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Leg Ulcer Care and Prevention (Wales) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care service’s approach to leg ulcer prevention, treatment and care in line with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, particularly Regulation 33: Access to Health and Other Services and corresponding best practice guidance.

It is the aim of {{org_field_name}} that leg ulcers are prevented wherever possible and effectively treated whenever they do occur.

{{org_field_name}} considers that all people who use services have the right to maintain intact and healthy skin as far as possible and that their environment should be designed to be safe and minimise the risk of damage to the skin caused by bumping into objects or tripping over potential hazards, such as inappropriately placed furniture.

{{org_field_name}} considers that, where a person develops a leg ulcer, they have the right to prompt referral to an appropriate healthcare professional and high-quality treatment and care provided. The person also has the right to a balanced diet to aid with wound healing and referral to other appropriate professionals, such as dieticians, should the leg ulcer not respond to treatment within accepted clinical guidelines. The person has a right to adequate analgesia should the leg ulcer cause pain or discomfort.

Procedures

All people who use services should undergo a full assessment upon admission or referral to the service which will:

• identify any existing leg ulcers and existing plans of care relating to these
• identify the person’s level of risk of developing a leg ulcer and preventive measures needed to reduce that risk.

The assessment should be repeated on a regular basis so that any developing leg ulcer will be identified as early as possible. {{org_field_name}} considers that it is essential that the cause of the ulcer is determined, ie whether it is venous or arterial, and the use of a Doppler ultrasound will be used as part of the assessment process to enable the cause to be established. A tracing and/or a Polaroid photograph of the ulcer should be taken and entered in the notes to help to provide an illustration of the extent of the ulcer before and after treatment began. An assessment of the individual’s ability to comply with the preferred treatment option will also need to be undertaken. The person should have the procedure fully explained to them to gain full co-operation. As adequate nutrition and hydration is linked firmly to leg ulcer prevention and treatment, the nutritional needs of the person will be assessed and their weight obtained. All information should be recorded in the individual care plan.

Measures to be Taken

Using a team approach, both care for an existing ulcer and preventive measures to reduce the risk of new ulcer development will be planned in partnership with care administered by other professionals and in accordance with any instructions from the person’s GP. In terms of a lower limb ulcer this will usually include:

1. facilitating rest and elevation
2. taking a wound swab
3. applying a non-stick sterile dressing
4. administering preparations to relieve pain (if present)
5. administering antibiotics if prescribed
6. applying appropriate dressings.

The nursing care of leg ulcers is only carried out by suitably trained professional staff who follow these guidelines.

1. Cleansing of the ulcer should be kept simple: irrigation of the ulcer, where necessary, with warmed tap water or saline is usually sufficient, dressing technique should be clean and aimed at preventing cross-infection — strict asepsis is unnecessary.
2. Routine bacteriological swabbing is unnecessary unless there is evidence of clinical infection such as:
   a. inflammation/redness/evidence of cellulitis
   b. increased pain
   c. purulent exudate
   d. rapid deterioration of the ulcer
   e. pyrexia.
3. Removal of necrotic tissue can be achieved through mechanical, chemical or enzymatic debridement.
4. Dressings must be simple, low adherent, low cost and acceptable to the person.
5. A prescribed compression dressing system should be applied only by a trained practitioner.
6. In the case of multi-layer bandages, these layers are left in place for seven days and then removed, and the progress of the ulcer is reassessed, the procedure is repeated until healing of the ulcer has taken place.
7. The person’s weight should be monitored regularly, at least weekly.
8. Information relating to ulcer history should be recorded in a structured format and may include:
   a. year first ulcer occurred
   b. site of ulcer and of any previous ulcers
   c. number of previous episodes of ulceration
   d. time to healing in previous episodes
   e. time free of ulcers
   f. past treatment methods
   g. previous operations on venous system
   h. previous and current use of compression hosiery.
9. The presence of oedema, eczema, maceration, cellulitis, degree of granulation tissue, signs of epithelization, unusual wound edges (eg rolled), signs of irritation and scratching, purulence, necrosis, slough, granulation and odour should be recorded.
10. In line with good practice, a Doppler ultrasound should be conducted:
    a. where people who use services present with ulcer recurrence
    b. before recommencing compression therapy
    c. where there is a sudden increase in size of ulcer or where an ulcer is deteriorating
    d. if an ulcer has not fully healed by 12 weeks
    e. where there is a sudden increase in pain, foot colour and/or temperature of foot change
    f. as part of ongoing three monthly assessment.
11. Health professionals should regularly monitor whether the person using services experiences pain associated with venous leg ulcers and formulate an individual management plan, which may consist of compression therapy, exercise, leg elevation and analgesia to meet the needs of the individual.
12. Ensure that the person has access to any medication associated with leg ulcers, ie antibiotic and analgesia.
13. A balanced diet should be provided in accordance with the person’s needs (proteins, vitamin C, mineral salts and trace elements are all essential for wound healing), where necessary advice from a dietician should be obtained.
14. Staff should seek referral to a tissue viability specialist if the leg ulcer does not improve.
15. Staff should encourage and support compliance of the person with their treatment.
16. All people who use services should have an adequate balanced diet to aid wound healing.
17. Staff should work with the person to prevent recurrence once the leg ulcer has healed.

Leg Ulcer Prevention

Varicose leg ulcers develop because of chronic venous insufficiency and poor circulation which contribute to a lack of oxygen and nutrients resulting in skin ulceration. This care service understands that the main causes of leg ulcers include:

• poor general circulation
• obesity
• standing for long periods
• injury.

These are the factors which contribute towards strain being placed on both the veins and their valves in the legs. To prevent these complications, staff should work with other members of the healthcare team to:

• identify people who are at risk of developing leg ulcers and work with them to try to prevent them occurring by maintaining a safe environment, encouraging and providing a good diet, and encouraging mobility and exercise
• arrange for a person whose leg ulcer has healed to be measured for and to use compression stockings/hose as per their care plan as this has be found to reduce venous ulcer recurrence rates
• ensure that the person receives health education on leg ulcers to increase compliance with compression hosiery and skin care
• discourage self-treatment and over-the-counter preparations and encourage the person who uses services to avoid accidents or trauma to legs and elevate affected limbs when immobile.

Training

All new staff should read the policy on leg ulcer prevention and management as part of their induction process. Existing staff will be offered training covering basic information about current evidence-based treatment and basic dietary advice. Only staff trained in wound management should dress the leg ulcer in line with the individual care plan.

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