Venous leg ulcer clinic standard operating procedure for assessment of venous leg ulcers

The following standard operating procedure (SOP) is intended as an outline for Health Boards to develop their own standard operating procedure. The example below has been adapted from procedures used by the clinical team at NHS Tayside. It may need to be adjusted or expanded depending on availability of facilities (e.g. photography) and services locally and to ensure links are established with relevant local services (e.g. Primary Care, District Nursing, Vascular Surgery, Dermatology).

Purpose/background

Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective treatment (RCN, 2024). Therefore it is advisable that the cause of ulceration should be diagnosed through holistic assessment of the patient including a full clinical history and physical assessment including assessment of the leg and of the ulcer itself. The aim of this SOP is to ensure safe and standardised assessment of venous leg ulcers.

Scope

This SOP applies to all registered nurses working within the Community Venous Leg Ulcer Clinic.

Responsibility

All registered nurses are responsible for reading this SOP and signing to say they have understood this SOP and will comply with the instructions within.

Procedure

Introduce all staff to the patient.
Confirm the patients name and date of birth.
Explain to the patient what they can expect from the consultation.
Commence full holistic assessment, including review of comorbidities and social circumstances affecting prognosis.
The leg should then be assessed for signs of venous disease*, oedema and joint mobility, particularly that of the ankle, as this is an important component of the calf muscle pump function.

Signs of venous disease:

Usually shallow ulcers situated on the gaiter area of the leg
Oedema
Eczema
Ankle flare
Lipodermatosclerosis
Varicose veins
Hyperpigmentation/haemosiderin staining
Atrophie blanche

The leg should also be assessed for signs of arterial disease** and any other Red Flag symptoms. Sufficient arterial supply is required to safely apply compression therapy, which is the standard treatment for venous leg ulcers. Measurement of the ankle brachial pressure index (ABPI) by hand held Doppler device is the most reliable way to detect arterial insufficiency (See Venous leg ulcer clinic standard operating procedure for assessment of ankle brachial pressure index (ABPI)

Red flag symptoms

Immediately escalate to the relevant clinical specialist and/or service:

Acute infection (e.g. increasing unilateral erythema, swelling, pain, pus, heat)
Symptoms of sepsis
Acute or suspected chronic limb threatening ischaemia (e.g. PAD in combination with rest pain, gangrene, or lower limb ulceration of more than 2 weeks duration
Suspected acute deep vein thrombosis
Suspected skin cancer
Bleeding varicose veins

Signs of arterial disease:

Ulcers with a ’punched out’ appearance
Base of wound poorly perfused and pale
Cold legs/feet (in a warm environment)
Shiny, taut skin
Dependent rubour
Pale or blue feet
Gangrenous toes

Mixed venous/arterial:

These will have features of a venous ulcer, in combination with signs of arterial impairment.

The ulcer itself should then be assessed. Deep ulcers which involve deep fascia, tendon, periosteum or bone may have an arterial component to their aetiology and should be referred for specialist assessment (see criteria for referral to secondary care below).
The ulcer should be measured; serial measurement of the surface area is a reliable index of healing. This should be done through tracing the wound and measuring the two maximum perpendicular axes.
An accurate clinical description of the wound should be documented (in the leg ulcer assessment record if this is used). This should include a description of the wound edge e.g. shallow, epithelialising, punched out, a description of the base of the ulcer e.g. granulating, sloughy and the position of the ulcer on the leg should be clearly described.
Compression therapy may be safely used in the absence of any signs of arterial disease and following the measurement of ABPI (where ABPI is between 0.8 and 1.3 inclusive) (see Community venous leg ulcer clinic standard operating procedure for treatment of venous leg ulcers).
Where there may be a delay in obtaining ABPI measurement, consider implementing first line reduced, graduated compression (20mmHg or less at the ankle). Those with symptoms that should be escalated to secondary care should be referred on urgently but also considered for first line mild graduated compression (20mmHg at the ankle). Such compression therapy is likely to be beneficial to most except those with acute or suspected chronic limb threatening ischaemia.
Assessment should be carried out at each dressing change and a full reassessment including Doppler should be carried out at 12 weeks. If there is no progress/improvement the patient should be referred to the specialist leg ulcer clinic (see criteria for referral to secondary care below).
If the leg shows signs of infection please refer to the local protocols for management of suspected infection in chronic wounds and ulcers.

Criteria for referral to secondary care

Suspicion of malignancy
Peripheral arterial disease (ABPI <0.8 or >1.3)
Vasculitis
Atypical distribution of ulcers
Suspected contact dermatitis or dermatitis resistant to topical steroids
Non-healing ulcer despite appropriate treatment at 12 week review