National survey of Irish community nurses leg ulcer management practices and knowledge.

This survey of found that while many aspects of Irish community nurses leg ulcer management complied with current guidelines, there was a worrying lack of understanding about the key concepts underlying compression therapy.

Lower extremity venous disorders: implications for nursing practice.

Lower extremity chronic venous disorders are significant and common causes of vascular morbidity and mortality worldwide. Venous ulcer relapse rates are as high as 72% and account for approximately 80% to 90% of all lower extremity ulcers. Venous disorders, much like arterial disease, are often progressive and chronic in nature, resulting in enormous economic and human costs in terms of treatment, pain, and suffering. Individuals with skin changes are at high risk of recurrent leg ulcers, which negatively affect the quality of life for both the individual and the family. Prevention efforts should target anatomical vein dysfunction, edema, and skin changes to prevent leg ulcers. This article presents an overview of both clinical and laboratory assessments of lower extremity chronic venous disorders, including descriptions of the risks and pathogenesis for differential diagnosis and implications for nursing.

Changes in leg ulcer management practice following training in an Irish community setting.

OBJECTIVE: To identify regional changes in leg ulcer management following leg ulcer training for community-based nurses which incorporated Doppler ankle brachial pressure index (ABPI) assessment. METHODS: This was a two-part study conducted in the Irish Health Service Executive, Mid-Western Area. An initial audit in 2005 gathered details on all leg ulcer patients treated in the community in one week, including patient demographics, ulcer aetiology, assessment and treatment. The first audit was carried out before the introduction of a training course for community-based nurses in leg ulcer assessment and management. The training programme was delivered in 2005 and again in 2006. In total 30 public health nurses and community registered nurses from this region completed the course. The second part of the study involved repeating the audit in 2007. By comparing the results from 2005 with 2007 we were able to identify changes in leg ulcer assessment and management. RESULTS: A total of 426 and 449 leg ulcers were identified, with a prevalence of 0.12% and 0.1% in 2005 and 2007 respectively. Prevalence increased to 1.2% (2005) and 1.1% (2007) in those aged over 70 years. Most ulcers were venous in origin (63.3% in 2005 versus 68.8% in 2007). From 2005 to 2007 the number of venous leg ulcers treated with high compression increased significantly, by almost 16% (p < 0.0001). Once-weekly dressing changes increased by a significant 10%, reducing the number of dressings requiring more frequent changes (p = 0.002). CONCLUSION: Significant improvements in leg-ulcer practices were noted in the 18-month study period. The results show very significant increases in number of patients treated with high compression and a significant reduction in more than once-weekly dressing changes. These positive changes may be partly attributed to the enhanced knowledge and skills nurses gained by participating in training.

The effects of education and training on clinical practice in wound healing.

This article considers the effects of two different types of educational programme on community nurse clinical practice in venous ulceration. One group of nurses (the experimental group) attended an educational programme designed to take account of training needs and learning styles. A second group of nurses (the control group) attended a standardised educational programme. A multiple-choice question examination and Objective Structured Clinical Examination were used to measure knowledge and skills. Kolb's Learning Styles Inventory was used to measure learning styles. Findings were that experimental nurses failed to show improved post-intervention clinical practice compared with the control group.

Survey of Doppler use in lymphoedema practitioners in the UK.

Lymphoedema practitioners anecdotally don't use Doppler in the vascular assessment of their patients prior to the application of compression. The belief is that the results are inaccurate in the presence of oedema. The objective of this article is to gather information about the use of Doppler by lymphoedema specialists in the vascular assessment of lymphoedema patients in the UK. A questionnaire on the use of Doppler in lymphoedema patients was distributed to 250 delegates attending the British Lymphology Society Conference in Glasgow in Ocotber 2005. There appears to be no consensus in the method of vascular assessment of lymphoedema patients. More research is needed to ascertain the accuracy of Doppler in the assessment of lymphoedema patients. Guidelines are also required in the vascular assessment of lymphoedema patients based on scientifically valid evidence.

