Leg Ulcer Nursing Care
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Direct answer
Roughly two-thirds of chronic leg ulcers are venous, a substantial minority arterial, and the rest mixed — and every leg ulcer nurse begins with the circulation, not the dressing. Assessment centres on the ankle-brachial pressure index (ABPI): about 0.8 to 1.3 is normal for compression, below 0.8 suggests arterial disease and contraindicates compression, and above about 1.3 signals calcified, incompressible vessels common in diabetes and chronic kidney disease. Venous ulcers in the gaiter area, with haemosiderin staining and lipodermatosclerosis, heal with sustained graduated compression (commonly 40 mmHg multilayer bandaging) plus simple non-adherent dressings; arterial ulcers need urgent vascular referral, not bandaging.
What you must remember
- Venous signature: shallow, moist, granulating ulcer above the medial malleolus, with oedema, haemosiderin staining, lipodermatosclerosis ("inverted champagne bottle" leg) and pain eased by elevation.
- Arterial signature: punched-out, dry ulcers over pressure points (toes, heel, lateral malleolus), night and rest pain relieved by hanging the leg down, absent pulses and claudication history.
- ABPI thresholds: about 0.8-1.3 normal; below 0.8 indicates arterial insufficiency — compression contraindicated, vascular referral mandatory; above 1.3 suggests calcification, so interpret with toe pressures or vascular review.
- Compression rules: graduated multilayer bandaging (commonly 40 mmHg at the ankle) for venous ulcers, applied only after ABPI confirms adequate arterial supply, re-applied weekly or when loose, always toes to knee.
- Dressing logic: compression heals the ulcer, not the dressing — simple low-adherent dressings beneath; heavy exudate may need an absorbent layer; avoid topical antibiotics.
- Infection markers: increasing pain, spreading erythema, warmth, purulence, fever — swab only when clinically infected and treat with systemic antibiotics guided by culture.
- Recurrence: healing takes months and recurrence is common, so compression hosiery after healing, skin moisturising, weight management and walking are lifelong prescriptions.
A teacher's ankle, worked through properly
A 58-year-old teacher presents with a six-month ulcer above the right medial malleolus, evening ankle swelling, brown staining and pain eased by elevation. The sequence: pulses palpated, ABPI measured at 0.95, glucose checked, and the ulcer read on TIME principles — granulating base, a little slough, no clinical infection, sloping edges. This is a venous ulcer with healing potential, and the prescription is four-layer compression.
Application is a taught skill: prominences padded, bandaging started at the base of toes with 50 per cent overlap, elastic layers at full stretch, finished below the popliteal fossa. She walks daily, because the calf muscle pump drives venous return. Weekly review checks ulcer, skin and edge; pain escalating, new numbness or blue toes within 24-48 hours of bandaging means remove and reassess immediately. Had the ABPI returned 0.65 with a dry punched-out heel ulcer and rest pain relieved by dependency, the pathway would flip completely: no compression, limb warm and dependent, analgesia and urgent vascular referral — the same bedside assessment producing opposite plans is exactly why the ABPI question recurs in nursing viva examinations.
Where students slip
The recurring error is treating compression as the universal answer to "how do you manage a leg ulcer" — applied to an ischaemic limb it can precipitate gangrene, so the complete answer begins "after ABPI confirms adequate arterial supply". The second slip is the pain logic: venous pain eases with elevation while arterial rest pain worsens when the leg is raised and improves when it dangles, a reversal students quote the wrong way round. Swabbing every ulcer is the third: colonisation is universal, so culture is reserved for clinical infection. Finally, an ABPI above 1.3 is not reassuring in a diabetic or renal patient — calcified vessels inflate the number, and compression decisions then need vascular input.
Frequently asked questions
Which leg ulcer type is relieved by dependency rather than elevation?
Arterial ulcers — rest pain improves when the leg hangs down because gravity marginally improves perfusion, whereas venous pain eases on elevation that drains oedema.
What ABPI value contraindicates compression bandaging?
Commonly an ABPI below 0.8: compression over critically reduced arterial supply risks further ischaemia and mandates vascular assessment instead.
Where do venous ulcers characteristically occur?
Over the gaiter area, typically just above the medial malleolus, in a limb showing haemosiderin staining, lipodermatosclerosis and oedema.
When should a leg ulcer be swabbed for culture?
Only when there are clinical signs of infection — increasing pain, spreading redness, warmth, purulent discharge or fever — because colonisation is universal and routine swabs mislead.
What is the role of walking in venous ulcer care?
Walking activates the calf muscle pump that drives venous return, so mobility plus compression is therapeutic; prolonged sitting or standing still undermines healing.