The panel identified a total of eleven clinical practice guidelines related to venous leg ulcers. An initial screening was conducted with the following criteria: Guideline was in English. Guideline was dated no earlier than 1998 as significant changes in venous leg ulcer management occurred in that year. Guideline was strictly about the topic area. Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence). Complete guideline was available and accessible for retrieval. Eight guidelines were short-listed for critical appraisal using the "Appraisal Instrument for Clinical Practice Guidelines" (Cluzeau et al., 1997).# Recommendations
- Assessment and clinical investigations should be undertaken by healthcare C professional(s) trained and experienced in leg ulcer management.

# A comprehensive clinical history and physical examination including blood C
pressure measurement, weight, urinalysis, blood glucose level and Doppler measurement of Ankle Brachial Pressure Index (ABPI) should be recorded for a client presenting with either their first or recurrent leg ulcer and should be ongoing thereafter.
Information relating to ulcer history should be documented in a C structured format. 10. Doppler ultrasound measurement of Ankle Brachial Pressure Index (ABPI) B should be done by practitioners trained to undertake this measure.
- If there are no signs of chronic venous insufficiency and the Ankle Brachial C Pressure Index (ABPI) is abnormal (greater than 1.2 or less than 0.8), arterial etiology should be assumed and a vascular opinion sought.
- Vascular assessment, such as Ankle Brachial Pressure Index (ABPI) is C recommended for ulcers in lower extremities, prior to debridement, to rule out vascular compromise.
C. PAIN 13. Assess Pain. C
- Pain may be a feature of both venous and arterial disease, and should B be addressed.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e 17. Cleansing of the ulcer should be kept simple; warm tap water or saline C is usually sufficient.
- Dressings must be simple, low adherent, acceptable to the client and A should be low cost.
- Avoid products that commonly cause skin sensitivity, such as those C containing lanolin, phenol alcohol, or topical antibiotics.
- Choose a type of dressing depending on the amount of exudate and C the phase of healing.
No specific dressing has been demonstrated to encourage ulcer healing. A
In contrast to drying out, moist wound conditions allow optimal A cell migration, proliferation, differentiation and neovascularization.
- Refer clients with suspected sensitivity reactions to a dermatologist for B patch testing. Following patch testing, identified allergens must be avoided, and medical advice on treatment should be sought.

# Venous surgery followed by graduated compression hosiery is an option C
for consideration in clients with superficial venous insufficiency. 28. An infection is indicated when > 10 5 bacteria/gram tissue is present. B
- The treatment of infection is managed by debridement, wound cleansing A and systemic antibiotics.
- Antibiotics should only be considered if the ulcer is clinically cellulitic C (presence of some of the following signs and symptoms: pyrexia; increasing pain; increasing erythema of surrounding skin; purulent exudate; rapid increase in ulcer size).
- Do not use topical antiseptics to reduce bacteria in wound tissue, B e.g., povidone iodine, iodophor, sodium hypochlorite, hydrogen peroxide, or acetic acid.
- Topical antibiotics and antibacterial agents are frequent sensitizers and B should be avoided.

# F. COMPRESSION
- The treatment of choice for clinical venous ulceration uncomplicated A by other factors, is graduated compression bandaging, properly applied, and combined with exercise. Graduated compression is the main treatment for venous eczema.
- High compression increases venous ulcer healing and is more effective A than low compression, but should only be used where ABPI  0.8 and ulcer is clinically venous.
Compression bandages should only be applied by a suitably trained and B experienced practitioner.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e Recommendations to achieve a pressure between 35-40 mm Hg. at the ankle, graduating to half at calf in the normally shaped limb, as per La Place's Law.
- Use protective padding over bony prominences when applying C high compression.
- Arterial insufficiency is a contraindication to the use of high compression. C
A modified form of compression may be used under specialist supervision.
- Use compression with caution in clients with diabetes, those with C connective tissue disease and the elderly.
- Compression therapy should be modified until clinical infection is treated. C 41. Bandages should be applied according to manufacturer's recommendations. C 42. When using elastic systems such as "high compression" bandages, the C ankle circumference must be more than or padded to equal 18 cms.
- Ankle circumference should be measured at a distance of 2.5 cm (one inch) C
above the medial malleolus.
- The concepts, practice, and hazards of graduated compression should A be fully understood by those prescribing and fitting compression stockings.
- Graduated compression hosiery should be measured and fitted by a C certified fitter.
To maintain a therapeutic level of compression, stockings should be C cared for as per manufacturer's instructions, and replaced every six months.
- Graduated compression hosiery should be prescribed for life. B

# External compression applied using various forms of pneumatic compression A
pumps is indicated for individuals with chronic venous insufficiency.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e 52. Therapeutic ultrasound may be used to reduce the size of chronic A venous ulcers.
H. REASSESSMENT 53. With no evidence of healing, a comprehensive assessment should be carried C out at three-month intervals, or sooner if clinical condition deteriorates.
For resolving and healing venous leg ulcers, routine assessment at six-month C intervals should include: physical assessment; Ankle Brachial Pressure Index (ABPI); replacement of compression stockings; and reinforcement of teaching.

# I. SECONDARY PREVENTION
- Measures to prevent recurrence of a venous leg ulcer include: wearing C compression stockings, regular follow-up to monitor Ankle Brachial Pressure Index (ABPI), discouragement of self-treatment with over-the-counter preparations, and avoidance of accidents or trauma to legs.
Inform the client after the ulcer has healed regarding: wearing and C maintenance of compression stockings; elevation of affected limb above level of heart when at rest; early referral at first sign of skin breakdown or trauma to limb; need for exercise and ankle-joint mobility; appropriate skin care; avoidance of products likely to be sensitizers; and life-long use of compression.

# RECOMMENDATION LEVEL OF EVIDENCE
Education 57. Guidelines are more likely to be effective if they take into account local C Recommendations circumstances and are disseminated by an ongoing education and training program.
- Develop educational programs that target appropriate healthcare providers, C clients, family members, and caregivers. Develop programs that maximize retention, ensure carryover into practice, and support lifestyle changes.
Present information at an appropriate level for the target audience using principles of adult learning.
- Design, develop, and implement educational programs that reflect a C continuum of care. The program should begin with a structured, comprehensive, and organized approach to prevention and should culminate in effective treatment protocols that promote healing as well as prevent recurrence.
- All healthcare professionals should be trained in leg ulcer assessment C and management. where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
Dedication of a qualified individual to provide the support needed for the education and implementation process.
Ongoing opportunities for discussion and education to reinforce the importance of best practices.
Opportunities for reflection on personal and organizational experience in implementing guidelines.

# Interpretation of Evidence
This RNAO guideline is a synthesis of a number of source guidelines. In order to fully inform the reader, every effort has been made to maintain the original level of evidence cited in the source document.

# Purpose and Scope
The purpose of this guideline is to:
improve outcomes for venous leg ulcer clients;
assist practitioners to apply the best available research evidence to clinical decisions; and promote the responsible use of healthcare resources.
Best practice guidelines are systematically developed statements to assist practitioners and clients' decisions about appropriate healthcare (Field & Lohr, 1990;McKibbon, Eady & Marks, 1999).
This best practice guideline is intended to provide direction to practicing nurses in all care settings, both institutional and community, in the assessment and management of venous leg ulcers, including prevention of recurrence wherever possible.
The guideline focuses on:
- Practice Recommendations: directed at the nurse to guide practice regarding assessment, planning and interventions.
Recommendations: directed at educational institutions and organizations in which nurses work to support its implementation.

# Organization and Policy
Recommendations: directed at practice settings and environment to facilitate nurses' practice.

# Evaluation and monitoring indicators.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
This nursing best practice guideline contains recommendations for Registered Nurses (RNs)
and Registered Practical Nurses (RPNs). Although these guidelines are written for the nurse, venous leg ulcer care is an interdisciplinary endeavour. Many settings have formalized interdisciplinary teams and the panel strongly supports this structure. Collaborative assessment and treatment planning with the client is essential. The recommendations made are not binding for nurses and should accommodate client/family wishes and local circumstances.
It is the intention of this guideline to identify best nursing practices in the treatment of venous leg ulcers. It is acknowledged that the individual competency of nurses varies between nurses and across categories of nursing professionals (RNs and RPNs) and is based on the knowledge, skills, attitudes and judgment enhanced over time by experience and education.
It is expected that individual nurses will perform only those aspects of venous leg ulcer assessment and management for which they have appropriate education and experience.
Further, it is expected that nurses, both RNs and RPNs, will seek consultation in instances where the client's care needs surpass the individual nurse's ability to act independently. It is acknowledged that effective client care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients, ever mindful of the personal preferences and unique needs of each individual client.