Use of Doppler ultrasound in assessing leg ulcers.

This article outlines the use of a hand-held Doppler ultrasound device as an aid in the assessment of patients with active and healed leg ulcers. It describes the benefits and limitations of Doppler assessment, the steps of the procedure, how to calculate the ankle-brachial pressure index accurately and how to recognise the significance of the findings.

An exploration of current leg ulcer management practices in an Irish community setting.

OBJECTIVE: To establish the prevalence of leg ulceration in the Irish Health Service Executive (HSE) mid-western region and to determine the level of assessment and treatment patients have been receiving in the local community. METHOD: Before the introduction of a Doppler training programme, all public health and community health nurses working in the Irish HSE mid-western area were requested to complete an audit form on each patient being treated for leg ulceration during a predefined one-week period. This form recorded details on patient demographics, ulcer aetiology, assessment and treatment. Out of 97 nurses, 96 responded to this audit, giving a response rate of 98.9%. RESULTS: A total of 429 patients with 449 leg ulcers were identified. Mean age was 75.5 years (standard deviation 10.7). Overall prevalence was 0.12%, which increased to 1.2% in those aged 70 years and over. Women were almost twice as likely as men to be affected (ratio of 1.8:1). The main causes of ulceration were reported as venous incompetence accounting for 63.3% (284/449) and arterial insufficiency accounting for 8% (36/449) of all ulcers. Only 59.9% (269/449) of all ulcerated limbs had ABPI measurements performed. Of those reported as venous in origin, 71.8% (204/284) had ABPI measurements recorded. Evidence-based care was generally apparent in this group, with 47.5% (97/204) receiving high compression and 18.1% (37/204) receiving reduced compression. However, in venous leg ulcers where ABPIs were not recorded (n=80) care appeared haphazard and inappropriate. CONCLUSION: Our study has identified the benefit of ABPI Doppler assessment.This assessment could be done in local health centres by trained nurses who could provide more appropriate and timely care to patients, thereby improving outcomes and relieving pressure on acute hospital clinics.

Doppler ultrasound--basics revisited.

Palpation of pedal pulses alone is known to be an unreliable indicator for the presence of arterial disease. Using portable Doppler ultrasound to measure the resting ankle brachial pressure index is superior to palpation of peripheral pulses as an assessment of the adequacy pf the arterial supply in the lower limb. Revisiting basics, this article aims to aid the clinician to understand and perform hand-held Doppler ultrasound effectively while involving the client or patient in the process. The author describes the basics of Doppler ultrasound, how to select correct equipment for the process, and interpretation of results to further enhance clinicians' knowledge.

Community nurse use of Doppler ultrasound in leg ulcer assessment.

Doppler ultrasound is used by community nurses to measure the ankle brachial pressure index (ABPI). This is required before applying compression therapy for patients with chronic venous insufficiency and venous leg ulcers.However, emphasis on the ABPI result has resulted in inappropriate referrals to the vascular department which led the author to survey current practice within one primary care trust. Results illustrated variations in how nurses obtain training and maintain their competency in using Doppler ultrasound. This has an impact on the accuracy of interpretation of the ABPImeasurement and subsequent management of the patient. Practical issues also explained the difficulties nurses encountered in using the correct procedure within the community, which may result in unreliable measurements. There is a need to standardize training for all community nurses, and to review the structure of current clinical guidelines to enable a wider analysis of arterial assessment, in order to reduce the emphasis purely on the ABPI measurement.

Utilizing the ankle brachial index in clinical practice.

The ankle brachial index is one of many tests that can be used to indirectly assess lower extremity peripheral blood flow. This article reviews ankle brachial index technique and presents some of its applications for clinicians and researchers based on a literature review. The ankle brachial index is relatively simple and inexpensive and can be performed in both clinical and home care settings. Reliability level is reported to be high, with an intraclass correlation coefficient range of 0.80 to 0.99. When used with other noninvasive vascular tests such as pulse volume recordings, lower extremity segmental systolic limb pressures, and transcutaneous oximetry mapping, the ankle brachial index is a valuable screening tool to detect individuals at risk for wounds and other problems associated with poor peripheral arterial circulation.

