A venous leg ulcer is a chronic wound as it takes longer than six weeks to heal. It is caused by venous hypertension which is high blood pressure exerted in the veins of the legs which causes damage to the skin. Fluid can leak from the veins and pool under the skin causing swelling and thickening, this then leads to the skin breaking down to form an ulcer.

Before a venous ulcer can be treated it is important to rule out peripheral arterial disease being the cause of the ulcer. Symptoms of peripheral arterial disease include pain in limb when exercising or walking, intermittent claudication, skin changes such as hair loss, cold to touch, oedema and ulceration. An arterial leg ulcer is caused by poor blood flow in the arteries and due to the current treatment of venous ulcers which is bandaging. This would reduce blood flow further and cause more damage making the ulcer worse. Having a history of varicose veins and a lack of mobility increases the chance of developing venous leg ulcers .

According to SIGN (2010) when assessing a patient for the first time with a venous ulcer it is important to obtain their medical history in case of previous varicose veins and deep vein thrombosis as well as their mobility. Knowing these factors will contribute to managing the patients treatment, care and help with the rate of improvement. The framework model used to assess leg ulcers is the leg ulcer care pathway which is dived up into four stages 1. Patient begins pathway, 2. Patient is assessed and ulcer is diagnosed, 3. Planned and implemented care, 4. Evaluation (Moffatt 2007).

Joan has a history of varicose veins. Varicose veins are veins which are enlarged and swollen. They develop when valves inside the vain fail to prevent the flow of blood flowing backwards. The blood then collect in the vein causing it to enlarge and swell. As the blood in the veins is not flowing properly it becomes difficult for the exchange of nutrients, oxygen and waste between the blood and the skin. When this occurs it is called venous insufficiency which in turn can lead to venous ulcers developing (Newton 2011).

Joan is at risk of having a deep vein thrombosis due to her age, past medical history of varicose veins and sustaining an injury to her calf. Deep vein thrombosis is a clot formation in the veins, presenting signs and symptoms include localised pain, swelling with pitted oedema, heat, redness and tenderness in the calf coupled with skin discolouration.

Diagnosis of a deep vein thrombosis is difficult to diagnose by a physical examination alone, therefore Joan would benefit from a blood test called D-Dimer test. As fibrin is involved in the clotting process of the blood, the blood test looks for the breakdown product of fibrin which is D- Dimer.

As well as the blood test Joan can be referred to a vascular specialist for a duplex scan, this is used to assess blood flow. It combines ultrasound with coloured imaging which makes it possible to determine the speed of flow and diagnose a deep vein thrombosis and chronic venous insufficiency.

Should Joan be diagnosed with deep vein thrombosis she would the given an anticoagulation such as Fragmin subcutaneously. This would breakdown the clot where ever it had formed and it would also make the blood thinner helping the flow through the veins.

According to the Royal College of Nursing (2006) Joan should be assessed for arterial disease using a Doppler measurement of the ankle-brachial pressure index.
Evidence through cohort studies and controlled studies have shown that using a
Doppler ultra sound along with a medical assessment can aid diagnosis of arterial and venous disease.

Joan has an active part in the Doppler assessment as it is important that she is in a relaxed comfortable lying position for at least thirty minutes prior to the procedure and any tight clothing is removed as this may cause a false reading. A Doppler assessment is the calculation of the ankle-brachial pressure index (ABPI). It involves using a hand held ultrasound machine, sphygmanometer and cuff, it is used alongside a medical assessment of the ulcerated wound and limb (Ruff 2003).

The Doppler assessment involves taking a blood pressure measurement of the dorsalis pedis pulse located in the foot alongside the first metatarsal and comparing it with the blood pressure measurement of the brachial pulse located in the arm and this is then repeated on the other limbs. The highest of these readings are used to calculate the ankle-brachial pressure index, dorsalis pedis pulse measurement is then divided by the brachial pulse measurement. Arterial blood pressure should be roughly the same in the arms and legs, anything less than 0.9 is a good indicator that it is arterial disease rather than vascular disease therefore is classed as unsuitable for compression bandaging and should be referred to a vascular specialist (Ruff 2003).

SIGN (2010) recommends “that all patients with chronic venous ulcers should have an ankle-brachial pressure index performed prior to treatment”.

The healing time for venous ulcers is lengthy; this is due to the damage occurred in the veins and tissues. To help minimise further damage and aid healing Moffatt
(2005) advocates the use of compression bandaging on the affected limb and according to NHS clinical knowledge summaries (2011) states that the gold standard treatment for venous ulcers is compression bandaging.

Compression is achieved through the layering of bandages. Compression bandages come in four groups and provide 3 different levels of tension. Grade1- light compression, Grade 2 – moderate compression and Grade 3 – strong compression.
They are made to give more support at the ankle area 30 – 40 mmHg with the pressure levelling out at 15-20 mmHg below the knee ( Alexander et al 2006).

Compression works by forcing the fluid from the interstitial spaces back into the vascular compartments thus helping to minimise or reverse the vascular and skin changes. The effects of compression therapy are the reduction in oedema, distension of the superficial veins are reduced and reverse hypertension takes place, blood velocity in deep veins increases thus greatly improving the healing rate of the chronic venous ulcer (Alexander et al 2006).

The cleansing of Joan’s venous leg ulcer Cutting (2010) suggests that evidence gathered over the past twenty years supports the use of water as a cleanser in the management of chronic leg ulcers. Investigations show that using saline or tap water does not cause further breakdown of the wound, however Joan’s choice and the requirement of the wound also must be taken into account when choosing a cleansing method. However Coley (2009) states that when water is used on its own it can have a drying effect to the wound and emollients need to be considered to help promote healthy skin.
The rationale for cleaning leg ulcers is the removal of any dry skin due to the wearing of bandages, it also removes any build-up of emollients that are being used. It allows time for the nursing team to evaluate the wound and the condition of the leg. It also allows Joan to see for herself the healing process and can provide her with some relief of being without bandages for a short time, which will add to comfort and well- being (Coley 2009).

According to Grey et al (2006) the presenting wound should be examined and assessed using the TIME assessment tool Tissue, Inflammation/Infection, Moisture,
Edges/Epithelium. The size of the wound must be documented and the wound margin traced onto grid acetate sheets, the depth of the wound should also be documented. In order to maintain the integrity of the surrounding skin exudate must also be managed, this can be acclomplished with the use of appropriate dressings.

Cameron (2007) states that to aid the healing of a venous ulcer it is important to understand how dressings work and if it is suitable for the wound. Inappropriate dressings can delay healing causing further breakdown of the wound and surrounding skin.