Lower limb management

8 Lower limb management

Melanie Sutherland RN MSc

With over 2000 diagnoses, dermatology is a field of medicine in which specialisation is often required. Specialising in lower limb dermatology involves seeing patients who have been referred with various lower limb conditions, including those with leg ulcers that have failed to heal and ‘red legs’ dermatoses.

Nurses generally have more exposure to, and experience with, wound care and dressings than doctors. For this reason, dermatology nurses are often best placed to provide patients with ongoing treatment and prevention advice about lower limb conditions. Indeed, patients can benefit hugely from seeing an experienced specialist nurse with a wide range of knowledge and training on lower limb management. Managing complex problems related to the lower leg can significantly improve physical and psychological outcomes for patients.

Often, patients have had inappropriate treatment with no explanation of the cause, so being able to spend time educating the patient and leading them on an appropriate care pathway is hugely satisfying and rewarding.

The nursing role

Scope of practice. When developing new roles in specialist lower limb services, the BDNG role descriptors should be used as a guide to establish roles and responsibilities at different banding levels (see page 12).1 These can range from a staff nurse at band 5 to the highly specialist responsibilities of an advanced practitioner (band 8a) or nurse consultant (band 8b). The difference between these bandings will be determined by specific responsibilities, the extent of independent practice and the competencies required to successfully deliver care at that level. As with all dermatological nursing roles, the higher the band the greater the level of independent decision-making around patient diagnosis and treatment.

Table 8.1 summarises the technical tasks that can be undertaken at specific band levels. The nurse must demonstrate competence before working independently; this will include proving they have underpinning knowledge in each area. Competency frameworks must be developed alongside Trust protocols.

TABLE 8.1

Roles and responsibilities of dermatology nurses in lower limb management Skin biopsy

No

Follow up

Yes Yes Yes Yes Yes Yes Yes Yes Yes

New assessment

Lymphoedema Compression management

therapy

Yes – simple cases No

Yes Yes – simple cases No

Yes No

Yes – more complex cases

Yes

Doppler assessment (ABPI)

Wound care

Yes Yes Yes Yes Yes Yes Yes – under supervision Yes

Yes – assessment of new referrals under supervision Yes – assessment of new referrals

Yes

Yes Yes Yes

Yes Yes

Band

5 6 7 8a 8b

ABPI, ankle brachial pressure index.

The patient care setting. Patients are usually referred from community care to specialist dermatology services when a diagnosis is needed or when advice and a management plan is required for difficult-to-manage cases. Patients with lower limb conditions are often initially assessed by a dermatology nurse with advanced skills to ensure an accurate diagnosis as well as advising on skin care, dressings and compression therapy. Patients with more complex conditions may require joint review with the medical team, particularly if the patient requires systemic treatment or management of an underlying condition.

The key to successful lower limb services is joint working between primary and secondary care so that once specialist services have a clear diagnosis and management plan established, care is transferred back to the community.

Competencies

By band. The role of band 5/6 nurses is to provide patient education and skin care demonstrations, assess wounds, calculate ankle brachial pressure index (ABPI) and measure for appropriate compression therapy. Nurses at this level must be able to recognise the more common causes of ulceration – venous or arterial disease – and know when to flag this to a dermatology advanced nurse or doctor for further investigations when an ulcer does not seem to be responding as expected. Nurses at the higher bands (7/8) must be able to recognise and diagnose the causes of lower limb problems in addition to the roles required for the lower bands. Underpinning knowledge should include other ulcer aetiologies beyond venous/ arterial disease.

Advanced clinical skills. Appropriate clinical supervision must always be available, particularly as the dermatology nurse takes on more advanced roles in lower limb management. As medical colleagues rarely specialise in this field it may be that, for some aspects of the role, clinical supervision will need to be provided by senior nursing colleagues. Those wishing to develop specific technical skills, for example undertaking biopsies, should follow the guidance provided in Chapter 4 on skin surgery.

