vlu.wocn.orgWound Ostomy and Continence Nurses Society™ WOCN®

-- -- Wound, Ostomy and Continence Nurses Society™ Compression for Primary Prevention, Treatment and Prevention of Recurrence of Venous Leg Ulcers An Evidence- and Consensus-based Algorithm for Care Across the Continuum Get Started Funded through an unrestricted educational grant from JOBST/BSN medical: Back -- -- Skin & Pressure Ulcer Risk Assessment -- An Evidence- and Consensus-based Algorithm Compression therapy is the cornerstone of treatment for CVI. Compression has been shown to improve healing rates in patients with existing venous leg ulcers (VLU) and reduce the likelihood of VLU recurrence. In an effort to customize compression therapy for each individual with CVI, the Wound, Ostomy and Continence Nurses Society™ (®) set out to develop an evidence- and consensus-based algorithm on Compression for Primary Prevention, Treatment and Prevention of Recurrence of Venous Leg Ulcers. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article. The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. Tap or click the "Back" button to return to the previous page or step. Tap or click the home icon to return to the beginning. Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. A hand icon will guide you to the next step in the algorithm. You cannot proceed until the hand disappears. Tap or click any number to return to that step in the process. Tap or click the "Full Screen" button to optimize the fit to your device's viewable area. Clinical Assessment of Lower Extremities Health History triggers (e.g., injury to leg, cellulitis, dry skin with itching, etc.) risk factors (e.g., family history, previous deep vein thrombosis, surgery/trauma to leg, etc.) comorbid conditions (e.g., obesity, impairment of calf muscle pump, varicose veins, sickle cell disease, etc.) Physical assessment: Examination of both lower extremities noting condition of the skin, hemosiderosis, ankle range of motion and calf muscle strength, functional mobility, extent and location of edema, superficial vascular changes, presence of any wounds, capillary refill < 2 seconds and palpation of pulses. Obtain appropriate studies such as Ankle Brachial Index (ABI)/Ankle Brachial Pressure Index (ABPI) to exclude significant arterial disease. Refer to ABI Procedure and Value Table. * ABI Procedure and Value Table Conduct differential diagnosis (Refer to LEVD Appendices C: Differences between Edema, Lymphedema, & Lipedema and D: Venous Eczema and Cellulitis located in Society Guideline for Lower-Extremity Venous Disease [2011]) Refer to Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide (2017) * Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide * Society Guideline for Lower-Extremity Venous Disease: Appendix C: Differences between Edema, Lymphedema, & Lipedema and Appendix D: Venous Eczema and Cellulitis What do your findings indicate? Chronic venous insufficiency Disease or wound of other etiology (e.g., lymphedema, lipedema, arterial, or neuropathic) Refer to Society document: Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide *2017 Society document: Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide Refer to CEAP table to determine severity of chronic venous insufficiency * Refer to CEAP table No wound (CEAP 1-4) or healed wound (CEAP 5) Active wound (CEAP 6) No visible or palpable signs of venous disease (CEAP 0) Proceed to the CEAP 1-2 pathway Proceed to the CEAP 3-4 pathway Proceed to the CEAP 5 pathway Educate patient and family about lifestyle factors that promote leg health including effects of smoking, advise smoking cessation following healthy nutrition practices such as weight management avoiding mechanical trauma to leg avoiding crossing legs, prolonged sitting or standing exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program) avoiding wearing high heels. Manage Signs/Symptoms per Facility Protocol OR Clinical Guideline Here is your result Patient should be reassessed at least annually to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes). Test again Determine need for compression based on symptoms (i.e., burning, itching, heaviness, aching, or pain) Compression is needed Compression is not needed Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg. Refer to Tables: Compression Therapies , Compression Stocking Classifications , Formulary of Compression Therapy Products Special Considerations for Compression . Evidence of prior deep vein thrombosis No evidence of prior deep vein thrombosis Clinical Assessment of Lower Extremities -- Educate patient and family/caregiver about: effects of smoking, advise smoking cessation avoiding mechanical trauma to leg avoiding prolonged sitting or standing exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program) extremity elevation prevention of trauma appropriate footwear (e.g., avoid high heels) nutrition, weight management use of non-sensitizing emollients to prevent dermatitis Here is your result Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage). Test again Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers. When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations. Clinical Assessment of Lower Extremities -- Educate patient and family/caregiver about: effects of smoking, advise smoking cessation avoiding mechanical trauma to leg avoiding prolonged sitting or standing exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program) extremity elevation prevention of trauma appropriate footwear (e.g., avoid high heels) nutrition, weight management use of non-sensitizing emollients to prevent dermatitis use of compression stockings/devices Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers. Refer to ABI/ABPI If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression. In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance. If ABI/ABPI < 0.5 or > 1.3, do not use compression. Initiate referral for evaluation and management of significant arterial disease. Educate patient and family/caregiver about: effects of smoking, advise smoking cessation avoiding mechanical trauma to leg avoiding leg elevation exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program) appropriate footwear nutrition, weight management use of non-sensitizing emollients to prevent dermatitis use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table) Here is your result Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circul...