on VU care AAWC Venous Ulcer Guideline

AAWC Venous Ulcer Guideline
Content Validated, Evidence Based
“Guideline of Venous Ulcer Guidelines”
Using the AAWC Venous Ulcer (VU)
Guidelines to Manage Venous Ulcers
• 3 Steps to manage a VU patient:
– Assess and document patient, skin & VU
– Prevent VU with care plan focused on reducing risk
– Treat patient and VU to heal and prevent recurrence
• For guideline details, references, implementation
tools, patient brochure and evidence please see:
Fonts Used Here and in AAWC VU Guideline Checklist
• Recommendations in bold font are
– Ready to Implement :
• A-level evidence support (Strong evidence)
• + Content validity index (CVI)>0.75 (Strongly recommended)
• Recommendations in bold italics
– Need more Education
• Content validity index (CVI) <0.75 (Raters say not relevant to VU care)
• A-level evidence support
• Recommendations in normal font
– Need more research to be considered evidence-based , but
have a CVI of at least 0.75,
– i.e. 75% of independent raters or more believed this
recommendation was clinically relevant for VU practice.
AAWC VU Guideline Recommendation
Strength of Evidence Ratings
A. Supported by at least 2 VU-related human:
1. randomized controlled trials (RCTs) for efficacy or…
2. For diagnostics or risk assessment screening: 2
prospective cohort studies and/or above RCTs
reporting diagnostic (sensitivity or specificity) or
screening (+ or - predictive validity) measures.
B. One A-level study + at least one non-randomized
controlled human VU study or at least 2 RCTs on
animal model(s) validated for VU
C. One A-level study without B-level support (C1),
case series (C2) or expert opinion (C3)
Overview of AAWC VU Guideline:
Who does What to Whom by When?
Trained staff: regularly per protocol, as feasible
Assess patient, skin, VU condition, patient/family goals
Coach patient/family on safe, effective, appropriate care
 Generate appropriate care plan to meet agreed on goals
 Perform care or order consults as needed to meet goals
 Document, communicate skin and ulcer progress to
those providing or consulting on care, patient and family
• Patient / family : regularly as needed
 Communicate goals, needs and capabilities
Participate in choosing appropriate, effective care plan
 Engage in care
AAWC VU Guideline
Step 1: Assess and Document
Physical/medical/surgical history to diagnose
ulcer causes & risk factors to guide care:
Patient and family goals
Step 1. Trained Professional
Assess Patient, Skin, Wound
• Document CEAP signs of venous insufficiency developed
and validated by the American Venous Forum:
– Clinical signs of venous disorders, including no signs (C0) or:
• Lower leg edema (C3), skin changes (C4), healed (C5) or active (C6) VU
– Etiology including no venous cause identified (En) or:
• Congenital (Ec), Primary reflux (Ep), secondary or post thrombotic (Es)
– Anatomic including no venous location identified (An) or:
• In superficial (As), perforator (Ap) or deep (Ad) veins
• Optionally identify involved superficial or deep vein or perforator
– Pathophysiologic including no signs of vein disease (Pn) or:
• Reflux (Pr), obstruction (Po) or reflux and obstruction (Pr,o)
Step 1. Trained Professional
Assess Patient, Family Goals Capabilities
and Risk Factors for Slow Healing
– Patient and family goals including:
• pain
• quality of life
– Risk factors for slow VU healing
VU > 5 cm2
VU persists > 6 month
patient is obese and/or over 50 years of age
patient is male
Step 1. Assess: VU Differential Diagnosis
• Who: Trained professional or interdisciplinary wound team member
• When: On admission and if VU closes < 40% in 3 weeks
• What:
ABI< 0.8 or local TcPO2 <30 mmHg: arterial consult
Vein refill time > 20 seconds: likely venous
Local heat  >1.1○ C: suspect infection
Local hair growth suggests non-arterial ulcer
• Document progress regularly using reliable, valid measures
– VU area or longest length x widest width to estimate area
– Standardized edema measure
• Ensure formal assessments are accessible to those providing or
consulting on VU care
AAWC Venous Ulcer Guideline:
Step 2: Venous Ulcer Prevention Overview
Trained staff address patient goals and risk factors to
prevent VU or improve edema and venous return.