Advanced practice within the field of lower limb management can have huge benefits for patients, helping to ensure continuity of care and access to clear and well-designed patient pathways. Being able to offer diagnostic skills (including biopsy) and prescribe appropriate therapies (for example, antibiotics or topical preparations) will shorten the patient pathway and ensure treatment is promptly provided. Skin biopsies are usually undertaken to rule out or diagnose malignancies or other complex conditions such as vasculitis. It is important to be able to recognise when a skin biopsy is required, as unnecessary biopsies can further lengthen the patient pathway with risk of infection and slowed healing.

Patient education and support are key roles for the dermatology nurse. Lower limb conditions are usually chronic in nature and require long-term care and ongoing review. To facilitate effective patient education, consultation and communication skills are vital so that patients understand the fundamentals of their condition and what they need to do to help manage it. Developing an appropriate management plan must take into account patient abilities and preferences in order to optimise patient outcomes.

Often patients are jointly managed with community nurses; twoway communication channels need to be clearly established so that treatment plans can be shared. Patient passports can be useful tools to enable effective communication between primary and secondary care.2 Patient passports contain useful information that allows communication between different services, enables the patient to take control and encourages self-management. Passports usually include the patient’s details, contact details for district nurses or the leg ulcer clinic, aetiology of the leg ulcer, assessment details, and current and previously prescribed treatments. Key issues to discuss with patients are shown in Table 8.2.

Common lower limb conditions

Around two-thirds of wounds treated by the NHS are on the lower legs.3 Patients requiring lower limb wound care are primarily managed in community care settings and referred, as required, to specialist services in secondary care, such as vascular or

TABLE 8.2

Key education points to discuss with patients

• Basic description of the condition • Skin care: washing, drying and use of topical products (e.g. emollients and topical steroids) • Importance of elevation • Passive foot exercises • Importance of compression therapy • General lifestyle advice (e.g. weight management, stopping smoking) • When and how to seek further support

dermatology. There are numerous lower limb conditions; four of the most common are leg ulcers, cellulitis, red legs dermatoses and lymphoedema (Figure 8.1).

Leg ulcers. A leg ulcer is classified as a break in the skin, generally on a lower limb, which has not healed within 2 weeks;4 60–80% of leg ulcers are due to venous disease.5 Arterial ulcers or those of mixed aetiology are less common. Correct diagnosis of a leg ulcer can be challenging, so an HNA should be made. Indeed, anyone presenting with a wound on a lower limb that has failed to heal within 2 weeks should have a comprehensive assessment followed by a suitable treatment plan (see Assessment, page 130).6 Manchester University NHS Foundation Trust has published a useful example of a local leg ulcer pathway to assist with assessment and treatment decisions depending on clinical presentation. This has been adopted as part of NICE’s medical technology guidance for treating diabetic foot ulcers and leg ulcers.7,8

Acute or chronic inflammatory lower limb conditions, such as cellulitis, red legs dermatoses and lymphoedema, are also seen in specialist dermatology clinics. There is significant overlap in the management of these conditions. Dermatology nurses with training and skills in both wound care and oedema management, as well as experience with skin conditions, can provide huge benefits to patient outcomes.

(a) (b)

(c) (d) (e)

Figure 8.1 Examples of lower limb conditions managed by dermatology nurses: (a) leg ulcer; (b) bilateral red legs dermatosis, seen here with chronic oedema; (c) cellulitis; (d) lymphoedema and fungal infection; (e) venous eczema. Photographs (b) to (e) reproduced courtesy of Medical Illustration, Norfolk and Norwich University Hospital.

Cellulitis. The Clinical Resource Efficiency Support Team (CREST), set up in 1988 to promote clinical efficiency in the health service in Northern Ireland, provides the most recent guidelines on the management of cellulitis in adults in the UK.9 Cellulitis commonly occurs in the legs and is an acute bacterial skin infection that spreads rapidly if not treated.10 It develops following failure of skin integrity after trauma, surgery, insect bites or tinea infection, and often presents in patients with existing skin conditions such as eczema, psoriasis and lymphoedema. Patients can be successfully treated by their primary

care provider with oral antibiotics if treatment is started early; however, treatment delays often result in the cellulitis becoming progressively worse, requiring hospital admission for intravenous antibiotics.