Pulse oximetry vascular assessment in patients with leg ulcers.

Arterial screening of the lower limbs is recommended before compression therapy is initiated in patients with ulceration or dermatitis. Hand-held Doppler ABPI is the accepted assessment tool but has limitations. Pulse oximeters have potential as alternative screening instruments with some advantages over Doppler. This article reviews the mode of action, application and limitations of pulse oximeters. A pulse oximetry toe/finger arterial screening index, which may be used as an alternative to Doppler ABPI, is described. Case studies are reported in which arterial blood flow which was easily detected by pulse oximetry could not be detected by Doppler.

HNE Diagnostics Dopplex ultrasound machines.

Doppler ultrasound is a technique that has a variety of uses. These include venous and arterial circulation assessment, pre- and postoperative arterial assessment, digital pulse assessment, carotid stenosis screening, penile blood flow measurement and fetal heart rate assessment.

The use of holistic assessment in the treatment of leg ulcers.

Leg ulcers are costly to both patients and also the NHS. It is therefore of paramount importance that the treatment regimen is based on a holistic assessment to determine the underlying aetiology. It is only then that an appropriate treatment plan can be formulated. This article reviews the issues involved in the holistic assessment of leg ulcers.

Teaching bandaging and Doppler usage for venous ulcer treatment.

This article describes how an assessor's guide and a student learning contract about compression and Doppler therapy was presented to community nurses and practice nurses in an NHS acute and community trust. The objectives were to provide potential assessors with standardized practice in the application of compression bandaging and the use of Doppler-assisted diagnosis in the treatment of venous leg ulceration. This was achieved by a teaching session using two checklists, one for the assessor and the other for the 'student'. Role play was used to allow experience of assessing or being assessed in a classroom setting. References to key pertinent articles were provided to support the learning contract, and the development of a resource file was proposed. In recognizing their own limited knowledge and experience, a small number of practitioners felt unable to assess 'officially' other members of their staff.

Use of Doppler ultrasound in leg ulcer assessment.

Adequate patient assessment is the most important element of chronic wound management, and the use of holistic techniques enables practitioners to make informed clinical judgements. Doppler ultrasound is integral to the holistic assessment of leg ulcers. This article reviews the procedure for measuring ankle/brachial pressure indices using Doppler ultrasound and outlines various diagnostic tests that employ the Doppler principle.

PICCs: how Doppler ultrasound can extend their use.

Peripherally inserted central catheters were relatively unknown in the UK five years ago. Now, however, they are used in more than 100 centres around the country. PICCs have played a key role in improving vascular access for a wide range of patients and the growth in their use has been nurse led. This article explains how nurses can help to extend the use of PICCs to a group of patients who have traditionally been excluded, those with apparently inaccessible antecubital fossa.

Cambio de técnica de punción de la fístula arteriovenosa nativa a partir de los hallazgos ecográficos / Changing the arteriovenous fistula (avf) needling technique based on the ultrasound findings

