applied to the limb is determined by the width of the bandage, the degree of overlap and degree and technique of stretch applied (usually both 50%) but this is dependent on the ankle being smaller than the calf. Shortstretch bandaging is different in that it is applied at 100% stretch.
- 80% of leg ulcers are venous
- Venous ulcers are caused by chronic venous insufficiency; pooling in the leg leads to venous congestion, leading to fluid being forced out of the vessel and into the surrounding tissues as oedema.
- Erythrocytes leaking through into the tissue can stain the leg, a symptom of chronic venous disease.
- Oedema can also be caused or exacerbated by renal or cardiac conditions, and therefore their involvement needs to be ascertained as part of care planning.
- Grade 0: foot at risk, pre-ulcerative lesions, bony deformity and/or previous healed ulcers
- Grade 1: uninfected superficial ulcer
- Grade 2: frequently infected deeper ulcer, no osteomyelitis
- Grade 3: deeper than grade 2, formation of abcess common, osteomyelitis
- Grade 4: grangrene (localised) may affect the toe, heel or forefoot
- Grade 5: gangrene of the entire foot.
In 2003 studies were carried out which found that there were at least 100,000 people in the UK who were living with some type of lymphoedema, although this is a conservative estimate, and there could well be 200,00 Britons with lymphoedema (Moffatt 2003).
The lymphatic system maintains homeostasis by transporting interstitial fluid which contains protein, waste products and water back into the blood supply (Keen 2008). If this system fails, or is impaired, protein and fluid can accumulate in the tissues, attracting more water by osmosis which then results in a clearly visible swelling. This is known as lymphoedema (Huit 2000). A sign of lymphoedema is when there is an inability to pinch up a skin fold at the base of the second toe – this is known as Stemmer’s sign (Keen 2008). Oedema ‘pits’ when pressed, and after a few seconds the pit will disappear as the fluid returns (Nigam 2008).
Primary oedema is caused by filiaritic infection caused by mosquito bites (more prevalent in the developing world), congenital conditions such as Milroy’s disease (MacLaren 2001). Idiopathic lymphoedema is thought to occur when there is an underdevelopment of lymph vessels (King 2006).
The most common cause of lymphoedema in the UK is due to cancer treatment such as surgery or radiotherapy which cause damage to lymph nodes or removes them completely (MacLaren 2001). This is known as secondary lymphoedema, it can also be caused by trauma, inflammation (including inflammatory arthritis), or infection such as bacterial cellulitis, tuberculosis or filarial infections (Keen 2008).
Common causes of oedema are pregnancy, immobility, varicose veins and cardiac failure. All of these can contribute to the impairment of the lymph vessels’ ability to transport interstitial fluid back to the blood. Cardiac failure can result in pooling of venous stasis, pooling in the legs, which then puts pressure on the venous system, this can lead to pulmonary oedema (Nigam 2008).
Lymphoedema is not a condition that can be cured, but it can be controlled, and through treatment patients can improve their mobility, decrease the impact inflammatory episodes have on their lives, and enhance their quality of life (Huit 2000). If treatment is not initiated, the condition will gradually become worse. After time, as a result of the accumulation of the excess interstitial fluid, fat and fibrous deposits appear (King 2006). The tissue hardens and the oedema no longer pits; in such cases hyperkeratosis is common (excessive growth of skin to form scaly, horny layers), as is papillomatosis (preponderance or wart growths), and lymphorrhoea (leakage of lymph fluid) (Keen 2008), in some cases if oedema continues, massive oedema known as elephantiasis can develop as the lymph vessels become almost completely blocked, ulcers can also develop which are difficult to heal (Nigam 2008). Because the lymph fluid is protein rich, bacterial and fungal infections are common, which increases the risk of acute exacerbations (Huit 2000). Cellulitis can occur during an acute inflammatory episode and should be treated with broad-spectrum antibiotics (King 2006).
Accurate diagnosis, treatment and patient education of lymphoedema is essential if the best outcomes are to be achieved (Huit 2000). It is also important to diagnose the cause of lymphoedema in order to rule out other causes such as cardiac failure, hypertension, lipoedema, protein deficiency, DVT, or immobility. Defining the cause will ensure the most effective treatment and therefore the best outcome. Clinical presentation, previous medical history, and the results of investigations are all invaluable in determining the cause (King 2006).
Treatment (not cure) is aimed at reducing the oedema and encouraging improved lymph fluid flow (King 2006). There are several principles in the treatment and management of lymphoedema: skincare, compression, exercise, and lymphatic drainage (King 2006). From these four points, it is clear to see how essential patient education is, and how patients themselves can ensure the effectiveness of the treatment prescribed. As with all care planning, the patient should be involved in decision-making and should therefore to be able to give informed consent to proposed treatments.
It is likely that for treatment to be effective, the patient will need to make some lifestyle changes, such as increasing the level of activity and exercise taken, making changes to diet by reducing the intake of salt, and losing weight. Also patients may need to develop new habits such as elevating the affected limb(s) to aid venous return, (oedema responds to gravity and therefore if the affected limb is elevated, this assists in the drainage of the fluid back into the blood supply (Nigam 2008)), taking prescribed medication regularly, and adopt the use of compression garments (Nigam 2008). Because this may mean significant changes to a person’s lifestyle, it is particularly helpful if information can be written down for the patient in order for them to refer back to it in the future (Honner 2009).