Red legs dermatoses, such as lipodermatosclerosis and different types of eczema/dermatitis, are often misdiagnosed and treated as cellulitis. An audit of one UK service following transfer of care of patients with lower limb cellulitis from primary to secondary care found that nearly half of the patients had been misdiagnosed as having cellulitis and treated with unnecessary antibiotics.11 The rising incidence of antibiotic resistance through overprescribing12 emphasises the importance of an accurate diagnosis for red legs. The British Lymphology Society has developed a red leg pathway to ensure correct identification of the cause of red legs and to reduce incorrect diagnosis leading to overprescribing of antibiotics for cellulitis.13

Being able to make the distinction between red legs caused by a dermatological condition and those caused by cellulitis is a critical diagnostic skill. The key differentials are outlined in Table 8.3 (also see Figure 8.1).

Lymphoedema. Some dermatology services may also have a lymphoedema service. Often red legs or recurrent episodes of cellulitis can contribute to developing lymphoedema. Lymphoedema is a chronic incurable oedema caused by failure of the lymphatic system.14 This failure can have primary or secondary causes. Primary lymphoedema is a genetic disorder that develops from birth or later in life. It can occur anywhere in the body. Secondary lymphoedema is related to damage to the lymphatic system caused by cancer treatment, trauma, infections, immobility, obesity or venous disease. It is important to consider why a patient may have oedema in the limb when assessing the lower legs. Patients should be referred to a lymphoedema service if ongoing management is required.

TABLE 8.3

Differential diagnosis of cellulitis and venous eczema

Diagnostic feature Cellulitis Venous eczema*

Symptoms • Unilateral limb erythema • Pyrexia • Not itchy • Painful • Feels unwell • Nausea

Signs • Spreading erythema • Lymphangitis may be present • Hot to touch • Blistering History • Fast onset • Present for a day or a few days

Portal of entry

• Sometimes unknown but common entry points include tinea pedis, ulceration, insect bites Investigations • Blood tests – raised WBC and CRP • Blood cultures – often negative • Skin swabs can be helpful but sometimes negative growth • Skin scrapings and nail clippings to confirm fungal infections • Bilateral limb erythema but can present worse on one leg • Apyrexia • Itchiness • Tenderness • Fluctuating erythema • Crustiness • Weeping • Warm to touch • Present for months or years • Little or no response to antibiotic therapy • History of DVT • Varicose veins • Not applicable

• Blood tests and blood cultures – normal • Skin swabs – often

Staphylococcus aureus

*Also known as varicose, gravitational or stasis eczema. CRP, C-reactive protein; DVT, deep vein thrombosis; WBC, white blood cell count.

More complex lower limb conditions

As discussed above, most patients with lower limb conditions are cared for in the community. However, a small number of patients will require referral to secondary care for more complex and ongoing management under the care of a dermatologist (Figure 8.2). For example, patients with a confirmed diagnosis of skin cancer, having first presented with a non-healing leg ulcer, will revert to a skin cancer pathway. They may require a surgical procedure or non-surgical treatments, depending on the type of skin cancer (see Chapter 3). In addition, conditions such as pyoderma gangrenosum or vasculitic ulcerations will often require more complex management involving an MDT approach, which may include systemic medications requiring ongoing review (see Chapter 6).

Assessment

The importance of an HNA cannot be overemphasised as it enables the dermatology nurse to support the patient, ensures all aspects of care are considered and improves patient outcomes. ABPI is a fundamental part of the HNA and can improve patient outcomes as well as reducing costs; however, it is not performed widely enough.15 Table 8.4 outlines the key elements of an HNA.

Assessment must be undertaken in a suitable clinic environment. This should be a dedicated space with an appropriate couch, the height of which can be adjusted, facilities to wash lower limbs and access to appropriate paperwork, assessment tools, topical treatments and compression bandages.

