How do you engage the visit?

Shall you ask Anna?

Slide Image
Slide Image

Here is Anna's wound,
the GP prescribed a neutral foam dressing.

Which dressing do you apply on Anna's wound?

What to do next?

Risk factors of venous
and arterial disease

Venous disease Arterial disease
  • Calf muscle pump failure:
    • immobility (any cause)
    • muscle weakness/paralysis
    • fixed ankle, knee or hip joints
  • Venous valve damage
    • Congenital absence
    • DVT
    • Lower limb fracture
  • Congestion of central venous circulation
    • Obesity
    • Pregnancy (multiple)
  • Venous Hypertension
    • Cardiac failure
    • Renal disease
    • Lymphatic disease
    • Obstruction - tumour/trauma
  • Obesity
  • Lack of exercise
  • Smoking
  • High blood pressure
  • High cholesterol
  • Diabetes
  • Coronary Heart Disease and Stroke

What to do next?

You prescribe compression bandages to be applied during your next visit to Anna. In the meantime, you change Anna's dressing.
You refer Anna for a doppler exam in order to determine her ABPI
Slide Image

Here is Anna's wound,
the GP prescribed a neutral foam dressing.

Which dressing do you apply on Anna's wound?

Slide Image

Here is Anna's wound,
the GP prescribed a neutral foam dressing.

Which dressing do you apply on Anna's wound?

2 days later
2 days later
After changing Anna's dressing, you schedule a follow-up visit and say goodbye to Anna.
2 days later
The day after you applied compression bandages on Anna's leg for the first time, you receive a call.
2 days later
When she opens the door, your patient Anna does not feel very well
When Anna opens the door, you see that she is not wearing her compression bandages.

Anna's wound has not improved since your last visit

You decide to ask her a few questions to understand what could be delaying healing.

What can you advice to Anna?

2 days later

ABPI = 0.9

ABPI Interpretation
>1.3 Suggests the arteries are calcified, so reading is unreliable. Consider measuring the Toe Brachial Pressure Index*.
1.0-1.3 Normal range.
Low probability that arterial disease is present in lower limb.
0.81-1.00 Mild peripheral arterial disease is present.
0.5-0.8 Moderate peripheral arterial disease.
<0.5 Indicates severe arterial disease (critical ischaemia) is present.

Which compression bandages to choose?

  • Have a low resting pressure and a high working pressure; they have a high stiffness index. When the calf muscle is activated, the bandage resistance creates a massage effect which forces blood upwards and improves venous return. They have a limited efficacy for patients with reduced mobility who are unable to activate their calf muscle pump.
  • Have a tendency to slip and lose pressure rapidly1,2
  • Maintain a constant pressure by continuously "squeezing" the muscle whether the muscle pump is activated or not; they have a low stiffness index. When the muscle pump is activated, the bandage will follow the expansion of the muscle without resistance; there is therefore little increase in pressure and no massage effect delivered.
  • Are not well tolerated at night, leading to compliance issues3.
  • They combine the advantages of short stretch and long stretch bandages.
  • They create a massage effect at a walk while maintaining the therapeutic level of pressure at rest.
  • They stay in place and maintain pressure in time better than short stretch bandages.
  • They can be left in place day and night.
  • Kits are a hosiery alternative to bandages for healing leg ulcers. Two garments are worn one on top of the other. A 10mmHg liner followed by higher a compression stocking.
  • Normal footwear can be worn.
  • The kit is generally worn for a week at a time and at night.
  • Wound dressings may be worn under hosiery but not everyone with a leg ulcer is suitable for the hosiery kit and some people may need to wear bandages depending on the oedema, patient's ability to put on, the size and shape of the leg and ulcer.
  1. Junger M. et al. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J.W.C. 2009: 18,11: 474-480.
  2. Parstch M. Understanding Compression Therapy: EWMA Position Document. Medical Education Partnership Ltd; 2003. Understanding the pathophysiological effects of compression; pp. 2–5.;
  3. QIPI IDE France 2016
2 days later
2 days later
You change the dressing and apply the multicomponent bandages
2 days later

What is your action in this situation?

Now convinced that the compression bandages will help her leg ulcer to heal sooner, Anna has been wearing them continuously for several weeks. You come for your weekly visit.
2 days later
Slide Image

You have been too slow

Let's reduce healing time for patient

The decision is yours

Congratulations!

Anna's venous leg ulcer is healed! It took you min to solve the case. The shortest healing pathway was min. This illustrates how healing times for leg ulcer patients can be reduced in practice through:

  1. Early identification of the cause of the ulceration through a comprehensive patient assessment.
  2. Intervention with the right evidence-based care from the start, including reliable continuous compression and a local treatment that addresses local factors that can impair healing.
  3. Effective communication with the patient to promote concordance and continuity of care.

Simple VLUs should heal within 12 weeks if treated appropriately. More complex VLUs can take up to 24 weeks to heal(1). A review of VLU healing rates by Guest et al.(2) indicated that as few as 6-9% of patients with VLUs healed within 26 weeks. Low Healing rates can be attributed to lack of clinical assessment and poor adherence to guidelines on best practice, which consider compression therapy as essential to facilitate healing and prevent recurrence (1;3;4;5). Patient non-concordance is another key factor which needs to be addressed.

(1) Harding, K., Dowsett, C., Flas, L et al. Simplifying venous leg ulcer management: consensus recommendations.Wounds International, 2015.
(2) Guest,J.F.,Taylor R.R.,Vowden, K.,Vowden, P. Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK. J Wound Care 2012; 21: 8, 389- 8.
(3) Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic venous leg ulcers. A national clinical guideline 120. SIGN, 2010.
(4) Franks, P, Barker,J, Collier, M. et al. Management of patients with venous leg ulcers: challenges and current best practice. J Wound Care 2016; 25: 6 (Supp). 1-67.
(5) Wounds UK. Best Practice Statement. Holistic Management of Venous Leg Ulceration. Wounds UK, 2016.

Let's reduce healing
time for patients

The decision is yours

This is Anna, a dynamic and vibrant retiree. At 72 years old, she loves to meet her friends from the walking club to discover the wonders of hiking. While she was gardening, Anna took her feet in a root and fell. The fall is not serious; she injured her elbow and sustained a wound to her leg. She self-treated for a few weeks. She attended the General Practitioner for the renewal of her hyper-tension medication, she shows him her wound in the leg which was getting worse and which was exuding under the dressing that she has applied.

You are called as a nurse to change dressings every 2 days. Get into the character of her home nurse and make all decisions that will lead to her to speedy recovery! Each of your decisions will have an impact on the course of the story.

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