1. AAWC Venous Ulcer Guideline
Content Validated, Evidence Based “Guideline of Venous Ulcer Guidelines”

2. 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:

3. 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.

4. AAWC VU Guideline Recommendation Strength of Evidence Ratings
Supported by at least 2 VU-related human:
randomized controlled trials (RCTs) for efficacy or…
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.
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
One A-level study without B-level support (C1), case series (C2) or expert opinion (C3)

5. 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

6. 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

7. 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)

8. 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

9. 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:
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

10. 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

11. 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

12. 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
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
It’s worth the effort!

13. Step 2: Venous Ulcer Prevention: Protect the Skin
Moisturize dry skin
Protect affected skin from
Irritation
Sensitization
Chemical injury
Physical trauma

14. 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:
Nutrition
Circulation
Infection
Physical therapy
Other as appropriate

15. 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

16. 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____

17. 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

18. 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.

19. 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