Next steps

As a dermatology nurse wanting to specialise in this field, skills and knowledge related to general dermatology are a key starting point: for example, how to manage chronic inflammatory dermatoses. Next steps are to develop the relevant specialised knowledge base along

(a)

(b) (c)

Figure 8.2 Examples of conditions that require more complex management involving an MDT approach: (a) Marjolin’s ulcer (SCC); (b) pyoderma gangrenosum; (c) vasculitic leg ulcers. Photographs reproduced courtesy of Medical Illustration, Norfolk and Norwich University Hospital.

TABLE 8.4

Key elements of a holistic needs assessment for lower limb conditions

• Calculate ABPI • Assess skin, in particular noting signs of dryness, erythema or infection • Check interdigital spaces for signs of fungal infection • Note any general health problems • Take a comprehesive medication history • Assess level, type and duration of pain • Check previous dressings • Take vital signs, including temperature (especially if cellulitis is suspected) • Evaluate impact on quality of life • Discuss social situation, including who else is at home • Evaluate mobility • Determine need for other investigations (e.g. biopsy, wound swab)

with the skills needed to assess and manage lower limb conditions (Table 8.5).

Courses and training. There are various courses available for lower limb management. However, these often focus on specific aspects and do not cover all aspects of lower limb conditions. For example, a leg ulcer course may not cover lymphoedema, even though these conditions often overlap. Some of the courses count towards a postgraduate degree. Universities in Glasgow and Hertfordshire run chronic oedema and lymphoedema management courses. Many universities also run leg ulcer management courses locally, but content can vary. It is important to review these courses to ensure the content will cover your learning needs.

There are also many industry-developed e-learning modules. It is important to be aware that these are corporate with a focus on

TABLE 8.5

Core knowledge domains and clinical skills for lower limb management

Core knowledge domains • Different conditions that present on the lower limb • A holistic approach to assessment, including ABPI where appropriate • Stages of wound healing • Types of dressings • Theory and types of compression bandaging and garments • Types of oedema • Red flags and when to seek urgent advice • Skin care and application of topical therapies, including emollients and topical steroids • Pain management • Psychological support Core skills

• HNA • ABPI • Compression bandaging • Compression garments (measuring and application) • Skin care (e.g. emollients, topical steroids) • Wound dressings (according to stage of wound healing) Advanced skills • Skin biopsy • Diagnosis • Coordinating care in complex cases • Prescribing treatments • Leading discussions in MDT meetings

promoting products; however, they can be a good starting point in developing the relevant knowledge and skills.

Who to talk to. It is helpful to talk to colleagues who have specialised in lower limb management. The BDNG can also provide direction with regard to educational opportunities and people in your local area who can be contacted for further advice.

Personal reflection

I never thought about being a nurse in dermatology when I qualified; however, I was inspired by a nurse during a lecture on a local leg ulcer course. I joined dermatology in 2009 and have been encouraged to specialise in lower limb conditions, including lymphoedema and lower limb cellulitis. I encourage other nurses not to rule out specialising in this field as there are so many avenues within dermatology that nurses can focus on. Providing patients with information on their condition can be both rewarding and satisfying, especially when the condition improves.

Key points – lower limb management

• Initial assessment of patients with common lower limb conditions is often undertaken by a dermatology nurse with advanced skills. Most patients are cared for in the community, but those with more complex conditions are referred to secondary care for MDT review. • The importance of an HNA cannot be overemphasised as it ensures all aspects of care are considered and improves patient outcomes. • Nurses of bands 5–8+ undertake a range of responsibilities in lower limb management, including wound care, ABPI, compression therapy and follow up – the higher the band the greater the level of independent decision-making. • Dermatology nurses have a vital role helping patients understand the fundamentals of their condition and how to manage it. Being able to spend time educating patients and ensuring they follow an appropriate management pathway is immensely satisfying and rewarding. • Numerous lower limb conditions are managed by dermatology nurses, including leg ulcers, cellulitis, red legs dermatoses and lymphoedema. Accurate assessment of these conditions is a critical skill that can prevent misdiagnosis and inappropriate treatment.