# Guideline Development Process
In February of 2001, a panel of nurses with expertise in the practice and research related to venous leg ulcers, from community and academic settings, was convened under the auspices of the RNAO. At the onset the panel discussed and came to consensus on the scope of the best practice guideline.
A search of the literature for systematic reviews, clinical practice guidelines, relevant articles and websites was conducted. See Appendix A for a detailed outline of the search strategy employed.

# Assessment and Management of Venous Leg Ulcers
Ottawa-Carleton Community Care Access Centre Leg Ulcer Care Protocol Task Force (2000). is a synthesis guideline that was based on all of the above noted guidelines with the exception of the Care of People with Chronic Leg Ulcers: An Evidence Based Guideline which was developed by the New Zealand Guidelines Group (1999).

# Ottawa-Carleton Community
A critique of systematic review articles and pertinent literature was conducted to update the existing guidelines. Through a process of evidence gathering, synthesis and consensus, a draft set of recommendations was established. This draft document was submitted to a set of external stakeholders for review and feedback -an acknowledgement of these reviewers is provided at the front of this document. Stakeholders represented various healthcare professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel -discussions and consensus resulted in revisions to the draft document prior to pilot testing.

# Assessment and Management of Venous Leg Ulcers
A pilot implementation practice setting was identified through a "Request for Proposal" (RFP)
process. Practice settings in Ontario were asked to submit a proposal if they were interested in pilot testing the recommendations of the guideline. These proposals were then subjected to a review process, from which a successful practice setting was identified. A nine-month pilot implementation was undertaken to test and evaluate the recommendations. The evaluation took place in a chronic care hospital and community care organization in Southern Ontario.
An acknowledgement of these organizations is included at the front of this document. The development panel reconvened after the pilot implementation in order to review the experiences of the pilot site, consider the evaluation results, and review any new literature published since the initial development phase. All these sources of information were used to update/revise the document prior to publication. 23 N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Definition of Terms
An additional Glossary of Terms related to clinical aspects of the document is located in Appendix B.
Clinical Practice Guidelines or Best Practice Guidelines: Systematically developed statements (based on best available evidence) to assist practitioner and client decisions about appropriate healthcare for specific clinical (practice) circumstances (Field & Lohr, 1990).
A process for making policy decisions, not a scientific method for creating new knowledge. At its best, consensus development merely makes the best use of available information, be that of scientific data or the collective wisdom of the participants (Black et al., 1999).
Education Recommendations: Statements of educational requirements and educational approaches/strategies for the introduction, implementation and sustainability of the best practice guideline.
Evidence: "An observation, fact or organized body of information offered to support or justify inferences or beliefs in the demonstration of some proposition or matter at issue" (Madjar & Walton, 2001, p.28).
The use of statistical methods to summarize the results of independent studies, thus providing more precise estimates of the effects of healthcare than those derived from the individual studies included in a review (Clarke & Oxman, 1999).

# Assessment and Management of Venous Leg Ulcers
Organization & Policy Recommendations: Statements of conditions required for a practice setting that enable the successful implementation of the best practice guideline.
The conditions for success are largely the responsibility of the organization, although they may have implications for policy at a broader government or societal level.
Practice Recommendations: Statements of best practice directed at the practice of healthcare professionals that are ideally evidence-based.

# Randomized Controlled Trial:
For the purposes of this guideline, a study in which subjects are assigned to conditions on the basis of chance, and where at least one of the conditions is a control or comparison condition.
Stakeholder: A stakeholder is an individual, group or organization with a vested interest in the decisions and actions of organizations who may attempt to influence decisions and actions (Baker et al., 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by the change or solution to the problem. Stakeholders can be of various types, and can be divided into opponents, supporters, and neutrals (Ontario Public Health Association, 1996).
Systematic Review: Application of a rigorous scientific approach to the preparation of a review article (National Health and Medical Research Council, 1998). Systematic reviews establish where the effects of healthcare are consistent and research results can be applied across populations, settings, and differences in treatment (e.g., dose); and where effects may vary significantly. The use of explicit, systematic methods in reviews limits bias (systematic errors) and reduces chance effects, thus providing more reliable results upon which to draw conclusions and make decisions (Clarke & Oxman, 1999).
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Background Context
Leg ulcer disease is typically cyclical and chronic, with periods of healing followed by recurrence.
It is not uncommon for leg ulcers to persist for years, with recurrence rates as high as 76 percent within one year (Nelzen, Bergquist & Lindhagen, 1995). Leg ulcers are a major cause of morbidity, suffering and high health service costs. The negative impact on the sufferer's quality of life is significant, as individuals may experience mobility loss, chronic pain, fear, anger, depression, and social isolation (Phillips, Stanton, Provan & Lew, 1994;Pieper, Szczepaniak & Templin, 2000;Price & Harding, 1996).
International studies on leg ulcer prevalence from all etiologies have demonstrated rates of between 1 and 6 per 1, 000 population in Western countries (Baker, Stacy, Jopp-McKay & Thompson, 1991;Callam, Ruckley, Harper & Dale, 1985;Cornwall, Dore & Lewis, 1986;Nelzen et al., 1995). A one-month prevalence study in one large Canadian region found a prevalence rate of 1.8 per 1,000 for the population over the age of 25 (Harrison, Graham, Friedberg, Lorimer & Vandervelde-Coke, 2001). The care of this population is compounded by the fact that the condition is highly associated with age, with the prevalence rate reported in the 2 percent range for those over age 65 (Callam et al., 1985;Cornwall et al., 1986). Reports on the percentage of lower limb ulcerations that result predominantly from a venous etiology range from 37 to 62 percent (Baker et al., 1991;Callam et al., 1985;Cornwall et al., 1986;Nelzen, Bergquist, Lindhagen & Halbrook, 1991;Nelzen et al., 1995). Some studies found venous leg ulcers had a longer duration and a higher recurrence rate than those of a non-venous etiology (Baker et al., 1991;Nelzen et al., 1995).
Surveys have shown wide variation in the clinical management of leg ulcers. Numerous types of wound dressings, bandages and stocking are used in the treatment and prevention of recurrence (Lees & Lambert, 1992;Stevens, Franks & Harrington, 1997). In leg ulcer care, using treatments with known efficacy leads to improvements in both healing rates and quality of life for the leg ulcer sufferer (Cullum, Nelson, Fletcher & Sheldon, 2000;Franks et al., 1995a). Despite the evidence supporting effective leg ulcer management, many clients are not receiving this care (Harrison et al., 2001;Hickie, Ross & Bond, 1998).
The cost of caring for individuals with leg ulcers is significant. Reports from the United Kingdom and France indicate that the cost of venous diseases of the leg accounts for 2 percent of their total national health budgets (Laing, 1992). One study in the UK estimated that district nurses spend as much as 30 to 50 percent of their time with clients in leg ulcer care (Lees & Lambert, 1992). Over 80 percent of the ongoing management of chronic wounds such as leg ulcers occurs mainly in the community (Callam et al., 1985;Lees & Lambert, 1992;Lindholm, Bjellerup, Christensen & Zederfeldt, 1992). As the prevalence of leg ulcers increases with age, the swell in the elderly population with the advance of the "boomer" generation, and an anticipated increment in longevity will result in higher resource demand for community leg ulcer care.

# Assessment and Management of Venous Leg Ulcers
Guiding Principles/Assumptions in Venous Leg Ulcers Care 1. Venous leg ulcers can significantly compromise quality of life.
- Interdisciplinary, collaborative assessment, and treatment planning with the client is essential.
3 Early prevention strategies decrease the potential for ulcer development.
- Therapy involves client acceptance and participation.
- Clinicians must be knowledgeable of the features and management of venous disease.
- Venous leg ulcers are managed with effective compression and wound management therapy.
- An Ankle Brachial Pressure Index (ABPI) measurement must be done prior to commencement of compression therapy.
- Clinicians must have sound practical knowledge and experience in the use of Ankle Brachial Pressure Index (ABPI).
- Clinicians must have sound practical knowledge and expertise in the use of therapeutic compression.
- Maintaining therapeutic measures reduces the risk of re-occurrence.
- Proactive care supports rehabilitation and return of client independence.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Discussion of Evidence:
Although little guidance is given, the literature strongly supports the importance of assessment and clinical investigations for venous leg ulcers. Recognizing significant arterial insufficiency is important, as no healing will occur in the presence of severe occlusive arterial disease of the affected limb. Kunimoto et al. (2001) caution that the high levels of compression necessary to correct venous hypertension will be potentially dangerous in this situation. Keast & Orsted (1998) add that a chronic wound should prompt a search for underlying causes.
According to Zink, Rousseau & Holloway (2000), twenty-one percent of individuals with venous ulcers experience concomitant arterial disease, with the risk of co-existing arterial dysfunction increasing with age, which again supports the importance of a thorough assessment.
Research repeatedly confirms the necessity of trained healthcare professionals in leg ulcer management. Surveys of reported practice by nurses demonstrate that knowledge of nurses in wound care often falls short of what is ideal (RCN, 1998). Providers of healthcare recognize that the mismanagement of wounds is both costly and unnecessary. Kerstein, van Rijswijk & Betiz (1998), among others, maintain that providing optimal cost-effective wound care requires extensive skills, as well as knowledge, and that classroom teaching alone will not meet the needs of our aging population. An assessment for a history of venous insufficiency also includes:
Family history of venous disease.

