This two-part series will discuss common lower limb problems, including venous leg ulceration, oedema (including oedema associated with lymphovenous disease), lymphoedema and lipoedema. This article will focus on the causes of these conditions and discusses the signs and symptoms to enable community nurses to diagnose and differentiate between the types of lower limb problems. Part two of the series will focus on management strategies for simple, uncomplicated venous leg ulceration and oedema, which can be successfully managed with skin care and compression therapy, without specialist skills. It will also briefly outline the management of lymphorrhoea or ‘leaking legs’, which can be challenging for nurses. The aim of this series is to enable community nurses to choose the most effective treatment in terms of efficacy and patient acceptability.
District nursing teams are under increasing pressure to cope with demands on their time and the skills to meet the needs of their local community. The author’s local nursing team has been struggling to manage the clinical skill mix required to meet the complex needs of their patients with lower leg wounds who should be treated with compression therapy. The task of managing compression therapy was mainly undertaken by nurses, but it was proving extremely time-consuming — especially when patients needed leg washing and compression treatment for bilateral leg wounds. After successfully using a Velcro™ compression system, a six-month evaluation of juxta products for the leg ulcer pathway was proposed for one community nursing team. This project was undertaken with an initial cohort of 17 patients to evaluate if switching to this product could help to improve the use of the team’s skill mix and reduce costs on wound products from the formulary by improving wound healing rates.
This article highlights the normal and abnormal physiology of fluid circulation in the lower limb with particular reference to venous and lymphatic flow. Consideration is given to the assessment and diagnosis of disease and its severity, particularly the impact on the patient including chronic oedema, ulceration, cellulitis and loss of mobility. Options for disease management and prevention such as compression bandaging and hosiery are also discussed, and the gaps between theory and practice are highlighted to provide community nurses with the most up-to-date information and practical solutions.
In patients with venous and lymphovenous disease, skin changes to the lower limb(s) occur gradually, and become more serious over time if left untreated. The CHRonic Oedema Signs and Symptoms (CHROSS) Checker is a tool kit consisting of an assessment chart and key cards that have been developed to help clinicians easily identify the skin changes that occur as a result of underlying venous and lymphovenous disease, when carrying out holistic patient assessment. It also provides clear guidance on which compression products can be used to manage the disease type and severity of skin change. For clinicians unfamiliar with some or all of the signs and symptoms listed on the CHROSS Checker chart, the key cards contain further information in the form of a photograph, definition and cause of each sign and symptom listed. This article will describe the theory behind the development of the CHROSS Checker tools and explain how to use them in clinical practice.
Janice Bianchi, Independent Medical Education Specialist and Honorary Lecturer, Glasgow University
