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Nurse looking at an older ladys leg

Identifying immediate and necessary lower limb care

Access guidance and practical resources to support you in identifying individuals at risk of developing lower limb wounds and delivering effective care.

Introduction

This resource provides practical guidance to help you:

  • support patients who may present with mild swelling and lower limb wounds
  • promote healing
  • reduce the risk of venous leg ulceration.

This resource is aimed at all primary care nursing staff involved in early wound prevention and care, for example, health care assistants, nursing associates and registered nurses. England has a wound care educational resource which outlines levels of practice for different nursing roles and could be applicable UK wide.

Research over the past decade has highlighted the wound care crisis in the UK and the impact on patient quality of life and health care resources.

 (PDF). It is a long-term condition that, when identified early, can be treated and its progression slowed. highlights that referral to a vascular specialist should be considered, as superficial venous surgery may be an appropriate treatment option for some patients.

The number of people affected by leg ulcers is rising. This is multifactorial but includes aging, obesity and patients living with multi morbidity. At the same time, .

There is a clear need to shift from a reactive approach to one centred on prevention, with an opportunity to reduce the growing impact of lower limb wounds and improve quality of life.  

Identifying patients at risk of poor lower limb health

Primary care nursing staff are often the first point of contact for patients who may be at risk, or who have current lower limb complications, which could develop into ulceration or poor skin integrity.

Encouraging patients to undertake a , is the first step in identifying individuals at risk of developing lower limb wounds.

The (2024) promotes early identification and prevention, providing guidance on ‘Immediate and Necessary Care’ to help stop lower limb wounds from deteriorating into venous leg ulcers and support healing.

As part of the early intervention strategy, patients may safely begin mild compression therapy (British Standard Class 1: 14–17 mmHg) without an Ankle Brachial Pressure Index (ABPI), as long as no red flags are present.

To provide immediate and necessary care safely, registered nurses can employ early intervention with mild compression without an ABPI by undertaking a red flag assessment before treatment.

See the red flag assessment section for more information.

Please note: NWCSP resources, such as ‘Improving Wound Care: Building on the NWCSP’ are now hosted on the .  

Primary care nurses can use standard health checks as an opportunity to examine lower limbs for early signs of venous disease, such as mild swelling (which often resolves overnight), mild varicose veins, ankle flare and spider veins.

Skin changes, including varicose eczema, dryness and hemosiderin skin staining are also early indicators of venous insufficiency. 

Corona phlebectatica (ankle flare)

Corona phlebectatica, or ankle flare, is a pattern of visibly dilated skin and capillary vessels on the ankle and foot that signals underlying chronic venous insufficiency (CVI) or vein disease. For more information visit:  (BMJ Best Practice).

Corona phlebectatica on a persons ankle

 

 

 

 

 

 

 

 

Telangiectasis spider veins

Telangiectasias, also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes. They are often the first visible signs of venous problems. For more information, visit: (Thomson, 2016).

Telangiectasis Spider veins on a persons leg

 

 

 

 

 

 

 

 

Varicose veins

Varicose veins are dilated, tortuous, superficial veins which most commonly affect the lower limb. They are often visible and palpable and are an indication of superficial lower extremity venous insufficiency. For more information, visit: (NICE, 2024).

Varicose veins on a persons leg

 

 

 

Pregnancy can cause , as it increases total body fluid and intra-abdominal pressure, both of which may cause venous distension. Hormonal changes during pregnancy also increase venous relaxation which may play a role in the development of varicose veins ().

This is an opportunity for assessment and initiating the use of mild compression, as per .

Oedema in pregnancy may indicate pre-eclampsia, and if anyone identifies concerns, they should make an urgent referral.

It is important to identify if there is a clear cause for the wound and/or swelling, for example, an injury, such as a skin tear or laceration.

You should then carry out a wound assessment as outlined within the structured wound assessment section of this resource. 

If the wound is on the foot, below the malleolus, this is classified as a foot ulcer and requires immediate referral to the multidisciplinary foot care service. For further guidance, refer to the . 

 

Lower Limb skin tear

 

 

 

 

 

 

 

 

Lower limb skin tear - Image used with permission of the International Skin Tear Advisory Panel (ISTAP™).

Further can be found on the ISTAP™ website.

 

 

 

Using a structured, evidence-based wound assessment framework is a useful way to support the assessment process. 

Examples include:

  • Lumbers M (2019). , British Journal of Community Nursing, 24(Sup12), pp. S22–S25. 

  • World Union of Wound Healing Societies (2016). (PDF).

The Triangle of Wound Assessment

Diagram showing the triangle of wound assessment

 

 

To deliver immediate and necessary care safely, registered nurses must first complete a red flag assessment, as outlined in the National Wound Care Strategy Programme (NWCSP) Leg Ulcer Recommendations Summary 2023. You should document that you have completed this in the medical notes.

Immediately escalate to the relevant clinical specialist and/or service those with the following ‘red flag’ symptoms/conditions. 