# Client history of deep vein thrombosis (DVT).
Lower leg fracture or other major leg injury, previous vein surgery, varicose veins, or prior history of ulceration with/without use of compression stockings.
History of episodes of chest pain, hemoptysis, or history of a pulmonary embolus.
Lifestyle factors (e.g., sedentary lifestyle, chair-bound), obesity, poor nutrition.

# An assessment for signs indicative of Non-Venous Disease also includes:
Family history of non-venous etiology.
Heart disease, stroke, transient ischemic attack.
Peripheral vascular disease (PVD)/intermittent claudication.

# Ischemic rest pain.
A combination of the features described above may be indicative of mixed arterial/venous disease (RCN, 1998).

# Discussion of Evidence:
Several clinical studies show strong support for the need for thorough history taking for assessment of venous insufficiency (NZGG, 1999;RCN, 1998). The New Zealand Guidelines Group (1999) further suggests assessing the history of the ulcer, the mechanism of injury, and previous methods of treatment.
Assessment and Management of Venous Leg Ulcers Zink et al. (2000) recommend a guided interview to obtain the history most pertinent to the cause of the ulcer, explaining that while the client may be able to relate important symptoms, living with a chronic disease often blunts the ability to be discriminatory. Zink et al. (2000) further adds that the initial encounter with the client is critical to establishing a positive, therapeutic relationship. Establishing trust is instrumental for successful client outcomes, particularly as venous leg ulcers often involve a lengthy healing time.
Misdiagnosis of ulcers can cause harm or lead to long periods of inappropriate treatment. It is therefore important to have an accurate diagnosis of ulcer etiology (NZGG, 1999). Despite this, there is only one population study that has systematically investigated and published data on the etiology of identified ulcers.

# Recommendation - 3
Information relating to ulcer history should be documented in a structured format.
(Level of Evidence = C - RNAO Consensus Panel, 2004) An ulcer history should include:
The year first ulcer occurred.
Site of ulcer and of any previous ulcers.

# Number of previous episodes of ulceration.
Length of time taken to heal in previous episodes.
Length of time with no recurrence of ulcers.
Past treatment methods (both successful and unsuccessful).
Previous operations on venous system.
Previous and current use of compression hosiery.

# Discussion of Evidence:
Although no specific evidence was cited, the Royal College of Nursing (1998) supports the theory that collection of data in a structured format will enable consideration of clinical factors that may have an impact on treatment and healing progress, as well as provide baseline information on ulcer history. They cautioned, however, that a diagnosis of ulcer type should not be made solely on this information.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Recommendation - 4
Examine both legs and record the presence/absence of the following to aid in the assessment of underlying etiology.

# Discussion of Evidence:
Research strongly recommends that the person conducting the assessment should be aware that ulcers may result from many different causes, such as arterial insufficiencies, diabetes, rheumatoid arthritis, or malignancy. Where there is mixed venous/arterial etiology, this condition will have the features of venous ulcer in combination with signs of arterial impairment (RCN, 1998).
Several studies confirm that malignancy can cause and may be a sequel of leg ulceration (NZGG, 1999). The RNAO guideline development panel supports the practice of checking for a history of skin cancers, although little guidance is offered in the literature. Signs suggestive of malignancy include:
irregular nodular appearance of the surface ulcer raised or rolled edge rapid increase in ulcer size failure to respond to treatment.
Any unusual appearance or signs of malignancy should be documented, and if present, refer to a physician or to a dermatologist for a biopsy.
For characteristics specific to ulcer types, see:
Different Types of Leg Ulcers and Their Causes (Appendix C)

# Recommendation - 5
Measure the surface areas of ulcers, at regular intervals, to monitor progress. Maximum length and width, or tracings onto a transparency are useful methods.

# (Level of Evidence = B)

# Discussion of Evidence:
The New Zealand Guidelines Group (1999) confirms that surface area and volume measurement are indicators of ulcer healing. Common reproducible techniques, such as those described in this recommendation, closely correlate to wound area determined by computerized planimetry of photographs (a reliable and valid objective measure, but not widely available).
During an assessment, the following characteristics should be observed and recorded:

# Discussion of Evidence:
Issues relating to quality of life for leg ulcer clients have been well documented in the literature, with several studies confirming that the negative impact of venous ulcers on quality of life is significant (Phillips et al.,1994;Pieper et al., 2000;Price & Harding, 1996). Healing the ulcer and normalizing the clients' lives can and should form the basis of care (Husband, 2001a).
Increased sensitivity to, and understanding of the impact of painful venous ulcers on quality of life may lead to more effective intervention strategies and improved outcomes for these clients (Krasner, Sibbald & Coutts, 2001). Although it is widely accepted among healthcare professionals that the individual needs of the client should be considered, and that a positive management outcome will likely be influenced by client insight into the severity of the venous disorder, there has been little conclusive research done in this area. One qualitative study cited by Krasner (1998), focused on understanding and interpreting the meaning of living with a painful venous leg ulcer, and the resulting quality of life.
From the point of view of the client, quality of life is crucial in assessing the effectiveness of medical treatments (Phillips et al., 1994). Compliance Network Physicians (1999) add that compliance in clients may be enhanced as a result of regular communication in the physician-client and nurse-client interaction.
In one study conducted in Sweden, where standard questionnaires were distributed to clients, results showed that chronic leg ulcers had a marked impact on the client's subjectively perceived health. Males exhibited elevated scores, while for women the impact of leg ulcer disease, although obvious, seemed much less marked (Lindholm et al., 1992). Lindholm et al.
(1992) further added that the impact of chronic disease on health is closely related to personal, social, and environmental factors.
Research also indicates that quality of life is impacted if clients attend a leg ulcer clinic. Liew, Law & Sinha (2000) found an improvement in three quality of life indicators -pain, sleep and mobility, over an average of one to three visits to the clinic, and home visits by primary care nurses. There is also some evidence demonstrating an improvement in the quality of life resulting from healing of leg ulcers, but again, results are inconclusive.
See Appendix F for a Quality of Life Assessment Tool.

# Recommendation - 7
Assess The RNAO guideline development panel believes that the presence or absence of a social support system is important for the treatment and prevention of venous leg ulcers.

# Discussion of Evidence:
Pieper, Rossi & Templin (1998) describe how persons with leg ulcers describe interferences in their functional status and psychological well-being. They experience more pain, less vitality, more restrictions in physical and social functioning, and poorer general health and limitations in their physical and emotional roles compared with age-matched cohorts.
Pain and increased sensitivity can serve as a constant reminder of the presence of an ulcer, and contribute to sleep disturbances and decreased mobility (Liew et al., 2000). In a study where 62 individuals with chronic leg ulcers were interviewed, Phillips et al. (1994) found the leg ulcer was associated with altered mobility (81 percent of cases), burdensome care (58 percent), negative emotional impact on life such as fear, isolation, anger, depression, and negative depression (60 percent). Pieper et al. (2000) documented similar findings.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Recommendation - 8
Regular ulcer assessment is essential to monitor treatment effectiveness and healing goals. (Level of Evidence = C - RNAO Consensus Panel, 2004) Common features of venous ulcers include:
Irregular borders that are flat and slope into a shallow crater.
Loss of epidermis with a dermal base.
Base may be covered with yellow fibrin, or ruddy granulation.
Ulcer located often over medial malleolus where long saphenous vein is most superficial and has the greatest curvature. In severe cases, ulcers may extend over the circumference of the ankle.
Exudate evident and may be minimal to copious.
Periwound skin that may be dry, scaly, irritated (stasis dermatitis) or macerated.
Edema that may be pitting or firm.

# B. DIAGNOSTIC EVALUATION

# Recommendation - 9
Venous disease of the leg is most commonly detected by a combination of clinical examination and measurement of a reliably taken Ankle Brachial Pressure Index (ABPI).