Educate and coach patient and family
Aid venous return
Protect the skin
Address causes of tissue damage
Step 2: Venous Ulcer Prevention:
Educate Patient and Family
• Educate patient and family on
– Cause(s) of skin breakdown,
– How and why to
• Compress,
• Exercise calf muscle and
• Elevate lower legs
– Smoking cessation
– Other behaviors that may damage veins
Step 2: Venous Ulcer Prevention:
Aid Venous Return
• Apply safe, effective, cost effective VU compression
• Multilayer sustained, elastic high-compression
bandages, stockings or tubular bandages afford similar
VU outcomes
• Match compression to patient needs & calf size
Better outcomes with multilayer than 1-layer compression
2-layer improves comfort and quality of life vs 4-layer
Elastic compression is generally better than inelastic
Unna’s Boot is better than no compression: improve results
by adding an elastic layer (Duke Boot)
– Pneumatic compression, inelastic strapping device or
standardized lymphatic massage are each more effective
than no compression
Step 2: Venous Ulcer Prevention:
Protect the Skin
• Moisturize dry skin
• Protect affected skin from
– Irritation
– Sensitization
– Chemical injury
– Physical trauma
Step 2: Venous Ulcer Prevention:
Address Causes of Tissue Damage
• Perform consult(s) as needed and feasible to
identify and reduce VU risk and control infection
consistent with patient and family goals and
professional consult advice on:
Physical therapy
Other as appropriate
AAWC Venous Ulcer Guideline
Step 3 Overview:
Heal Venous Ulcer: Keep It Healed!
• Treat patient and VU to
– Improve healing
– Improve pain, quality of life & costs of care
– Prevent hospitalization
– Prevent recurrence
AAWC Venous Ulcer Guideline Step 3:
Treat Patient and VU To Foster Healing
• Continue or implement measures to prevent VU
• Manage venous return per institutional protocols and to
meet patient and family needs and goals
Compress (Consistent, multilayer, elastic wraps or socks)
Elevate (above heart: e.g. books under foot of bed)
Exercise calf (e.g. tip toes, walking, ankle flex)
 Other as appropriate (e.g. lymphatic massage, PT, IPC, SEPS)
• Cleanse VU (4-15 psi) with safe non-antimicrobial fluid
• Debride non-vital tissue using (debridement used):
 Autolytic Enzymatic Surgical  Other____
AAWC Venous Ulcer Guideline Step 3:
Treat Patient and Venous Ulcer To Improve
Pain, Quality of Life (QoL), Costs of Care
• Moisture sealing dressings plus elastic
compression improve VU healing, pain,
application time compared to short-stretch or
Unna’s Boot compression.
• Add absorbent primary dressing if needed to
prolong wear to allow weekly dressing changes.
– Frequent dressing changes cost and  QoL
AAWC Venous Ulcer Guideline Step 3: Heal VU
Treat Patient and VU To Prevent Hospitalization
• Evaluate VU at each dressing change for signs and
symptoms of clinical infection
– Use antimicrobial only if VU has clinical infection signs/
symptoms: increased pain, heat, odor, color, edema
• Dress VU to maintain a moist environment, manage
excess exudate if needed, & protect ulcer and local skin
• Manage VU-related pain to meet patient needs
• If VU area  <40% in 3 weeks: re-evaluate diagnosis
and care plan
• If VU does not  in area by 4 weeks: consider effective
vascular surgery or adjunct intervention + appropriate
Step 3 interventions.
AAWC Venous Ulcer Guideline Step 3: Treat
Patient and Healed VU To Prevent Recurrence
• Continue or implement all measures to
prevent VU after it has healed
• Perform weekly community nursing, coaching
and peer support to encourage consistent…
– Elevation of the lower leg above heart
– Calf muscle exercise
– Optimal, consistent compression use, e.g.
• Medium compression elastic stockings are used more
consistently than high compression ones, with similar
VU recurrence rates

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