Suspected or confirmed:

  • .

Do not start compression therapy if any of these are present, as it may indicate serious underlying conditions requiring urgent medical attention.

Identifying signs of critical ischaemia

If limb-threatening ischaemia is suspected, assess peripheral perfusion using capillary refill time at the tips of the toes:

  • press firmly for five seconds, then time how long it takes to return to original colour
  • a normal refill time is under 3 seconds.

You should also assess:

  • skin temperature
  • skin colour.

If there are concerns about perfusion or critical ischaemia, refer immediately via local urgent pathways and do not start compression therapy.

For further information on lower limb assessment download the  (2024) (PDF).

 

Intact sensation

Before using mild compression, it’s important to assess sensation in the feet and check for signs of neuropathy. If there is a loss of sensation, the patient may not be aware if the compression stocking causes rubbing or damage.

In such cases, the use of British Standard Class 1 hosiery stockings is not recommended. If you have any concerns, follow your local referral pathways to escalate the issue. 

Immediate care of the lower limb

If the patient has a lower limb wound, the NWCSP (2023) leg ulcer recommendations advise the following immediate action:

  • cleanse the wound and surrounding skin
  • record a digital image of the wound
  • apply emollient to the surrounding skin
  • apply a simple non-adherent dressing, with sufficient absorbency (as per local guidance and formulary).

Further management

Arrange for a comprehensive assessment to be undertaken within 14 days, including ABPI. 

Necessary care of the lower limb

For those without red flags symptoms or conditions, offer mild graduated compression (British Standard Class 1: 14-17mmHg) and explain the reasons for compression therapy.  

Compression hosiery is primarily used to prevent venous ulceration because it improves blood circulation and reduces venous pressure in the legs.

Venous ulcers are caused by chronic venous insufficiency, where the veins in the legs struggle to pump blood back to the heart effectively.

This leads to increased pressure in the veins (venous hypertension) and poor blood flow, which can cause damage to the skin and surrounding tissue, eventually leading to ulcers. Compression therapy works by:

  1. Improving venous return: Compression stockings apply graduated pressure, which is stronger at the ankle and gradually decreases up the leg. This pressure helps push blood from the lower legs back toward the heart, improving circulation and reducing blood pooling in the veins.
  2. Reducing venous pressure: By promoting better blood flow and reducing the volume of blood that stagnates in the veins, compression stockings lower the pressure inside the veins. This helps prevent damage to the blood vessels and tissues, reducing the risk of ulcer formation.
  3. Enhancing the calf-muscle pump: The calf muscles act as a pump to help move blood through the veins. Compression stockings support this function by improving the efficiency of the calf-muscle pump, further aiding venous return.
  4. Preventing skin breakdown: Poor circulation can lead to swelling, skin damage, and inflammation, which increases the likelihood of ulcers. Compression helps minimise oedema and helps prevent the skin from breaking down.

By addressing the underlying causes of venous hypertension and poor circulation, compression hosiery plays a crucial role in preventing venous ulcers and improving overall leg health.

Following guidance from the NWCS on immediate and necessary care, compression stockings should apply mild graduated compression, of 20mmHg or less at the ankle. This would be equivalent to British Standard Class 1 hosiery:

  • Class 1 (mild compression): 14–17 mmHg
  • Class 2 (moderate compression): 18–24 mmHg
  • Class 3 (strong compression): 25–35 mmHg. 

Read the (Wounds UK 2021).

The practitioner needs to check that the patient has an appropriate limb shape to wear a mild compression stocking. It is important to check for a normal limb profile, where the ankle circumference is smaller than the calf circumference.

The material of a British Standard Class one stocking is thin and elastic, with low stiffness. These stockings are not designed to support large amounts of swelling and if used in this instance, they are likely to create further problems.

Deep pitting oedema, skin folds, or irregular limb shape may indicate that the patient is not suitable for mild compression, and they should be referred for further assessment.

Offer first-line mild graduated compression to patients who have no red flag symptoms or conditions, intact sensation, a normal leg profile and a low risk of pressure damage over bony prominences.

Do not offer compression to patients with red flags. Refer them urgently for treatment, as recommended by the NWCS. 

For British Standard Class 1 stockings you generally need two measurements as a minimum: the widest part of the calf and just above the ankle bone. Always check the company requirements, as these can vary.

Patients should be prescribed a minimum of two pairs of medical British Standard Class 1 compression hosiery (one to wear and one to wash), every three months, to ensure the effectiveness of the compression.

This will show you how to measure and fit British Standard duo med soft compression hosiery.  

Image and video used with permission from medi UK.  

Compression stockings measurement diagram

It is important to ensure the patient, or their carer/family, can apply the hosiery. There are a variety of donning and doffing aids that are available on prescription.

Wearing rubber gloves with soft interior linings can aid grip during application and removal of all types of compression stockings.