# (Level of Evidence

# Recommendation - 12
Vascular assessment, such as Ankle Brachial Pressure Index (ABPI) is recommended for ulcers in lower extremities, prior to debridement, to rule out vascular compromise.
(Level of Evidence = C - RNAO Consensus Panel, 2004) 36

# Assessment and Management of Venous Leg Ulcers

# Discussion of Evidence:
The importance of making an objective etiological diagnosis by measuring the Ankle Brachial Pressure Index (ABPI), in addition to visual inspection of the ulcer, pedal pulse palpation and a thorough clinical and physical assessment, is highlighted in a number of studies (CREST, 1998a;Moffatt, Oldroyd, Greenhalgh & Franks, 1994).
Expert opinion recommends that the ABPI is used to rule out arterial disease and to determine the safe use of therapeutic compression therapy (RNAO Consensus Panel, 2004). The Royal College of Nursing (1998) also notes that all clients should be given the benefit of Doppler ultrasound management to ensure detection of arterial insufficiency, which could result in commencement of inappropriate or even dangerous therapy.
According to Zink et al. (2000), the Trendelenburg test also assists in the physical evaluation of venous valve competence in the perforators and saphenous system.
Research evidence cautions that Doppler ultrasound measurements of ABPI can be unreliable if operators have not undergone training, adding that reliability can be considerably improved if operators have received instruction and training to undertake this measure (Cornwall et al.,1986).
Based on available research from the New Zealand Guidelines Group (1999), Doppler ultrasound measurement of ABPI should be repeated when: a leg ulcer deteriorates an ulcer is not fully healed within three months clients present with recurrence (of whichever leg)
there is a sudden increase in pain colour and/or temperature of foot changes (RCN, 1998).
In addition, the New Zealand Guidelines Group (1999) recommended that:
The presence of palpable foot pulses alone are insufficient to rule out arterial disease.
All ulcers should be screened for arterial disease using Doppler ultrasound to determine the Ankle Brachial Pressure Index (ABPI). A single measure of ABPI < 0.8 makes the presence of peripheral arterial occlusive disease (PAOD) highly likely.
Further tests should be considered prior to initiating compression bandaging if a client has an ABPI > 0.8 in the presence of signs and symptoms of PAOD, rheumatoid arthritis, diabetes mellitus or systemic vasculitis.
Clients with ABPI < 0.6 should be considered for referral to a vascular surgeon.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
A Specialist medical referral may be appropriate for: clients with suspected sensitivity reactions (should be referred to a dermatologist for patch testing). Following patch testing, identified allergens must be avoided and medical advice on treatment should be sought (RCN, 1998) a non-healing or atypical leg ulcer which should be considered for biopsy (CREST, 1998a) In the case of clients with diabetes, some studies note that there may be a higher risk of peripheral vascular disease, and as a result ABPI readings may be unreliable (greater than 1.2) due to arterial calcification. As results are inconclusive, further investigation is required.

# C. PAIN

# Recommendation - 13
Assess Pain (Level of Evidence = C - RNAO Consensus Panel, 2004

# Recommendation - 14
Pain may be a feature of both venous and arterial disease, and should be addressed.

# Discussion of Evidence:
Research results consistently indicate that clients with venous leg ulcers can experience considerable pain (RCN, 1998), and that a significant proportion of clients with venous leg ulcers report moderate to severe pain. Sibbald (1998a) reports that 76 percent of severe venous ulcers are painful. In a study cited by Kunimoto et al. (2001), pain in three distinct locations was reported by clients -within ulcers, around ulcers, and elsewhere in the leg. Pain often increases when the limb is in a dependent position.
Assessment of pain is complex, but a structured discussion and frequent re-assessment are important (CREST, 1998a;SIGN, 1998). The importance of pain management in venous leg ulcer clients is often cited in the literature, yet in one particular study, 55 percent of district nurses did not assess the clients' pain.
Pieper et al. (1998) identified a need for better control of venous leg ulcer pain so people felt more confident and positive about treatment and could reduce activity restrictions, complementing the observation by Liew et al. (2000), that pain can significantly reduce clients' quality of life (see Recommendation 6).
Although utilization of a pain assessment tool is strongly recommended in the literature, no research evidence could be identified that examined the use of a pain assessment method specifically designed for clients with venous leg ulcers, or compared different methods of 39 N u r s i n g B e s t P r a c t i c e G u i d e l i n e relief. There are several samples of pain assessment tools currently available being used;
the RNAO guideline development panel does not consider one tool superior to others.

# (See Appendix G for examples of Pain Assessment Tools).
Although other pain relief strategies may be considered, there is little conclusive research on interventions such as exercise or leg elevation (RCN, 1998). However, Johnson (1995) observed that increased pain on mobility may be associated with poorer healing rates.
The presence of severe pain does not necessarily indicate arterial disease or infection, and Krasner (1998) observes that pain is often inadequately controlled in these clients. According to Scottish Intercollegiate Guidelines Network (1998), "the pain associated with a dressing change can be reduced by adequate soakage before the dressing is removed. In two trials, one of a hydrocolloid and the other of a foam dressing, the ulcer pain was less when compared with a non-adherent dressing" (p.8).
The RNAO guideline development panel has found that there is very limited guidance in the literature on how best to manage pain associated with debridement.

# D. VENOUS ULCER CARE

# Recommendation - 16

# Recommendation - 21
No specific dressing has been demonstrated to encourage ulcer healing.
(Level of Evidence = A)

# Recommendation - 22
In contrast to drying out, moist wound conditions allow optimal cell migration, proliferation,

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
Debridement is necessary to remove devitalized tissue and exudate, reduce the risk of infection, prepare the wound bed and promote healing. Debridement can be:
Autolytic, the natural self-clearance of debris in the wound bed by phagocytosis and proteolytic enzymes
Mechanical, the use of wet-to-dry dressings, hydrotherapy or irrigation with saline solution Enzymatic Sharp, using a scalpel or scissors (Fowler, 1992) Select the method of debridement most appropriate to the client's condition and goals.
Sharp debridement is a high-risk procedure. Debridement with a scalpel should be undertaken with caution and performed by specially trained and experienced healthcare professionals.
Subcutaneous debridement with a scalpel is a controlled act that must be carried out by a physician or the delegate.

# Discussion of Evidence:
There is no evidence to favour any one method of debridement, whether mechanical, autolytic, enzymatic/chemical or sharp (NZGG, 1999). Fowler (1992) states that debridement of non-viable tissue in open wounds is clearly an overlapping function of medicine and nursing, and nurses who are trained to perform this function are practicing within the scope of nursing.
There is a body of research showing a wide variation in the clinical management of venous leg ulcers through the use of dressings, however it is unlikely that a single type of dressing will be appropriate for all types of wounds (Bryant, 2001). Bryant (2001)also explains that if the dressing material transmits less moisture than the wound loses, then the wound will remain moist. Several articles confirm that there are numerous types of wound dressings, bandages, and stockings used in the treatment and prevention of recurrence (Lees & Lambert, 1992;Stevens, Franks & Harrington, 1997). The RNAO guideline development panel, however, found insufficient evidence to determine whether any particular dressing increases healing or reduces the pain of venous leg ulcers. The most important factor, according to the Royal College of Nursing (1998), is that the dressings be simple, low adherent, acceptable to the client, and low in cost.
The New Zealand Guidelines Group (1999) cautions that a number of cleansing agents currently on the market may commonly cause skin sensitivity, and that some antiseptic and chemical agents have been shown to damage cells. (See Appendix H for a list of Cleansing Agents and Their Associated Toxicities). Health professionals should also be aware that clients can become sensitized to elements of their treatment at any time (RCN, 1998). (See Appendix I for a list of Potential Allergens).
Wound cleansing can be accomplished by showering and ensuring peri-wound skin is dried carefully.
The nutritional status of clients appears to be a key factor in the management of venous leg ulcers. Several studies show a strong link between deteriorating nutritional status and the development and healing of chronic, non-healing wounds (Himes, 1999;Whitney & Heirkemper, 1999;Wissing, Unosson, Lennernas & Ek, 1997). Himes (1999) observed that clients with chronic wounds require higher intake of protein and calories, suggesting that aggressive intervention may be required to prevent malnutrition.
While the importance of specific nutrients to wound healing, including ascorbic acid, Vitamin A and zinc is well documented, the actual understanding of the precise nutritional requirements needed for tissue repair is still developing (Whitney & Heirkemper, 1999).

