Nursing Interventions in Prevention and Healing of Leg Ulcers: Systematic Review of the Literature

Aim: The purpose of this study was to define nursing interventions for patients with venous, arterial or mixed leg ulcers. Methodology: A survey was conducted in EBSCO (CINAHL Plus with Full Text, MEDLINE with Full Text), MedicLatina, Academic Search Complete, with full text articles, published between 2008/01/01 and 2015/01/31, with the following keywords: [(MM "leg ulcer") OR (wound care) OR (wound healing)] AND [(nursing) OR (nursing assessment) OR (nursing intervention)]. Results: The different leg ulcer etiologies require different therapeutic approach to prevention and treatment. Predictive factors were identified associated with healing: patient-centred care, interpersonal relationship, pain control, control of the exudate, education for health self-management, self-care, therapeutic compliance, implementation of guidelines, auditing and feedback on the practices. Conclusion: Evidence-based practice helps to improve efficiency, safety and quality of nursing care directed to people with leg ulcers or at risk of developing this type of wounds.


Introduction
Currently, the needs of healthcare clients are increasingly demanding and complex, as a result of the increase in average life expectancy [1,2], and the resulting prevalence of chronic illnesses, such as leg ulcers. The possibility of ulceration increases with age, due to which an exponential increase in its incidence and prevalence is expected [3]. Leg ulcers can be defined as ulceration below the knee on any part of the leg [4], including the foot, and is classified as a chronic wound, that is, a wound that remains stuck in any of the phases of the healing process for a period of 6 weeks or more, or that requires a structured intervention of nursing care [5,6]. There are several known leg ulcer aetiologies, among which those of venous origin are the most common, at 70% of the cases, followed by those that are arterial in origin, at 10-20% of the cases, and those of a mixed aetiology, at 10-15% of the cases [7]. The main causes of the appearance of leg ulcers are chronic venous hypertension, arterial disease or a combination of the two [5,6]. The less-frequent causes are neuropathy, infection, vasculitis, neoplasia, blood and metabolic disorders, or lymphedema and disorders that are iatrogenic in origin [5,6]. The relevance of this problem is supported by statistics, in which 1.5-3 in every 1000 individuals have leg ulcers, with increased prevalence at higher ages, leading to 20 for every 1000 individuals aged more than 80 years [2,8]. The literature mentions that leg ulcers are interpreted as "a forever healing experience" [9,10], associated with the fact that 50% of the time, primary healthcare nurses are involved in treating leg ulcers, with the presence of pain in 49-90% of cases, where 50% of venous ulcers heal after 4 months, 20% of venous ulcers heal in between 4 months and 1 year, 20% require a period greater than 2 years to heal, 8% remain unhealed even after 8 years and 69-26% recur in the first year [9].
The repercussions of leg ulcers also have an effect on healthcare expenditure, wherein 1-2% of the total health budget in Western countries [11], of which Portugal is part, is directed to this type of chronic wound [4,12,13]. In European countries, an economical investment of approximately 6.5 million Euros/year is estimated in the treatment of leg ulcers [14]. Its impact interferes significantly with human lifestyles, affecting the performance of day-to-day activities, quality of life, functional capacity and self-esteem, leading to workplace absenteeism, financial problems, isolation, sleep disorders and the development of mental illness [15,16].
Hence, a systematisation is proposed of nursing interventions aimed at persons with venous, arterial or mixed leg ulcers. The process for searching and selecting material for analysis is explained in Table 1. Table 1. Process for searching and selection for the systematic review of the literature.

Results
In order to make the methodology used easy to understand and transparent, the list of 12 articles selected is explained (Table 2) for the body of analysis, which formed the basis for the preparation of the discussion and the corresponding conclusions, having been subjected to classification by levels of evidence. Case study-

Discussion of the data
The evaluation of the awareness, expectations, quality of social support, need for information enables the adaptation of education, training and instruction on healthy lifestyles, wound care, physical exercise and elevation of lower limbs in venous aetiology. The patient, on feeling involved, with the use of an easy-to-understand language, increases his or her motivation, selfefficacy and capacity for self-care [12].
The creation of spaces (Leg Clubs) has proved to be a fundamental strategy in therapeutic compliance [10], where nurses with specific training in the area of leg ulcers promote social interaction between patients with the same type of ulcer, evaluate the support required by each individual, provide training aimed at self-care and case management, provide the corresponding treatment and constant monitoring [4][5][6][7][8][9]. The result of the implementation of this project was the reduction in pain intensity, significant progress in healing and an increase in quality of life, specifically at the workplace, in moods, in mobility, sleep patterns and other aspects [10]. The positive effect of this model is also reflected at the social level [9], given that more extended social contact with people who have or have had the same problem, reduces social isolation and provides effective coping mechanisms for dealing with the crisis situation -the illness [3,4,16].

