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Chronic Wound Management: Knee Ulcers

Keywords: wound management nursing, leg ulcers medical, venous calf ulcers


This article is an integral part of the study of nursing practices in chronic Wound Management based on venous lower leg ulcers. The essay covers the various aspects of this particular condition, its symptoms, triggers, consequences, various treatment treatments in the united kingdom and costs incurred by NHS every year in dealing with Venous Calf Ulcers. The analysis commences with an intro to the Venous Leg Ulcer, its explanation, symptoms, percentage of prevalence in the United Kingdom and is supposed to acquire an insight to efficient wound management practices.

Venous Lower leg Ulcers:


According to the information provided by the NHS on Venous leg ulcers, a lower leg ulcer can be an area of ruined skin area below the knee on your knee or ft. that takes longer than six weeks to heal. The most common type of knee ulcer is a venous knee ulcer, accounting for 80-85% of all cases, costly to treat, and respond better to early prognosis and treatment.

When veins in one's thighs do not work properly it is termed venous insufficiency and causes venous calf ulcers and are due to the major risk factors like diabetics, over weight, genealogy and lifestyle. Venous leg ulcers are more popular among the elderly set alongside the youth. As Myers (2004, p. 230) points out that 'women are three times more likely than men to have a venous insufficiency ulcer'. Among the major implication of Venous calf Ulcer is that it is a chronic wound with poor treatment system and its likely that high for a recurrence.


The main symptoms of a venous calf ulcer are itching, bloating, eczema, aching, pain, edema and varicose veins.

Management of the Wound:

According to Vowden (2010), there are four phases to effective leg ulcer management: examination, treatment, review of progress and management of the healed ulcer. Hartmann (2008) says venous lower leg ulcer is a chronic wound with a poor or absent curing tendency which chronic wounds like venous knee ulcer also heal in a phase-specific manner. No matter the sort of wound and the extent of tissue reduction, every wound healing process proceeds in phases which overlap with time and cannot be separated from one another. Used, the three phases of wound treatment are recognized for short as the detoxification, granulation and epithelisation stage.


According to Hartmann (2008, p. 16) a precise diagnosis is essential since 'about 90 % of lower leg ulcers develop because of this of venous hypertension extra to severe chronic venous insufficiency and about 6 % of the venous knee ulcers are attributable to reduced peripheral arterial blood circulation and about 4 % to specific epidermis diseases. This requires taking a detailed medical history, a professional medical and instrumental assessment and differential diagnostic methods to rule out non-venous etiopathological factors. '

Doppler studies:

Doppler review is a test carried out to verify a diagnosis of venous lower leg ulcer conducted on both of the patient's legs to check for arterial insufficiency (high blood pressure anticipated to poor blood circulation). Like venous insufficiency, arterial insufficiency refers to blood not flowing properly through your arteries. Signals of arterial insufficiency include hair loss in the damaged area and the skin in the afflicted area being pale and cool to the touch. However, there are some conditions like diabetes, atherosclerosis, systemic vasculitis, arthritis rheumatoid etc that can make the results of Doppler studies unreliable in which case a specialized treatment is required. According to Hartmann Medical Release (2008), the one technique which can offer further diagnostic information in this situation is acral oscillography or possibly coloring duplex sonography.


The treatment plans for venous leg ulceration are diverse and contentious, which range from topical realtors, compression therapy, pharmaceuticals and surgery, to natural treatments and healthy intervention. Treatment goals should be to decrease the bloating, any pressure in the veins focused on a recovery with minimized complications. Since ulcers can be of both arterial and venous insufficiency a carefull and in depth assessment is required befire deciding the treatment option. Where there is absolutely no arterial problem, treatments can be based on exercise, elevation of the knee at leftovers positions and compression remedy.

Vowden (2010) is of the thoughts and opinions that peri-wound pores and skin management is important, particularly if high degrees of exudate can be found. Topical steroids aren't required. Pain management is an important aspect in treatment. Increasing pain can suggest a growing bacterial load, peri-wound skin surface damage or bandage problems, and really should be investigated rapidly.

Cleaning the wound

No subject what the reason for the ulcer, careful skin care, and detoxification of the wound are essential. Hartmann (2008) says experience has shown that this first phase needs great patience and can need more time to complete the longer the ulcer has been around. Rigorous cleansing of the wound bed runs the chance of damaging new, fragile muscle but gentle detoxification of the encompassing skin will reduce the risk of excoriation.

Wound dressings

There is a whole range of professional dressings available to assist with the various periods of wound curing grouped as non-absorbent, absorbent, debriding, self-adhering etc. Dressings are usually occlusive as ulcers heal better in a moist environment. Generally, it is found that dressing selection appears to have little effect on ulcer restoration rates and that a simple non-adherent dressing is usually sufficient. Vowden (2010) in his work has assessed the EWMA position documents determining standards for wound infection which found that antimicrobial dressings may be required if a growing bacterial weight is suspected or local infection exists. Briggs et al (2010) are of the view that 'as these ulcers are often unpleasant some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to lessen the pain both during and between dressing changes'.