Introducción: La técnica de punción en área debe evitarse siendo la técnica escalonada de primera elección en la mayoría de los casos. Objetivo: Identificar a los pacientes portadores de una fístula arteriovenosa nativa que se puncionan mediante la técnica del área y que son susceptibles de cambiarla por la técnica escalonada a partir de los hallazgos obtenidos mediante la exploración mediante ecografía doppler. Pacientes y métodos: Los enfermos del estudio son enfermos tratados mediante hemodiálisis asistida (HD) tres veces por semana que cumplen los siguientes criterios de inclusión: Edad superior a 18 años, prevalentes en programa de HD crónica, con acceso vascular permanente tipo fístula arteriovenosa nativa humeral o radial y puncionado mediante la técnica del área. El método de exploración de la fístula arteriovenosa nativa fue la ecografía doppler portátil. Los parámetros ecográficos se determinaron por duplicado y fueron los siguientes: flujo sanguíneo de arteria nutricia (ml/min), diámetro y profundidad del segmento de vena arterializada que no se punciona (cm). Se diseñó un estudio transversal y observacional que se efectuó durante el mes de enero de 2016. Resultados: De un total de 63 pacientes prevalentes en HD crónica, se registraron: 24 fistulas arteriovenosas protésicas o catéteres y 39 fístula arteriovenosa nativa. De éstas, sólo 9 se puncionaban mediante la técnica de área (14,4%): 6 humerobasílicas y 3 humeroperforantes (edad media 73,0±13,3 años, 77,7% con alguna comorbilidad). Respecto al resultado de los parámetros ecográficos, se objetivó una media de 0.7± 0.3 cm de diámetro y 0.5± 0.3 cm de profundidad en el segmento de vena arterializada que no se punciona y el flujo medio de la arteria humeral fue de 1309,9± 966 ml/minuto. En la mayoría de los mismos fue posible utilizar directamente la técnica escalonada gracias a la ampliación de la zona puncionable de la vena arterializada utilizando la ecografía doppler. Y en dos enfermos, fue imprescindible la superficialización previa de la misma. Por tanto, todos los casos de técnica del área pueden ser potencialmente cambiados por la punción escalonada. Conclusión: 1) Se ha registrado una baja incidencia de utilización de la técnica de punción en área en nuestra Unidad de HD. 2) Según los resultados de nuestro estudio, es factible cambiar la técnica de punción en área por escalonada en todos los casos a partir de los parámetros morfológicos y funcionales obtenidos en la fístula arteriovenosa nativa. 3) La ecografía doppler portátil utilizada 'in situ' en la sala de HD es una herramienta valiosa que permite optimizar la técnica de punción de la fístula arteriovenosa nativa (AU)

Introduction: Most AVFs for hemodialysis (HD) should be punctured by the rope-ladder method. The area technique for AVF cannulation should be avoided whenever possible. On the other hand, cannulation guided by Doppler ultrasound (DU) can increase the success of difficult cannulation procedures. Objective: Identify the patients dialyzed through an AVF using the area technique for cannulation that are susceptible for changing to the rope-ladder technique based on the DU findings. Patients and methods: • During January-2016 we have performed a crosssectional observational study in the prevalent HD patients dialyzed through an AVF with two needles using the area technique for cannulation. • All patients were explorer by DU using GE Logic E(linear array 7.5 MHz) device. The following parameters were explored by DU: blood flow rate of the feeding artery (ml/min), diameter and depth of the arterialized vein segment that never was punctured (cm). All parameters by DU were measured in duplicated and the results were averaged. All determinations by DU were performed by the same explorer. Results: From 63 prevalent HD patients, 39 patients had AVF (61.9%) and, of them, only 9 patients (14.3%) were dialyzed through an AVF using the area technique for cannulation (mean age 73.0±13.3 years, 11.1% diabetic nephropathy, time on HD 53.6±26.9 months). All AVF were brachial artery-based AVF (6 brachiobasilic and 3 braquioperforating). The ultrasongraphic findings were the following: mean diameter 0.7± 0.3 cm, mean depth 0.5± 0.3 cm and mean flow 1309.9± 966 ml/min. Only two cases had the arterialized vein in more than 0.6 cm of depth and, therefore, they will need will perform a vein transposition procedure for apply the rope-ladder technique for cannulation. In the remaining cases (n=7), is possible to perform the rope-ladder technique immediately using DU by increasing the puncture zone extension in the arterialized vein. Conclusions: 1. It has been recorded a low incidence of area technique for AVF needling in our HD Unit. 2. It is feasible to change the needling AVF technique from area to rope-ladder technique in all cases by means of the morphological and functional parameters recorded in the AVF. 3. The portable DU used 'in situ' in the HD Unit is a valuable tool that allows to change the technique for AVF cannulation (AU)