Lower limb wound care of patients in a community setting (G135)

The purpose of this document is to standardise the type and frequency of care for adult patients in the community setting, assisting all clinical staff including registered and skilled non-registered nursing staff to:

1. Ensure staff identify type and location of wound timeously.
2. Improve understanding of wound dressing selection and adherence to dressings formulary.
3. Improve the use of National Association of Tissue Viability Nurses (NATVNS) paperwork to document progress and highlight changes in patients’ condition.
4. Advise staff when to perform ankle brachial pressure index (ABPI) and apply compression.
5. Any ankle or foot wound is referred direct to Podiatry.
6. Encourage timeous referral to other services as appropriate.
7. Provide standardised care of all patients with a lower limb wound across the three H&SC partnerships.
8. Support the use of NATVNS, Venous Leg Ulcer Pathway and ABPI (G1326) (Appendix 1) to guide clinical decision making, treatment and onward referral

This SOP applies to:

1. Registered nurses who are involved in lower leg wound management.
2. Non-registered practitioners who are involved in wound care as per care plan.

1. A lower limb wound can be defined as a wound of any origin located anywhere below the knee, including the foot and ankle.
2. PECOS: Professional Electronic Commerce Online System.
3. NATVNS: National Association of Tissue Viability Nurses.
4. ABPI: Ankle Brachial Pressure Index.
5. SWAAG: Scottish Wound Assessment and Action Guide (Appendix 2)
6. Scottish Ropper Ladder for infected wounds (Appendix 3)

• Staff should have a sound knowledge and understanding of the wound assessment process and relevant documentation.
• Staff should be able to recognise and confidently take appropriate action if indicated.
• Registered staff in each base must complete an appropriate programme of education and be deemed competent in the use of ABPI and carrying out fully comprehensive holistic assessment.
• The minimum standard of education is the leg ulcer training as provided by the Tissue Viability Service, additional face to face training is also available.
• Practice must always be in accordance with local guidelines and procedures.
• All staff are accountable for their own practice.
• Non registered nurses must follow care plan as relevant to each patient.

This SOP covers all adults referred to Community Nursing clinical care with a lower limb wound.

Referral received

• Referrals received will be processed and allocated in line with local service provision.
• Visit is triaged depending on clinical need as outlined in referral.

Wound assessment and plan of care

Initial visit

1. Registered Nurse to carry out initial patient visit to assess patient and plan care.
2. Assess wound and document as per NATVNS for wounds.
3. Dress wound in line with Ayrshire & Arran formulary.
4. Commence nursing documentation and nursing notes.
5. Commence Lower Limb Wound Care Flowchart (Appendix 4)
6. Forward plan appointment on ehealth system. The frequency of visits should be agreed after the patient has had their initial assessment and a rationale documented in the patients records and care plan. The course of treatment and subsequent visits required will depend on the assessment i.e. if the wound is venous or arterial with appropriate wound dressings supplied.
7. Supply/prescribe two weeks of appropriate dressings from stock.

Subsequent visits

1. All staff i.e. unregistered staff and student nurses can visit and provide care once an assessment and care plan is in place. Registered nurse should visit at least every 4th visit.
2. Assess patient and evaluate suitability of care plan as implemented.
3. Dress wound according to Scottish Wound Assessment and action guide, SWAAG and Ayrshire & Arran Formulary.
4. Complete all documentation by third visit. Documentation required includes:
   • Nursing profile.
   • Patient care plan.
   • Risk assessments i.e. waterlow, moving and handling, falls, malnutrition screening tool.
   • NATVNS wound assessment chart.
   • leg ulcer assessment tool (Appendix 5)
5. All documentation must be dated, timed, initialled and signed.
6. Two weeks after referral, patients with non healing wounds should progress to ABPI. Subsequent treatment depends on this examination e.g.
   • compression therapy
   • swabbing suspected infected wound/antibiotics as per Scottish Ropper Ladder for infected wounds
   • topical steroid as per steroid/emollient ladder.

Implementation and evaluation of treatment

1. Subsequent visits will be assessed and carried out dependent on clinical assessment and patient need.
2. Registered staff will evaluate and update care plan as necessary.
3. If staff are in any doubt about what to do, their competency to deal with the situation, or are concerned about the patient’s skin or wound, they should seek help from the Charge Nurse as soon as possible who will then escalate as appropriate. These include:
   • suspicion of infection
   • cellulitis
   • DVT
   • malignancy
   • vascular changes which require prompt escalation.
4. Registered staff should be aware of the following:
   
   • All foot and ankle wounds should be referred to Podiatry.
   • Cellulitis, wounds suspicious of malignancy or DVT should be promptly referred to the GP.
   • Pressure ulcers, grade 2 or above, in patients on caseload should be reported on Datix.
   • Consider liaison with Tissue Viability Nurse (TVN).
   • Vascular referral depending on results from ABPI.
   • Consider ANP/SPDN involvement.
   • Health promotion advice eg nutrition, smoking cessation, elevation of legs/exercise to be given and documented, resources provided to patient/carers/families.
   • Pain control.
5. Patient is discharged from caseload when wound is considered healed and compression hosiery therapy supplied if appropriate.
6. Patient advised to contact District Nursing Service for their annual ABPI.

NHS Ayrshire & Arran Assessment & management of leg ulcer including ankle brachial pressure index (G126)

Scottish Wound Assessment and Action Guide (SWAAG) (healthcareimprovementscotland.org)

Scottish Ropper Ladder for Infected Wounds

Lower limb wound care pathway

Leg ulcer assessment tool