# Discussion of Evidence:
Avoidance of wound infection is a primary concern in the healing of acute injuries and wounds (Whitney & Heirkemper, 1999), and wound care regimens should be aimed at preventing infection, which delays healing. All wounds are colonized by a colony of bacteria, but most do not become infected. In chronic wounds, an infection should be suspected if the wound does not begin to show signs of healing.
There are numerous strategies cited in the literature regarding assessment of infection, but the Royal College of Nursing (1998) recommends that routine bacteriological swabbing is unnecessary unless there is evidence of clinical infection such as: inflammation/redness/cellulitis increased pain purulent exudate rapid deterioration of the ulcer pyrexia When a client with an ulcer develops sudden pain, a bacterial infection may be present (Kunimoto et al., 2001). An infection may be indicated based on the presence of bacteria/gram tissue (Compliance Network Physicians, 1999). The presence of bacteria in a leg ulcer, however, does not mean that it is infected as all chronic ulcers can be colonized by microorganisms which are not producing any inflammatory reaction. A diagnosis of infection should therefore be made on clinical evidence, e.g., cellulitis. Odour or increased exudate also does not necessarily indicate infection and can be managed with selective dressings. Again, a clinical assessment is recommended if infection is suspected.
There is strong support in the literature, citing clinical studies, stressing the avoidance of topical antibiotics and antiseptics to treat infections, as they are frequent sensitizers or cytotoxics (CREST, 1998a;Compliance Network Physicians, 1999;NZGG, 1999). (See Appendix H for Cleansing Agents and Their Associated Toxicities; and Appendix J for a list of Topical Antimicrobial Agents).

# F. COMPRESSION

# Recommendation - 33
The treatment of choice for clinical venous ulceration uncomplicated by other factors, is graduated compression bandaging, properly applied, and combined with exercise.
Graduated compression is the main treatment for venous eczema.

# Recommendation - 41
Bandages should be applied according to manufacturer's recommendations.

# (Level of Evidence = C -RNAO Consensus Panel, 2004)

# Recommendation - 42
When using elastic systems such as "high compression" bandages, the ankle circumference must be more than or padded to equal 18 cms.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
Discussion of Evidence:
Results of at least one randomized controlled trial recommends the use of graduated compression bandaging as the treatment of choice for clinical venous ulceration, uncomplicated by other factors (CREST, 1998a). Cotton (1996) notes that compression therapy increases skin perfusion pressure and decreases interstitial fluid volume, thereby increasing tissue oxygenation, thus promoting tissue healing.
Graduated compression may be achieved by prescribed bandages or by compression stockings.
Tensor bandages and post-operative anti-embolic stockings, e.g., TEDSTM, do not provide therapeutic compression for treatment and management of venous stasis disease. Thomas (1999) explains that these materials have limited elasticity and tend to "lock out" at relatively low levels of extension, further adding that they are not suitable for significant levels of pressure.
Compression systems must be applied correctly so that sufficient (but not excessive) pressure is applied. Incorrectly applied systems may be harmful or ineffective. CREST (1998a) in recommending the use of graduated compression bandaging, cautions that compression bandages should only be applied by a suitably trained and experienced practitioner.
Practitioners without training in compression bandages apply bandages at inappropriate and wide varying pressures (NZGG, 1999;RCN, 1998). More research is needed to see what training strategies improve compression techniques, and if the effects of training are maintained over time (RCN, 1998).
It is important to note, however, that no controlled studies have compared recurrence rates of venous ulceration achieved with or without compression hosiery, nor are there conclusive studies to indicate which high compression system (3 layer, 4 layer, or short stretch) is most effective (NZGG, 1999). The systematic review by Nelson, Bell-Syer and Cullum (2003) has found that there is no evidence to indicate that high compression hosiery is more effective than moderate compression in the prevention of ulcer recurrence. Compliance is lower in people wearing high compression stockings. From the same systematic review, it was suggested that clients should be prescribed the highest grade stocking they are able to wear. Kunimoto et al. (2001) note that recognition of significant arterial insufficiency is important, and that no healing will occur in the presence of severe occlusive arterial disease of the affected limb. Kunimoto et al. (2001) also add that the high levels of compression necessary to correct venous hypertension will be potentially dangerous in this situation.

# Assessment and Management of Venous Leg Ulcers
External compression using various forms of pneumatic compression pumps (PCPs) are indicated for individuals with chronic venous insufficiency. However, there is no strong evidence about the effects of intermittent pneumatic compression (IPC) on venous leg ulcer. In the review by Mani, Vowden and Nelson (2003), they found that there is conflicting evidence whether or not IPC can help heal venous leg ulcers.
Note: At time of publishing, this recommendation is not inclusive of elastic and non-elastic bandages (RNAO Consensus Panel, 2004).
Findings from several studies indicate that high compression bandaging should be used for venous leg ulceration, as per La Place's Law (NZGG, 1999):
La Place's Law:
The theoretical pressure produced beneath a bandage can be calculated as follows: It can be seen that sub-bandage pressure is directly proportional to the tension in the bandage during application and the number of layers applied, but inversely proportional to the radius of curvature of the limb (Logan, Thomas, Harding & Collyer, 1992).
The treatment of venous stasis disease demands the life-long use of therapeutic compression.
The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting (SIGN, 1998). Graduated compression hosiery should be prescribed for life (CREST, 1998a).
Provided the client has been measured by a certified stocking fitter for the correct size, elasticized stockings are a safe alternative to bandages. They can be full-length, but generally 49 N u r s i n g B e s t P r a c t i c e G u i d e l i n e below-knee stockings are the most frequently used, and are more acceptable to the client.
There are three classes of compression stockings. The stockings are unsuitable in clients with a high level of exudate, and are prescribed for use after compression therapy with bandages has reduced the edema. When edema and exudate are controlled, the use of therapeutic compression stockings may be considered. (See Appendix K for Classes of Compression Bandages).
The client should be prescribed regular vascular exercise by means of intensive controlled walking and exercises to improve the function of the upper ankle joint and calf muscle pump (Compliance Network Physicians, 1999;Kan & Delis, 2001).
Loss of ankle joint movement can accompany venous ulceration. Good calf muscle pump function is an important aspect of ulcer healing. Walking and passive ankle exercises should be encouraged. The immobility of the ankle joint is thought to influence ambulatory venous hypertension and may be a factor in causing venous ulceration. Exercise is necessary to enhance compression therapy. These can be modified to accommodate the needs of non-ambulatory and obese individuals. A physical and/or occupational therapist should be consulted. When resting, elevation of the limb above chest level is beneficial.

# G. COMPLEMENTARY THERAPIES

# Recommendation - 50
Consider electrical stimulation in the treatment of venous leg ulcers. (Level of Evidence = B)

# Recommendation - 51
Hyperbaric oxygen may reduce ulcer size in non-diabetic, non-atherosclerotic leg ulcers.

# (Level of Evidence = A)

# Recommendation - 52
Therapeutic ultrasound may be used to reduce the size of chronic venous ulcers.

# (Level of Evidence = A)

# Discussion of Evidence:
The clinical research evidence for complementary therapies to treat chronic venous leg ulcers is the subject of an article by Kunimoto et al. (2001).

# Assessment and Management of Venous Leg Ulcers
The New Zealand Guidelines Group (1999) reports that there is sufficient evidence to conclude that hyperbaric oxygen may reduce ulcer size in non-diabetic, non-atherosclerotic leg ulcers, and should be considered as a complementary therapy for venous leg ulcer clients.
There have been several randomized controlled trials examining the effect of ultrasound on chronic venous leg ulcers. In addition, a meta-analysis published by Johannsen, Gam & Karlsmark (1998) found a significant effect of ultrasound on wound size of chronic venous leg ulcers.
In a search of the literature, the RNAO guideline development panel also found that there is insufficient evidence to give clear direction on the use of laser therapy, maggot therapy, sugar, honey, vitamins, hormones, Vacuum Assisted Closure (VAC) Therapy TM, growth factors, mineral elements, and normalthermic therapies in the treatment of venous ulcers.

# H. REASSESSMENT

# Recommendation - 53
With no evidence of healing, a comprehensive assessment should be carried out at threemonth intervals, or sooner if clinical condition deteriorates.

# Discussion of Evidence:
Refer to a specialist (Dermatologist or Vascular physician) if there is a deterioration of the ulcer status, client status or if non-venous etiology is identified or suspected (e.g., rheumatoid disease; suspected malignancy; acute congestive heart failure (CHF); renal failure; diagnostic uncertainty; rapid deterioration of ulcers; new diagnosis of diabetes; lack of healing; recurrent ulceration; ischemic limb or foot infection; pain management; or for potential surgery).