References and resources

1. British Association of

Dermatologists Education

Board. Clinical Dermatology

Nursing Role Descriptors:

Guidance on Scope of Practice.

British Dermatological Nursing

Group, British Association of Dermatologists and Royal

College of Nursing, 2020. www.bdng.org.uk/wp-content/ uploads/2020/08/BAD-BDNG-

RCN-NURSING-WORKSTREAM-

A4-LANDSCAPE-002.pdf, last accessed 8 May 2021. 2. Wounds UK. Best Practice

Statement – Addressing

Complexities in the Management of Venous Leg Ulcers. Wounds

UK, 2019. www.wounds-uk. com/resources/details/bestpractice-statement-addressingcomplexities-managementvenous-leg-ulcers, last accessed 8 May 2021. 3. Guest JF, Ayoub N, McIlwraith T et al. Health economic burden that wounds impose on the

National Health Service in the

UK. BMJ Open 2015;5:e009283. 4. National Institute for Health and Care Excellence. Leg Ulcer –

Venous. National Institute for

Health and Care Excellence, 2021. https://cks.nice.org.uk/ topics/leg-ulcer-venous, last accessed 8 May 2021. 5. Scottish Intercollegiate

Guidelines Network. SIGN 120:

Management of Chronic Venous

Leg Ulcers. A National Guideline.

Scottish Intercollegiate

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Ulcers, Wounds and Non-Healing

Sores on the Leg. Legs Matter, 2022. https://legsmatter. org/help-information/forhealthcare-professionals/ ulcers-sores-and-knocks-onthe-leg-that-are-not-healing, last accessed 11 April 2022. 7. Manchester University NHS

Foundation Trust. Leg Ulcer

Pathway. Manchester University

NHS Foundation Trust, 2016. www.nice.org.uk/guidance/ mtg42/resources/manchesteruniversity-nhs-foundationtrust-leg-ulcer-care-pathwaypdf-6718514511, last accessed 11 April 2022. 8. National Institute for Health and Care Excellence. UrgoStart for Treating Diabetic Foot

Ulcers and Leg Ulcers. Medical

Technologies Guidance [MTG42].

National Institute for

Health and Care Excellence, 2019. www.nice.org.uk/ guidance/mtg42 9. Clinical Resource Efficiency

Support Team. Guidelines on the Management of Cellulitis in Adults. Clinical Resource

Efficiency Support Team (CREST), 2005. https:// legsmatter.org/wp-content/ uploads/2018/04/Cellulitisguidelines-CREST-05.pdf, last accessed 1 March 2021. 10. Phoenix G, Das S, Joshi M.

Diagnosis and management of cellulitis. BMJ 2012;345:e4955.

11. Levell NJ, Wingfield CG,

Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

Br J Dermatol 2011;164:1326–8. 12. National Institute for Health and Care Excellence. NICE

Impact Antimicrobial Resistance.

National Institute for Health and Care Excellence, 2018. www.nice.org.uk/media/ default/about/what-we-do/intopractice/measuring-uptake/ niceimpact-antimicrobialresistance.pdf, last accessed 1 March 2021. 13. Elwell R. Red Legs Pathway.

British Lymphology Society, 2020. www.thebls.com/ public/uploads/documents/ document-84341639738140.pdf, last accessed 8 May 2021.

Further reading and resources

British Lymphology Society www.thebls.com

Legs Matter https://legsmatter.org Lymphoedema Support Network www.lymphoedema.org 14. British Lymphology

Society. Lymph Facts: What is Lymphoedema? British

Lymphology Society, 2020. www.thebls.com/public/ uploads/documents/ document-78261580330781.pdf, last accessed 8 May 2021. 15. Wounds UK. Best Practice

Statement – Ankle Brachial

Pressure Index (ABPI) in Practice.

Wounds UK, 2019. www. wounds-uk.com/resources/ details/best-practice-statementankle-brachial-pressure-indexabpi-practice, last accessed 8 May 2021.

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