Video resources (YouTube)

  • Accelerate: . This video demonstrates various tools and techniques to guide the application and removal of compression garments, enhancing patient and clinician comfort and independence.
  • Accelerate: . This video explains how using mild compression for a new wound, skin tear or laceration on the lower limb can help prevent deterioration and support healing. 

Onward referrals should be considered when further assessment or specialist expertise is needed. Local guidance should outline the appropriate circumstances for referral and specify the relevant services or professionals. 

Examples include:

  • local leg ulcer clinic/community leg club
  • vascular specialist for diagnosis of venous disease and/or arterial disease and possible vascular intervention
  • lymphoedema specialist
  • dermatology
  • tissue viability nurse
  • 14-day holistic assessment. 

Patient education is key to ensuring effective use of compression therapy. Clear, straightforward guidance should be provided to help patients understand how to use their treatment confidently, such as:

  • Get used to the compression hosiery gradually by wearing it for short periods—the hosiery should never feel uncomfortable or painful to wear; however, patients may notice a feeling of compression or squeeze when they are worn.
  • The stocking should lie evenly and smoothly without creases. It should not be rolled over at the top, as this will affect the compression and may cause skin damage.
  • Patients should be prescribed two pairs at a time and be replaced every three months.
  • Hosiery should be washed by hand or on a gentle machine wash (depending on the manufacturer’s instructions). Do not use fabric conditioner, dry on a radiator or tumble dry, as this may damage the compression fibres and reduce effectiveness.  
  • Advice on daily wear time, skin care and how to monitor for discomfort or changes (for example, increased pain, tightness or new symptoms).

 

Once compression therapy has started, be alert to red flag symptoms that may indicate complications or require urgent referral. These include:

  • clinical signs of infection, such as increased exudate, malodour, erythema or swelling around the wound – the patient may feel generally unwell with pyrexia
  • increased pain or swelling in the affected limb
  • altered sensation or numbness in the limb
  • persistent skin changes or discolouration to the leg or toes (skin colour should return to normal within 15 minutes of removing stockings).

If any red flag signs or symptoms are identified whilst the patient is wearing compression hosiery, follow your local referral pathway immediately. 

Conclusion

Early identification and intervention in lower limb wounds is vital to prevent deterioration and reduce the risk of venous ulceration. When red flags are excluded, mild compression therapy can be safely started in primary care to support healing and improve outcomes.

Consistent education, assessment and referral pathways are key to successful long-term management and prevention.

Compression therapy plays a crucial role in reversing the effects of gravity in the lower limb and promoting wound healing. Mild compression can be safely used as part of first-line treatment to support recovery and help prevent the progression of venous disease.

In the absence of red flag symptoms, an ABPI is not required to begin immediate and necessary care. Where wounds are present, a holistic assessment should be arranged within 14 days.

Ultimately, a shift in mindset is needed—from reactive wound management to proactive prevention. Primary care nursing staff are well placed to lead this change and embed a preventative approach to lower limb care. 

Accelerate (2020). .

British National Formulary (2025). .

Clemett, VJ (2025). . British Journal of Nursing, Vol 34, (15), pp S20-S26.

Dowsett C and Hall Y (2019) , British Journal of Nursing, 28(6), pp. S17–S21.

Gray TA, et al. (2018). . BMJ Open 8(3): e019440. doi: 10.1136/bmjopen-2017-019440.

Guest J, Ayoub N, McIlwraith T, UchegbuI, Gerrish A, Weidlich D, Vowden K, Vowden P (2015) . BMJ Open 5(12): e009283 - live link - Health economic burden that wounds impose on the National Health Service in the UK - PubMed

Guest JF, Fuller GW, Vowden P (2018) . Int Wound J 15(1): 29–37 - Live link - Venous leg ulcer management in clinical practice in the UK: costs and outcomes - PubMed

Guest JF, Fuller GW, Vowden P (2020) in 2017/2018: update from 2012/2013. BMJ Open 10(12): e045253 – live link - Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from 2012/2013 - PubMed

Guest JF, Fuller GW (2023) . BMJ Open 13(2): e068845 – live link - Cohort study assessing the impact of COVID-19 on venous leg ulcer management and associated clinical outcomes in clinical practice in the UK - PubMed

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Legs Matter (2023). .

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Legs Matter.  Information for healthcare professionals.

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Saliba-Júnior, O. A., Rollo, H. A., Saliba, O., & Sobreira, M. L. (2022). . Jornal vascular brasileiro, 21, e20210101. https://doi.org/10.1590/1677-5449.210101

Skills for Health (2025). . 

Smyth, K (2024) Can GPNs stop leg ulcers in their tracks (PDF). Journal of General Practice Nursing. Vol 10 (3), pp 62-66 

Staines K & Mitchell A (2024). ‘Assessment of leg ulceration’ in Mitchell A, Ritchie G & Hopkins A (eds.) . Chichester: John Wiley & Sons Ltd, pp 226-284.

Vascular Society of Great Britain and Ireland (2018).  (PDF).

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