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
The active management of leg ulcers may be required over many months or years and may be carried out by several different healthcare professionals. It is important to reassess progress 12 weeks after the institution of treatment. This should involve a comprehensive review, similar to the initial assessment. Likewise, when an ulcer recurs, a full assessment should be carried out even though the client may be well known to the nurse or doctor.

# I. SECONDARY PREVENTION

# Recommendation - 55
Measures to prevent recurrence of a venous leg ulcer include:

# Discussion of Evidence:
The majority of venous leg ulcers recur. The rates of recurrence vary, but several large population studies found 59 to 76 percent of all identified ulcers were recurrent (NZGG, 1999).
Secondary prevention must be put into place and maintained in order to prevent this recurrence.
Secondary prevention presently takes the form of graduated compression, surgery, or drugs.
With graduated compression, it is important to take note that not all stockings produce an adequate pressure. Stockings are more effective when client adherence is taken into account.
The hazards of incorrectly fitting stockings are the same as those of improperly applied compression bandages.
In order to maintain a proper level of compression, stockings should be replaced every 3 to 6 months as per manufacturer's instructions. If a stocking is uncomfortable a change of the brand of stocking within the same class of stocking may be beneficial to the comfort and compliance of the client.

# Education Recommendations

# Recommendation - 57

# Recommendation - 63
The knowledge and understanding of the healthcare professional is a major factor in adherence to treatment regimens.
(Level of Evidence = C - RNAO Consensus Panel, 2004) 54

# Assessment and Management of Venous Leg Ulcers

# Discussion of Evidence:
Research using non-randomized comparison groups on pre-and post-test designs have shown that community nurses' knowledge of leg ulcer management is often inadequate, but that knowledge can be improved by provision of training (RCN, 1998).
In an article by Ruane-Morris (1995), programs of continuing support and education offer an alternative to discharge and loss of contact for clients in the United Kingdom. All clients with a healed ulcer and an ABPI of 0.8 or greater, are invited to participate in Healed Ulcer Groups (HUGS). The program focuses on daily life activities, exercise and movement, skin care, and the reasons for developing ulcers, with a goal to shifting clients from nurse-led to self-directed care.

# Organization & Policy Recommendations

# Evaluation & Monitoring
Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and - Cost for treatments.
- To evaluate the supports available in the organization that allow for nurses to integrate into their practice the assessment and management of venous leg ulcers.
- Review of best practice recommendations by organizational committee(s) responsible for policies and procedures. - Availability of client education resources that are consistent with best practice recommendations. - Provision of accessible resource people for nurses to consult for ongoing support during and after initial implementation period.
- Percentage of nurses attending the best practice guideline education sessions on assessment and management of venous leg ulcers.
- Percentage of clients admitted to unit/facility or seen at the clinic with venous leg ulcers.
- Cost related to equipment and products (e.g., Doppler, bandages).

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e Implementation Tips
This best practice guideline was pilot tested in a chronic care hospital and community care setting. There were many strategies that the pilot sites found helpful during the implementation, and those who are interested in implementing this guideline may consider these strategies or implementation tips. A summary of these strategies follows:
Have Samples of these implementation tools developed by the pilot sites can be found at the RNAO website, www.rnao.org/bespractices.
Organizational support, such as having the structures in place to facilitate the implementation.
For examples, hiring of replacement staff so participants would not be distracted by concerns about work, and having an organizational philosophy that reflects the values of best practices through policies and procedures and documentation tools.

# Assessment and Management of Venous Leg Ulcers
Organizations implementing this guideline should look at a range of self-learning, group learning, mentorship and reinforcement strategies that will, over time, build the knowledge and confidence of nurses in implementing this guideline.
Beyond skilled nurses, the infrastructure required to implement this guideline includes access to specialized equipment and treatment materials. A vigilant monitoring of the most effective pressure bandage products in the market needs to be established. A formal allocation of this monitoring activity to an appropriate staff or team is required.
Timely access to Doppler ultrasound measurements is essential to proper assessment.
Staff using the Doppler must have appropriate training and make frequent use of their skills in order to maintain a high standard of quality.
Orientation of the staff to the use of specific products must be provided and regular refresher training planned.
Teamwork, collaborative assessment and treatment planning with the client and family and through interdisciplinary work are beneficial in implementing guidelines successfully.
Referral should be made as necessary to the following services or resources in the community or within the organization: Wound Care Clinic, Wound Care Specialist or Enterostomal Nurse, Dermatologist, Infectious Disease Specialist, Vascular Surgeon, Plastic Surgeon, Other healthcare professionals who provide care to clients with venous leg ulcers such as family physician, dietitian, occupational therapist, physiotherapist, chiropodist/podiatrist, and Certified Compression Stocking fitter.
The RNAO's Advanced/Clinical Practice Fellowships (ACPF) Project is another way that registered nurses in Ontario may apply for a fellowship and have an opportunity to work with a mentor who has expertise in venous leg ulcer management. With the ACPF, the nurse fellow will have the opportunity to hone their skills in assessing and managing venous leg ulcers.
In addition to the tips mentioned above, the RNAO has developed resources that are available on the website. A toolkit for implementing guidelines can be helpful if used appropriately.
A brief description of this Toolkit can be found in Appendix L. A full version of the document, in pdf file, is also available at the RNAO website, www.rnao.org/bestpractices.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
Process For Update/ Review of Guideline
The Registered Nurses Association of Ontario proposes to update the Best Practice Guidelines as follows:
- Following dissemination, each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area every three years following the last set of revisions.

# During the three-year period between development and revision, RNAO Nursing Best
Practice Guideline project staff will regularly monitor for new systematic reviews, metaanalysis and randomized controlled trials (RCT) in the field.
- Based on the results of the monitor, project staff may recommend an earlier revision period.
Appropriate consultation with a team of members, comprised of original panel members and other specialists in the field, will help inform the decision to review and revise the best practice guideline earlier than the three year milestone.
- Three months prior to the three year milestone, the project staff will commence the planning of the review process as follows:
a) Invite specialists in the field to participate in the Review Team. The Review Team will be comprised of members from the original panel, as well as other recommended specialists.
b) Compilation of feedback received, questions encountered during the dissemination phase, as well as other comments and experiences of implementation sites. c) Compilation of new clinical practice guidelines in the field, systematic reviews, meta-analysis papers, technical reviews and randomized controlled trial research.
d) Detailed work plan with target dates for deliverables will be established.
The revised guideline will undergo dissemination based on established structures and processes.
The presence of bacteria or other microorganisms in sufficient quantity to damage tissue or impair healing. Clinical experience has indicated that wounds can be classified as infected when the wound tissue contains 10 5 or greater microorganisms per gram of tissue. Clinical signs of infection may not be present, especially in the immuno-compromised client or the client with a chronic wound.

# Local Clinical Infection.
A clinical infection that is confined to the wound and within a few millimeters of its margins -e.g., purulent exudate, odour, erythema, warmth, tenderness, edema, pain, fever, and elevated white cell count.

# Systemic Clinical Infection.
A clinical infection that extends beyond the margins of the wound. Some systemic infectious complications of pressure ulcers include cellulitis, advancing cellulitis, osteomyelitis, meningitis, endocarditis, septic arthritis, bacteremia, and sepsis. See Sepsis.
Inflammatory Response: A localized protective response elicited by injury or destruction of tissues that serves to destroy, dilute, or wall off both the injurious agent and the injured tissue. Clinical signs include pain, heat, redness, swelling, and loss of function.
Inflammation may be diminished or absent in immunosuppressed clients.
A process where healthcare professionals representing expertise from various healthcare disciplines participate in a prevention or treatment based program standardizing and practising pressure ulcer management.
Intermittent Claudication: Pain that occurs only with moderate to heavy activity and is relieved by 2 to 5 minutes of rest.
Irrigation: Cleansing by a stream of fluid, preferably saline, with sufficient surface pressure to mechanically debride wound surface debris.
Ischemia: Deficiency of blood supply to a tissue, often leading to tissue necrosis. A bandage applied with constant tension to a limb of normal proportions will automatically produce graduated compression with the highest pressure at the ankle. This pressure will gradually reduce up the leg as the circumference increases.

# Leucocytoclastic Vasculitis:
A vasculitis that results from leucocytoclasis, which is the disintegration of leucocytes.
Lipodermatosclerosis: Deposit of fibrin in the deep dermis and fat, resulting in a woody induration (woody fibrosis) of the gaiter area of the calf. May attribute to the inverted champagne bottle appearance of the lower leg.
Low Resting Pressure: When the muscle is relaxed, superficial veins are able to fill.
Lymphoedema: Edema and secondary skin changes resulting from lymphatic failure.
The breakdown of the epidermis (skin) as a result of prolonged exposure to moisture.
Malleolus: Ankle bone.
Malnutrition: State of nutritional insufficiency due to either inadequate dietary intake, or defective assimilation or utilization of food ingested.

