Promoting Healthy Skin - 3. Venous Leg Ulcers

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3C: Prevention

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Prevention strategies
Tips for using graduated compression stockings

Prevention strategies

Once you have learned how to assess and manage a venous leg ulcer, there are some important evidence based strategies that you can put in place to reduce the risk of the leg ulcer recurring. These include the following:

Strategy	Explanation
Use graduated compression stockings	After healing, the use of graduated compression stockings for life reduces ulcer recurrence rates. Compression stockings should be measured and fitted by a trained practitioner to ensure that they are the correct size for the person. Compression hosiery should be replaced at least every six months. Compression stockings must be worn every day except while in bed, bathing or swimming. Stockings should be applied as early in the day as possible to prevent the legs from swelling. Remove hosiery as close to bed time as possible. See further tips about using stockings below.
Recommend a medical review	Review by a vascular surgeon or vascular investigations may be of benefit for some individuals.
Follow up and check the client’s skin regularly	The key to preventing a venous leg ulcer from occurring or recurring is to check the skin daily. If a problem is detected, start treatment as early as possible
Encourage the client to exercise	Clients should do lower limb exercises, at least every hour. Simple exercises may include drawing figures with their toes, pushing their toes towards the floor and then pointing them up towards their nose, standing on the balls of their feet, tiptoeing up and down, walking, or swimming. Any movement of the calf muscle helps to move blood back to the heart. IMAGE - M3 18 Standing on balls of feet IMAGE - M3 19 Toes to nose IMAGE - M3 20 Toes to floor
Elevate the client’s leg	Elevate the affected limb at least 3 - 4 times every day for at least 15 minutes each time to help reduce high blood pressure in the lower legs and reduce swelling. Elevation means placing the client’s legs on pillows, a chair or other object so that the feet are above the level of the knees, and the knees are above the level of the hips. Try to discourage clients from sitting with their legs down and stationary for more than an hour at a time. Clients should put their feet up while performing sit down tasks. Elevating the legs to the level of the hips doesn’t reduce swelling but it keeps the swelling from getting worse. Elevating the legs above the level of the heart is needed to reduce swelling. IMAGE - M3 21 Leg elevation
Ensure the client avoids crossing his/her legs	Crossing the legs reduces the blood flow back to the heart and so clients should avoid doing this.

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Tips for using graduated compression stockings

For graduated compression stockings to be effective there are few simple things that you need to consider. These include:

Considerations	Tip
Ladders, tears or holes in the stockings	If the compression stocking has a ladder, tear or hole, this reduces the level of compression provided by the stocking.
Bruising or broken skin	If compression stockings are not applied correctly, they can damage the skin, particularly the shin, as they are pulled on.
Swelling above and below the stockings or toes purple/blue	If a person complains of swelling above or below the stocking or their toes turn blue or purple, this may indicate that the stocking is too tight and must be removed.
Extreme pain, particularly in the foot or calf muscle	Stockings should feel comfortable and be firm but not tight. If a person complains of extreme pain in the foot or calf muscle that they have not experienced previously, this indicates the stocking is too tight and must be removed.
Difficulty with applying and removing stockings	It is recommended that clients take off the stockings at night and reapply them first thing in the morning. However, this may not be practical for some people and assistance may be required. Compression stockings are not put on like ordinary hosiery. If you roll the stocking up to apply, it gets tighter and tighter because the compression starts at the ankle.
Encouraging independence	Teaching clients how to apply their stockings is essential to improve their independence.
The stocking has wrinkles	Wrinkles should be removed to reduce the risk of the stocking being too tight or slipping down.
Stockings folded over at the top	Folds in the stocking can cause problems. For example, tight bands at the top or over the foot may lead to pressure damage or more ulcers.
Using a moisturiser	Apply a pH neutral moisturiser to keep the skin in good condition but allow it to dry before applying the stocking.
Wearing jewellery when applying and removing stockings	Remove your rings, watch and jewellery as these can damage the stocking.
Wearing rubber gloves	It is recommended that you wear rubber dishwashing gloves when applying the stockings to make it easier to grip the stocking and help prevent holes, tears and ladders. IMAGE - M3 22 Rubber gloves
Using applicators	There are a variety of stocking applicators such as frames, slide sheets or sockets that can be used to help put stockings on more easily and to avoid trauma to the skin during application. The short video clips show stocking application and removal techniques. IMAGE - M3 23 Stocking applicator VIDEO - M3V02 Stocking application (View video transcript) VIDEO - M3V03 Removal of stocking (View video transcript) VIDEO - M3V04 Application of open-toe stocking (View video transcript) VIDEO - M3V05 Application of close-toe stocking (View video transcript)