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:
http://aawconline.org/professional-resources/resources/
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
Skin
Wound
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:
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–
–
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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
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–
–
–
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:
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–
–
–
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Nutrition
Circulation
Infection
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