# Assessment and Management of Venous Leg Ulcers
Microbiologic States of the Wound:
- Clean -Free of bacterial proliferation eliciting no response from the host.
- Contamination -The presence of bacteria on the wound surface without proliferation.
- Colonization -Presence and proliferation of bacteria eliciting no response from the host.
- Infection -Invasion of bacteria which proliferates and elicits a response from the host e.g., erythema, pain, warmth, edema, exudates (Gilchrist, 1997).
Moisture: In the context of this document, moisture refers to skin moisture that may increase the risk of maceration and impair healing of existing ulcers. Primary sources of skin moisture include perspiration, urine, feces, drainage from wounds, or fistulas.    A10. Edges -Definition: Indistinct borders -where you would not be able to trace the wound edge.
1 More than half of advancing borders may be indistinct because most of wound is epithelializing.
Advancing wound edge is 2 Less than half of the wound edge is advancing (the process of epidermal resurfacing appears smooth and shiny).  The patient rates pain on a scale from 0 to 10.

# SAMPLE 3 -Verbal Rating Scale (VRS)
No The patient rates the pain on a Likert scale verbally, e.g. "none", "mild pain", "moderate pain", "severe pain", "very severe pain" or "worst possible pain".
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# PRN medication
Behaviour Checklist: Behaviour changes can be used to assess pain or distress, and thereby evaluate the efficacy of interventions. At the top of the scoring graph, when the specific behaviour has been observed, it can be rated from 10 (always) to 0 (never). The behaviours being rated and scored over 24 hours are listed down the left column. This chart scores 9 different behaviours over 14 days. The caregiver can expand on the checklist, i.e., rocking, screams, etc. Note if rescue/PRN medication given. Both tools may be adapted for individual use.
Reprinted with permission. Brignell, A. (Ed) (2000). Guidelines for developing a pain management program. A resource guide for long-term care facilities, 3rd edition.  (Hirsch et al., 2006). For example, an ABPI >1.3 is considered indicative of noncompressible vessels that are found in individuals with diabetes, chronic renal failure and who are older than 70 years of age. In these cases, compression therapy may not be recommended.
Additional Literature Supports Hirsch et al., 2006;Partsch & Partsch, 2005;Schroder & Diehm, 2006 Recommendation 7
Prior to debridement, vascular assessment, such as Ankle Brachial Pressure Index (ABPI), is recommended for ulcers in lower extremities to rule out vascular compromise and ensure healability.

# (Level C)
The wording of this recommendation has been modified to indicate that vascular assessment (including ABPI) may also provide information regarding the healability of the wound. Adequate perfusion to these wounds indicates that healing is supported by the microvascular supply and that debridement, when appropriate, may be safely performed.

# Practice Recommendations: Pain Recommendation 8
Pain may be a feature of both venous and arterial disease, and should be addressed.

# (Level B)
A comprehensive approach to pain is beyond the scope of this guideline. Refer to the RNAO Best Practice Guideline Assessment and Management of Pain (Revised) (RNAO, 2007) for strategies by which to address pain.
Additional Literature Supports Charles, 2002;Nemeth et al., 2004

# Recommendation 9
Prevent or manage pain associated with debridement. Consult with a physician and pharmacist as needed.
(Level C)  Prior to commencing wound care, a treatment plan must be developed based on the goals of care for the particular client. The healing potential of the wound is one factor that may impact on the goals of care. Potential for healing is affected by local, host, and environmental factors. For any issues identified in the assessment that may impair healing, a plan needs to be developed that addresses these as well. Appendix N (page 16 of this supplement) provides a list of factors that may impact healing potential.

# Recommendation 11
Local wound bed preparation includes debridement when appropriate, moisture balance and bacterial balance.
(Level C) 6 + +
The panel strongly recommends a systematic approach to wound care. The aim of local wound bed preparation is the removal of barriers to healing. Appendix O (page 17 of this supplement) outlines important considerations when preparing the wound bed.
Not all wounds require debridement. The need for debridement is based on the goals of the client. Other issues when considering the appropriateness of debridement include the practice setting, skill of the clinician and the ability of the patient to tolerate the procedure. When choosing between particular techniques, considerations should include type, quantity and location of nonviable tissue, the depth of the wound, the amount of wound fluid and the general condition and goals of the client. Appendix P (page 17 of this supplement) compares the methods of debridement based on several key considerations. Refer to the original guideline (RNAO, 2004) for a more detailed discussion of debridement.
Moisture balance refers to the management of exudate and maintenance of fluids in the wound bed. When healing is the goal, a balanced moist wound environment ensures that there is sufficient moisture to facilitate cellular growth but not in excess to cause further skin breakdown. The primary approach to achieving moisture balance is through the appropriate use of moisture-balancing dressings (Okan et al., 2007).
Bacterial balance describes the bacterial level present in a wound and their ability to cause damage or infection. All chronic wounds contain bacteria. However, the impact of these bacteria on healing is dependent on several factors, including the number of organisms, the virulence of these organisms and host resistance (Sibbald, Woo, & Ayello, 2006).
Promoting host resistance, through optimizing overall health of the client, is an important aspect of achieving bacterial balance. The management of existing infection is addressed in the following section of this supplement.
Additional Literature Supports Sibbald, Woo, & Ayello, 2006;Okan et al., 2007

# Recommendation 12
Cleansing of the ulcer should be kept simple; warm tap water or saline is usually sufficient.

# Recommendation 13
First-line and uncomplicated dressings must be simple, low adherent, acceptable to the client and should be cost-effective.

# (Level A)
A recent systematic review by Palfreyman et al. (2007) found insufficient evidence to support the use of a particular first-line and uncomplicated dressing type (beneath compression therapy) for the treatment of venous leg ulcers. As such, the authors suggested that decisions regarding dressings should be based on local costs and practitioner or patient preferences (Palfreyman et al., 2007). Similarly, the RCN guideline (2006) states that for patients not requiring frequent compression bandaging, the cost-effectiveness of the dressing will be related to its ability to remain in place and manage the exudate. The wording of this recommendation was modified to reflect a consideration of cost-effectiveness when choosing a dressing.
In a systematic review by O' Donnell and Lau (2006), despite the findings that certain complex wound dressings resulted in better outcomes in both the proportion of ulcers healed and time to healing, the authors maintained that the selection of the specific dressing will depend on the dressing characteristics for ease of application, patient comfort, wound drainage absorption and expense.

# Additional Literature Supports
O' Donnell & Lau, 2006;Palfreyman et al., 2007;RCN, 2006;Schulze et al., 2001;Smith et al., 2004;Vanscheidt, Sibbald, & Eager, 2004;Vin, Teot, & Meaume, 2002

# Recommendation 14
Avoid products that are known to cause skin sensitivity, such as those containing lanolin, phenol alcohol, or some topical antibiotic and antibacterial preparations. The wording of this recommendation has been modified to indicate that not all topical antibiotic and antibacterial preparations are known to cause skin sensitivity. The change in the wording is for clarification only, and there has been no change in the intent of the recommendation.

# Recommendation 15
Choose a dressing that optimizes the wound environment and patient tolerance.

# (Level C)
This recommendation was revised to indicate that there are many considerations when choosing an appropriate dressing. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound (Palfreyman et al., 2007).
Additional Literature Supports Palfreyman et al., 2007;Schulze et al., 2001 Recommendation 16
No specific dressing has been demonstrated to encourage ulcer healing.
Additional Literature Supports Nelson, Cullum, & Jones, 2006;O'Donnell & Lau, 2006;Palfreyman et al., 2007;Vin, Teot, & Meaume, 2002;Wollina et al., 2005

# Recommendation 17
In contrast to drying out, moist wound conditions allow optimal cell migration, proliferation, differentiation and neovascularization.

# Recommendation 18
Refer clients with suspected sensitivity reactions to a dermatologist for patch testing. Following patch testing, identified allergens must be avoided, and medical advice on treatment should be sought.

# (Level B)
The panel notes that for most nurses, referral is outside their scope of practice. However, nurses are encouraged to advocate for appropriate referrals as necessary.