Venous ulcer Arterial ulcer Mixed ulcer • Apply compressive therapy if the
Ankle-Brachial Index (ABI) is greater than 0.8 • Select the type of compression to be used: multi-layer compression system below the knee (general treatment); reduced compression system (in case the patient does not tolerate higher compressions); compression stockings (after the ulcer's healing); intermittent compression system (can be used in isolation or together with another compression system, in order to increase venous return) • Select the compressive therapy material to be used: elastic bandages (long-stretch), considered more effective; nonelastic bandages (short-stretch), which cause less discomfort/pain; multi-layer elastic bandage systems (two, three or four layers); elastic stockings; multilayered elastic stockings; zincimpregnated bandage (Unna Boot) together with elastic bandages • Provide training in the following structural areas: control of associated pathologies; giving up smoking and drinking; encouraging the ingestion of food rich in vitamin B6 (increases HDL-C and reduces triglycerides), such as potato, banana, chicken breast, sunflower seeds, salmon, tuna, avocado, and others; prevention of chemical, thermal or mechanical trauma on the lower limbs; skin care; use of sui footwear and non-compressive stockings • Institute a regular physical exercise programme, for patients with intermittent claudication, based on 30-60-min walks (3 days a week at least), wherein the patient may stop and rest in case of pain • Refer to vascular surgery if: ABI is lower than 0.8; signs and symptoms of infection; continued pain at rest, even with the limb dropped; absence of both, pedis and posterior tibial pulses • If ABI is lower than 0.5, refer urgently for observation by vascular surgery Table 3. Nursing interventions in venous, arterial and mixed leg ulcers.

Worldwide Wound Healing -Innovation in Natural and Conventional Methods
On initial assessment, it is crucial to cover the history of health: associated co-morbidities, habitual therapy, psycho-emotional state, influence of odour on social life, nutritional state, presence and intensity of pain and individual treatment preference. In evaluating the amount of exudate, it is recommended to document the saturation of the absorbent dressing and support/compression bandage, instead of rating it as minimum (+), moderate (++) and high (+++), in order to increase the record's objectivity. If the perilesional skin is macerated, this indicates that the dressings must be applied more frequently, or that the selected material is not the most suited for controlling the exudate. In leg ulcers subjected to compression therapy, in venous aetiology, dressings that allow for evaporation of the exudate through their semi-permeable covering cease to be effective. In light of the above, the use of hydrofibre and alginates is recommended. The application of negative pressure on the wound bed and the use of protective sprays/creams on the surrounding area are measures to be considered in the case of ulcers with hard-to-control exudate [13,14].
The application of compression bandages is considered an essential element in the treatment of venous leg ulcers. The effect of compression on mixed leg ulcers can be beneficial in reducing local oedema, in improving microcirculation, contributing to improving arterial flow and improving venous as well as lymphatic drainage. Still, the application of compression on legs with mixed aetiology requires strong additional care, as it is generally contraindicated for the reduction of arterial flow, causing greater tissue damage, as shown in study [6], with the use of inelastic bandage. The number of layers to be applied is normally decided based on the malleolar circumference, based on the manufacturer's instructions (one layer is applied when the malleolar circumference is ≤25 cm, and two layers when it is >25 cm). However, in mixed aetiology, it is recommended to start the treatment with only one layer, for less-elevated compression levels. The interventions provided by specialist nurses when dealing with chronic wounds increase gains in health, due to their expertise in using tools for assessing compressive therapy: Doppler ultrasound and ankle-brachial index (ABI).
Concerning nursing interventions in the prevention and treatment of venous, arterial or mixed leg ulcers, it is fundamental to know the patient's clinical history (personal background, chronic pathologies, current state of the client) and the history of the ulcer (source, time, treatments performed) [6, 12, 14-16, 18, 22-24]. On meticulously evaluating the characteristics of the wound (size, depth, exudate, wound bed, type of tissues, perilesional skin, pain) [4,18], the decision must be made in partnership with the client ( Table 3) in order to establish common goals [15,[17][18][19][20][21].
Thus, the treatment must involve pain prevention [10], preparation of the wound bed [6][7][8][9], wound cleaning [14][15][16], management of products to be applied to the bed and perilesional skin [7], joint selection of the type of material for application of compressive treatment and preparation of a physical exercise plan [8, 14-16, 18, 22], continuous client empowerment [17], referral to specialities in case of allergic reactions [13], need for supplementary therapies and/or non-effective treatments carried out in which the ulcer/state of the client deteriorates.

Conclusions and implications for the practice of nursing
The presence of social support was the aspect most mentioned by the people as essential in their process of adaptation, whether provided by significant persons, or through contact with people in similar situations (self-help groups) or by the nurse. The education for health selfmanagement was considered of utmost importance in controlling other associated chronic illnesses, in the reduction of other existing risk factors and for creating physiological conditions that favoured better healing. The monitoring of the ulcer's characteristics, physical activity, nutritional diet, favoured healing and improved the perceived quality of life. Continuous and up-to-date training of nurses providing care to leg ulcer patients emerged as another aspect positively associated with the effectiveness and excellence of the interventions carried out.
An approach centred on the patient and on pain control, mainly when the therapeutic plan involves compression on the wound bed, is key determinants in increasing participation and involvement in the therapeutic plan.

Conflicts of interest
The author declares no conflict of interest.