In cases where the venous ulcers do not heal with conservative methods so when the ulcers are large and unpleasant, surgery is opted. Assessments of the venous and arterial systems are first completed and then any an infection is cared for, and thereafter any underlying risk factors should be controlled. In some patients, the ulcers fail to heal independently and require surgery which is done by skin grafting i. e. taking epidermis from anywhere else on the patient's body and positioning it over the ulcer.

Compression therapy

Compression therapy is an important area of the management of venous knee ulcers and serious swelling of the lower leg. This setting of treatment helps in healing around 40-70% of serious venous ulcers usually within 12 weeks. Compression is not used if the ABPI is below 0. 8 or when there is an arterial disease. In a study conducted by Vowden (2010), the info provided by WUWHS (2008) is analyzed and as such it is available that a amount of factors, such as the practitioner's knowledge and skill, the limb condition and the materials used, as well as patient popularity influence the application of effective compression. These factors will also effect the individual experience, patient results and treatment costs. Hosiery may be considered a suitable alternative for some patients with small ulcers and low degrees of exudate, and its role along with that of intermittent pneumatic compression is layed out by the WUWHS (2008).

In the view of Susan (EWMA 2008) Needs to be attained for compression therapy are high level of basic safety, high patient compliance, highest healing rate, ecological sub-bandage pressure, socio-economical (employees time put in, bandages, lost earnings). Susan (EWMA 2008) in her work examines the study on compression therapy completed by Satpathy et al in whose judgment compression must be employed with the correct sub-bandage pressure cf. ankle-brachial pressure index ABPI. If elastic, inelastic or multi-layer bandages are being used, the outcome will depend on the applying nurse's estimation of how to apply the bandage, resulting in possible ineffective treatment if the bandages are applied too loosely and risking severe personal injury if the bandages are applied too firmly. This risk can be prevented by using bandages with pressure indicators and/or by teaching staff how to apply the bandages with a sub-bandage pressure calculating device, which can be used in daily habit specialized medical practice. Hosiery supplies the highest degree of assurance for appropriate sub-bandage pressure.

Elastic and Inelastic Bandages:

Although compression is a cornerstone for dealing with venous-ulcerated patients, medical researchers declare that there are extensive restrictions to its use, such as pain and intolerance, leading to poor conformity. Elastic stockings have been reported to be not tolerated primarily in hypersensitive areas adjacent to an active wound or in a previously healed ulcer. High pressures applied initially to the wound also donate to intolerance.

Recurrence of Venous Ulcers:

The Western Wound Management Association (EWMA) in their position documents (2005, 2006) handles recurrence of healed ulcers, the percentage and management of the same and consequently with appropriate management 50-60% of venous calf ulcers should heal within 12 weeks. Venous ulcer recurrence remains a major problem, some 60% of ulcers starting treatment at any one moment recurrent. Management of the healed ulcer is therefore important. Hosiery and maintenance skincare remains the mainstay of treatment.

Chronic venous calf ulcers have a significant impact on aged individuals' well-being and healthcare resources. Chronic knee ulcers are associated with constrained ability to move, pain, poor mental health health and lowered quality of life. In recurrent leg ulceration, patients may feel it is inescapable but live with the uncertainty of when the ulcer will reappear.

Costs and Standard of living:

Anand et al's overview of quality of life tools examines the studies that discovered that knee ulcer management costs 600 million per time, and around 2% of the budget of the NHS resources is allocated to the management of venous diseases (Marlow 1999). Nelzen's analysis reveals a conservative estimation of 1200 is allocated to every patient per annum based on a visit per week by a district nurse. Factors influencing the cost of treatment include time and energy to mend, use of dressing regime, and ability to prevent recurrence and Standard of living.

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and public isolation. Constraints to exercise were also common in the ulcer-specific studies and were attributed either right to the ulceration or, for some, therefore of the pain. In serious venous leg-ulcerated patients, elimination or stop of disease is not attainable and the treatment could be much longer than first predicted. Various wound dressings and bandages are used to assist the treating venous ulcers, and also have a direct effect on patients' wellbeing. Anand et al (2003) has outlined the analysis by Callam et al finding that venous knee ulcers impact greatly the life of patients and their freedom, causing people a significant burden to life.


Going through the various studies conducted on the nursing procedures for venous calf ulcers, it is found that a new approach to the management of patients with long-term venous leg ulcers is required. Focus is required to equip medical professionals to develop services in tune to the patient's requirements, assisting the patient to adapt to life with the ulcer since a full healing is not necessarily practical and likelihood of recurrence are always there. The associated psychological conditions alike depression and quality of life shall be handled by improving do it yourself efficacy of the patient. As Vowden (2010) rightly points out, a multidisciplinary approach based on accurate initial assessment and a knowledge of the disease process that triggers venous ulceration, the use of a highly effective compression system and the early popularity of the hard-to-heal wound with referral of difficult or non-healing ulcers at an early on stage will ensure cost-effective care and improve patient outcomes.

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