Several of these recommendations were consolidated to provide 10 updated recommendations supported by recent evidence in this article in four categories, including:

1. Identification and treatment of cause (recommendations 1-6 in the paper updating RNAO R1-7;9-14; 48; and two new recommendations in the venous ulcer care category)

2. Patient-centered concerns (recommendation 7 updating RNAO R6-7)

3. Local wound care (recommendations 8-9 updating RNAO R5;44-47)

4. Multidisciplinary support (recommendation 10 updating RNAO R49-52)

The first six recommendations update topics associated with identifying and treating the cause and recommendations eight and nine discuss local wound care.

Recommendations 1 and 2 discuss the routine assessment procedures, including pertinent patient history, pain, and physical assessments. Patient history items involve risk factors related to age, gender, lifestyle choices (smoking), and others that are associated with the likelihood of developing venous ulcers. An outline of procedures to obtain an ankle-brachial pressure index (APBI) and its interpretation are outlined. Cautions are issued to assure that appropriately trained health care personnel perform the ABPI measurements and that interpretation may be different in certain populations, such as patients with diabetes. Pain assessment is used to understand additional problems and causes. Additional factors are also considered, such as nutritional deficiencies, current medical therapies and others. These two recommendations update RNAO’s general assessment, diagnostic, and pain evaluation recommendations.

Recommendation 3 suggests determination of the cause should include evaluation for abnormal valves, obstruction, and calf-muscle-pump failure. The authors outline the problems associated with calf-muscle pump failure, including those related to major injuries that involve neurological changes, vascular insufficiency, myositis, and bone/joint involvement.

Recommendations 4-6 suggest the implementation of appropriate types of compression therapy, expanding on the previous recommendation to apply external compression using pneumatic compression pumps. Specific information is offered about the evaluation of sub-bandage pressure. One comparison of evidence on the use of high or moderate compression suggested that while no evidence seems to show that one is better than the other, better adherence to therapy was achieved with moderate compression therapy. The authors quote a Cochrane Review of evidence that states that compression achieves better results than no compression that multilayered systems appear better than single-layered systems, and that high compression may be better than low compression.  However, there were no significant differences between the high compression therapies evaluated. Cautions were also issued with this recommendation, including the use of high compression by well-trained personnel and to use only in patients without signs of arterial disease with an APBI result 0.8 or greater. New evidence at a C level indicated that medical treatment of complications should be implemented in selected cases. In addition, the authors reviewed the use of therapies to deal with complications of vascular insufficiency in conjunction with compression, such as zinc oxide paste bandages, topical steroids, diuretics, and pentoxifylline.

Recommendation 7 suggests specifics on communication with both patients and their caregivers. R7 emphasizes the importance of a social support system to treat and prevent venous leg ulcers. The basis of this recommendation is evidence suggests that patient perceptions are important to the success of the treatment plan. Patient perceptions are affected by apparent attitudes and communication by health care professionals. Improved adherence to compression therapy was seen in cases where the health care provider exhibited empathy and understanding about the required patient effort and discomfort.

Recommendation 8 expands on the original R5 to a more general assessment of the wound to differentiate venous disease from arterial disease. Additionally, the discussion points out the need to expand the assessment in non-healing wounds to additional causes or problems, such as cancer and poor nutrition. Recommendation 9 discusses local wound care to include debridement and bacterial and moisture balance. The authors outline varying types of debridement and issues cautions about assuring that the procedure is properly conducted by well-trained personnel and performed only when there is adequate blood supply. Suggestions were made on determining the type of bacterial burden and treatment with systemic antibiotics. However, topical treatments were suggested in addition to systemic antibiotics in cases of critical levels of colonization. An outline for individualized choices for dressings was offered along with characteristics, uses, and contraindications. Precautions were made about the use of moist wound healing strategies in cases of inadequate blood supply to the wound area. Adjunctive therapies, such as negative pressure therapies, biologicals, and other complementary strategies were suggested for consideration in cases where wound healing has been unsuccessful and if there is no malignancy present. Specific recommendations were suggested for VAC therapy only in selected cases.

Finally, recommendation 10 emphasizes the importance of multidisciplinary input and individualization of patient care plans to enhance the appropriate use of complementary therapies, such as exercise and nutrition.

Summary:

Successful prevention and treatment of venous leg ulcers requires careful assessment, care planning and communication, and individualized choices for treatment and patient management. This paper is an update for guidelines that were previously issued to outline best practice in the prevention and treatment of venous leg ulcers that was originally released by the RNAO in 2004. New evidence was reviewed and revisions were made. Specific review was given on assessment, treatment, and monitoring strategies that have demonstrated benefit in venous leg ulcer care. Compression therapy continues to be recognized as a gold standard in the treatment of venous leg ulcers. Communication efforts and treatment choices are key factors in achieving the best outcomes. The authors also recognized and included the need to involve multiple disciplines with training and expertise in wound care to achieve the best results.