Good hygiene and skincare is vital for people living with lymphoedema; the aim is for the skin to be kept supple, healthy and hydrated. Even tiny breaks in the skin can lead to infection (Huit 2000). Soap should be avoided as it removes the natural oils that exist to protect the skin, making it more fragile and prone to breaking. Therefore emollients should be used instead such as aqueous cream. Skin should be patted dry, and care must be taken when moisturising that products are not rubbed into the skin, but rather smoothed over the skin in a downward direction (the direction of the hair) this reduces the risk of folliculitis (Penzer 2003). Skin should be inspected daily for any signs of inflammation discolouration or breaks in the skin, as these could signal an inflammatory episode (King 2006). Patients should also be advised to take care of their affected limbs to reduce the risk of injury to them, wearing footwear at all times, or gloves when gardening or washing up, and using insect repellents and sun block adequately (King 2006).
Compression garments or bandaging can be applied to provide a graduated compression to aid vessels transporting the lymph fluid back into the blood supply, it can also prevent the oedema occurring (Huit 2000). In patients with mild oedema where the shape of the limb has not been distorted and with no contraindication (such as arterial disease, cardiac failure, VTE, or allergies), compression garments can be applied immediately with great effect. Patients need to be assessed and measured for their suitability and sizing for compression garments or bandaging (King 2006). Such garments need to be worn daily if they are to achieve their purpose. Again, this is why patient engagement is essential; without concordance most lymphoedema treatments will fail. For patients with more significant oedema, a period of intensive treatment with compression bandages may be required to reduce the oedema and develop a normal shaped limb in order to fit with compression garments. All of this needs do be done and prescribed by an adequately trained practitioner (King 2006).
Exercise is a good way of decreasing oedema, however, because the oedema itself can be a reason for limited mobility any exercise plans should be tailored for the patient’s needs and abilities (Woods 2004); if compression garments have been prescribed, they will need to be worn during exercise (King 2006). Exercise should be moderate, introducing new exercises gradually and not overdoing it. Low impact exercise such as cycling, swimming and walking are advised (MacLaren 2001).
Lymphatic drainage massage works by promoting the removal of interstitial fluid away from the oedematous areas. It should only be performed by a competent [practitioner as the technique is substantially different from regular massage techniques (Huit 2000). This is a particularly good form of treatment for those patients who are unable to tolerate compression treatments for whatever reason. Again patient involvement is vital – patients can be taught to perform this technique on themselves, which can prove effective (King 2006).
The management of lymphoedema can be difficult, there are many factors to consider, causes, contraindications to treatment, patient concordance, education and lifestyle. The more involved the patient is in their treatment, the more likely it is to be effective. Lymphoedema is often overlooked, but if poorly managed can have a seriously negative impact on a person’s lifestyle, body image, and outlook. Therefore it is imperative that lymphoedema is swiftly diagnosed, treatment determined and initiated to minimise distress and inconvenience to the patient (King 2006).
- Honner, A. (2009) The information needs of patients with therapy-related lymphoedema Cancer Nursing Practice. 8, 7, 21-26
- Huit, M. (2000) A guide to treating lymphoedema Nursing Standard 96, 38 42
- Keen D.C. (2008) Non-cancer-related lymphoedema of the lower limb Nursing Standard. 22, 24, 53-6.
- King, B. (2006) Diagnosis and management of lymphoedema Nursing Times 102, 13, 47
- Lymphoedema Network (2006) Best Practice for the Management of Lymphoedema International Consensus. London. MEP Ltd
- MacLaren, J.A. MA, (2001) Lymphoedema
- Moffatt et al, (2003) Lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738
- Nigam, Y. & Knight, J. (2008) The Lymphatic System Part 4 – Pathophysiology Nursing Times 104, 16, 24-25
- Penzer, R. (2003) Lymphoedema. Nursing Standard. 17, 35, 45-51.
- Woods, M. (2004) Causes and treatment of early Lymphoedema Cancer Nursing Practice 3, 5, 25-30
Diabetes is a condition with far-reaching consequences. As the population ages, more diabetes-related conditions will occur.
Diabetes is the root cause of the majority of non-traumatic limb amputations, and therefore diabetic foot problems need to be treated as an emergency, according to NICE guidelines.
Diabetic foot problems can include neuropathy, charcot arthropathy (or other deformity), gangrene, ulcers, osteomyelitis, peripheral arterial disease, or infection.
For care of diabetic foot problesm, the multidisciplinary team in an acute setting will comprise: tissue viability nurse, diabetologist, relevant surgeon, diabetes specialist nurse, podiatrist, and possibly a physiotherapist. The aim of the MDT is primarily mobilisation.
Patients with diabetes-related foot problems need to be referred to the responsible MDT within 24 hours of admission. this team will then assess and initiate treatment of the patient’s underlying diabetes, assess and coordinate care for the presenting foot problems, (the assessment is to include a vascular assessment). Infection also needs to be treated immediately; a swab may be taken, but depending on the stage of infection, it is likely that antibiotics are started before results return from the lab. At this point the patient will be assessed with regard to their need for orthotics or other interventions to protect the feet and revent/reduce future problems where possible. The MDT will also begin to consider discharge, so there is a workable plan in place at the right time.
At all stages, the patient must be kept in the loop with discussions and must be a part of the decision-making process. Patient education and empowerment is paramount, as is effective communication with the primary care team taking over care (if necessary).