Encouraging patients to undertake a three-point leg check, as recommended by Legs Matter, is the first step in identifying individuals at risk of developing lower limb wounds.

The National Wound Care Strategy Programme (NWCSP) (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 NHS Futures Collaboration Platform.  

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: Chronic venous insufficiency (BMJ Best Practice).

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: Sclerotherapy of telangiectasias or spider veins in the lower limb: A review (Thomson, 2016).

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: Varicose veins: what is it? (NICE, 2024).

Pregnancy can cause mild lower limb swelling, 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 (BMJ Best Practice, 2023).

This is an opportunity for assessment and initiating the use of mild compression, as per NICE guidance - causes and risk factors.

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 NWCSP Recommendations for Foot Ulceration. 

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

Further tools and resources for skin tears 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). TIMERS: undertaking wound assessment in the community, British Journal of Community Nursing, 24(Sup12), pp. S22–S25. 

• World Union of Wound Healing Societies (2016). Position Document. Advances in wound care: the Triangle of Wound Assessment (PDF).

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:

• Acute infection
• Symptoms of sepsis
• Acute or suspected chronic limb threatening ischaemia
• Suspected acute deep vein thrombosis (DVT)
• Suspected skin cancer
• Bleeding varicose veins.

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 Lower Limb and Leg Ulcer Assessment and Management (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.