# Recommendation 19
Venous surgery followed by graduated compression hosiery is an option for consideration in clients with superficial venous insufficiency.
The level of evidence has been updated in the context of recent research that indicates a significant reduction in ulcer recurrence after venous surgery for clients with superficial venous insufficiency.
Additional Literature Supports Barnwell et al., 2004;Obermayer et al., 2006;Roka, Binder, & Bohler-Sommeregger, 2006;Ting et al., 2006;van Gent et al., 2006

# Assess for signs and symptoms of infection (Level A)
The wording of this recommendation was modified to appropriately reflect nurses' scope of practice. It is imperative that the assessment and treatment of infection be addressed as it can influence the plan of care, such as the use of local dressings, compression modalities and adjunctive therapies. Refer to Appendix Q (page 18 of this supplement) for a list of signs and symptoms of infection.

# Recommendation 21
Manage wound infection with cleansing and debridement, as appropriate. Where there is evidence of cellulitis, treatment of infection involves systemic antibiotics.

# (Level B)
This recommendation, which reflects a combination of original Recommendations 29 and 30, was modified based on infectious disease guidelines and current evidence. Cellulitis is characterised by the presence of some of the following signs or symptoms: pyrexia, increasing pain, increasing erythema of surrounding skin; purulent exudate; and rapid increase in ulcer size.
Additional literature supports Cutting and White, 2005;Gardner, Franz, & Doebbeling, 2001;Grayson et al., 2002;Rosser et al., 2005;

# Recommendation 22
The use of topical antiseptics to reduce bacteria in wound tissue should be reserved for situations in which concern for bacterial load is higher than that of healability.

# (Level C)
This recommendation has been modified in the context of current evidence that suggests that the use of topical antiseptics may be beneficial for short term use, particularly when bacterial levels are sufficiently high to cause tissue destruction and the goal of care is the maintenance of the wound. Some antiseptics have been shown to be safe and efficacious for this purpose in wound care. Appendix R (page 18 of this supplement) provides a summary of evidence for various antiseptics.
Additional literature supports Drosou, Falabella & Kirsner, 2003 Practice Recommendations: Compression  The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting compression stockings. (Level B)  Ankle circumference should be measured at a distance of 2.5 cm (one inch) above the medial malleolus. (Level C) Original Recommendations 33, 34, 35, 43 & 44 have been combined and modified to emphasize important considerations when providing compression therapy in the care of venous ulceration. This recommendation no longer addresses care of venous eczema as treatment approaches for conditions that could lead to ulceration, dermatological or otherwise, was beyond the scope of the current review. The level of evidence for original + + + + Recommendation 44 has also been updated to reflect current knowledge. The panel notes that despite the evidence to support the use of high compression bandages for the treatment of uncomplicated venous ulcers, there is insufficient evidence to support the choice between using elastic versus non-elastic bandaging systems.
Additional Literature Supports Brooks et al., 2004;Edwards et al., 2005;Franks et al., 2004;Iglesias et al., 2004;Nelson, Cullum, & Jones, 2006;Nelson et al., 2004;O'Brien et al., 2003;Padberg, Johnston, & Sisto, 2004;Partsch & Partsch, 2005;Partsch et al., 2001;Polignano, Guarnera, & Bonadeo, 2004

# Recommendation 24
External compression applied using various forms of pneumatic compression pumps can be indicated for individuals with chronic venous insufficiency.

# (Level A)
The wording of this recommendation has been modified to emphasize the need for clinical judgement in determining whether this treatment is appropriate for a particular client. The change in the wording is for clarification only, and there has been no change in the intent of the recommendation.
Where 1 is most desirable and 5 is least desirable.

# Effect on Clinical Actions

# Appendix A: Appendix C: Different Types of Leg Ulcers and Their Causes
Arterial leg ulcers are caused by insufficient arterial blood supply to the lower limb, resulting in ischemia and necrosis. A vascular assessment is required to establish the location and extent of the occlusion and presence of small vessel disease. The client may require angioplasty or major vascular surgery.
Rheumatoid ulcers are described as deep, well demarcated and punched-out in appearance.
Persons with rheumatoid arthritis may develop vasculitis, which causes occlusion of small vessels leading to tissue ischemia. Ulcers resulting from vasculitis tend to have a purplish hue around the edges.
Diabetic ulcers are usually found on the foot, often over bony prominences such as the bunion area or under the metatarsal heads and usually have a sloughy or necrotic appearance.
An ulcer in a diabetic client may have neuropathic, arterial and/or venous components. It is essential to identify underlying etiology. The Doppler measurement of the ABPI may be unreliable in the diabetic client if calcification prevents compression of the artery. Therefore, specialist assessment is required.
Malignancy is a rare cause of ulceration, and more rarely, a consequence of chronic ulceration.
Ulcers with atypical site and appearance such as rolled edges, or non-healing ulcers with a raised ulcer bed should be referred for biopsy.

# Reprinted with permission.
Ottawa-Carleton Community Care Access Centre Leg Ulcer Care Protocol Task Force (2000).
Ottawa-Carleton Community Care Access Centre (CCAC) venous leg ulcer care protocol: Development, methods and clinical recommendations. Ottawa, Ontario: Ottawa-Carleton CCAC Leg Ulcer Protocol Task Force.

# Prognostic indication:
The prognostic indication considers the benefits and risks, requirements, and outcomes of the selected therapy. It takes into account the patient compliance, the physical, cognitive and emotional state, the social integration in the family, the circle of acquaintances and the living conditions together with the everyday and occupational capabilities of the patient.
A treatment plan is produced with therapeutic aims broken down into separate aims. The necessary cooperation of the patient is allocated to the various parts of the break-down.  Toxicity Index 10 10 100 100 100 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Toxicity Index 1,000 10,000 10,000 10,000 10,000 10,000 10,000

# Appendix I: Potential Allergens

# Commonly Reported Allergens In Patients With Chronic Ulcers
Reprinted with permission from Dr. Gary Sibbald.

# Many creams, ointments and emollients
Present in many creams preparations e.g., in aqueous cream and some corticosteroid cream. Also in some ointments e.g., emulsifying ointment, and in some paste bandages.
Sticking plaster, adhesive in some bandages and some hydrocolloid dressings.
Bandages, tubular elastic bandages, elastic stockings containing natural rubber and latex gloves worn by carer In many medicaments and some paste bandages Solutions, creams, tulles Home care preparations: a. with perfume b. with local anaesthetic action Marker of corticosteroid hypersensitivity particular to hydrocortisone 107 N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e Appendix K: Classes of Compression Bandages
Below are examples of compression bandages commonly used in the management of venous leg ulcers: Performance Characteristics Sustained compression; can be worn continuously for up to 1 week; can be washed and re-used, but may slip. Can use flexible cohesive for slippage. Designed to apply 40 mmHg pressure at the ankle, graduating to 17 mmHg at the knee; sustainable for 1 week. Reusable with slight stretch giving low resting pressure but high pressure during activity. Non compliant, plaster-type dressing. Need ankle mobility if slippage problem. Bandages can be made by combining Kling and a Tensor (spiral or figure 8) and a flexible cohesive bandage on top. Components can be re-used. Self-adherent to prevent slippage; useful over non-adhesive bandages such as elastocrepe and paste bandages; compression well sustained. Provides approximately 23 mmHg or higher at the ankle graduating to approximately one-half this pressure at the knee. Low pressure obtained; used alone it gives only light support; a single wash reduces pressure by about 20 percent. For holding dressings in place, as a layer within the multilayer bandage, for light support of minor strains and sprains; pressures alone are too low to be effective in management of venous ulcers; 40 to 60 percent of pressure lost in first 20 minutes after application. Notes: 1. Applying in a figure 8 increases compression by 10 to 15 mmHg over spiral, for any bandage. 2. Latex-free products -Unna's paste boot and other specially marked latex-free products. 3. Supportinelastic bandages usually require more frequent changing with reduced edema. 4. Inform clients to notify healthcare professional if there is pain in foot, or if it turns blue or black.

# Type of Compression

# Appendix L: Description of the Toolkit

# Toolkit: Implementation of Clinical Practice Guidelines
Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation.
RNAO, through a panel of nurses, researchers and administrators has developed a Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.
The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps:
- Identifying a well-developed, evidence-based clinical practice guideline.
- Identification, assessment and engagement of stakeholders.
- Assessment of environmental readiness for guideline implementation.
- Identifying and planning evidence-based implementation strategies.
- Planning and implementing evaluation.
- Identifying and securing required resources for implementation.
Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
The Toolkit is available through the Registered Nurses Association of Ontario. The document is available in a bound format for a nominal fee, and is also available free of charge from the RNAO website. For more information, an order form or to download the Toolkit, please visit the RNAO website at www.rnao.org/bestpractices. This supplement should be used in conjunction with the guideline as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.