Mr. RU Swollen is referred to your clinic from his primary care provider. He walks into the clinic with an antalgic gait then rests in the waiting room. On examination, both lower extremities are edematous, the left greater than the right. He has purulent draining ulcers over the left foot and leg as well as the right leg. Pedal pulses are weakly palpable and his blood glucose level is 196 mg/dL. Should this patient receive compression for his lower extremities?
Compression therapy is considered a standard of care for chronic venous insufficiency (CVI) patients. A wound care practitioner’s instinctive response is to compress the edematous leg in an effort to control the cause of the wound rather than to simply dress the ulcer. Knowing when to apply compression, what compression or support to utilize, and how to safely compress are critical in the care of these patients.
The Overall Picture
Assessment. The bedrock of the treatment plan must be a comprehensive patient assessment. Through appropriate clinical testing, the root cause of the edema must be determined. Does the patient have lymphedema, CVI, or a combination of the two? Is the patient experiencing an acute flare or episode related to another diagnosis such as deep vein thrombosis or congestive heart failure (CHF) exacerbation? A thorough history and exam should rule out disease processes (eg, arterial occlusive disease) that would put the limb at greater risk with the addition of a compression therapy. If arterial patency is in question, comprehensive arterial studies should be done before compression therapy is applied. Special consideration and precaution should be given to diabetic patients who may have a deceptively elevated ankle/brachial index (ABI) secondary to disease related atherosclerotic changes and calcification of vessels.
If it has been established that the patient’s lower extremity arterial system is adequate and compression would be of benefit, the source of the swelling (ie, edema or lymphedema) must be determined. Patients with lymphedema ideally should have been seen and treated by a clinician trained in manual lymphatic drainage (MLD) and complete decongestive therapy (CDT), a certified CLT-LANA therapist. Although edema and lymphedema patients both are treated with compression therapy, the lymphedema therapy regimen may be quite different from the management of edema resulting from CVI.
Wrap of choice. Multiple types of compression wraps are available for use in wound clinics. Selection of the wrap or bandage type requires not only a comprehensive assessment of the patient and the wound, but also a thorough understanding of the patient’s lifestyle including occupational and social needs, shoe wear, and functional status. For example, a construction or landscape worker likely would be challenged to wear a wrap for a full week due to perspiration and potential for external soiling. Additionally, that same construction worker may be required to wear high boots that would not fit over a multilayered wrap. Missing work is not an option for this patient. What are the alternatives?
Access to multiple types of wraps and compression systems is not a supply redundancy. Rather, it is almost imperative for the wound center treating large numbers of patients with edema to have multiple options available to meet the needs of this large patient group. The ability to match the compression choice with the patient’s body, leg type and shape, occupation, shoe requirements, and the like is imperative.
Options for Compression
Tubular bandages. Tubular bandages are fabric tubes with horizontal rings of elastic. Used as single or double layer, available with latex or latex-free, they are supplied primarily in rolls, but also in single patient “unit dose” type of packaging. A single layer provides approximately 8 mm Hg of compression. Because they are available in a variety of graduated sizes, each manufacturer provides a measuring tape to determine the appropriate choice based on the size of the patients calf, and the degree of stretch, low, medium or high. While not an ideal delivery system for adequate long-term compression, these bandages are an alternative when vascular status is being evaluated or when other options fail. Tubular bandages can be removed at night and may be washed and reused.
Examples: Tubigrip (Convatec, Skillman, NJ), Comperm LF (Hartmann-Conco, Rock Hill, SC). (See Figure 1).
Long-stretch bandages. Typically, these elastic bandages offer sustained pressure over a longer period of time. They exert pressure from the outside of the leg, expanding and recoiling as the calf muscles contract and relax. These wraps often are inexpensive compared to wraps; they are are washable, reusable, and easy to apply. Most brands are available premarked with guides to indicate the appropriate amount of stretch. Cotton padding can be applied as a first layer to make the wrap more comfortable.
Examples: SurePress and SetoPress (Convatec, Skillman, NJ). (See Figure 2).
Multilayer systems. Provided in pre-packaged kits, multilayer wraps include a soft cotton padding as a skin-side layer that helps absorb skin moisture, provide padding to bony prominences, and add bulk and padding to the ankle, around the heel, and at the post-tibial area, helping to equalize the pressures exerted by the elastic layers. This graduated compression usually equals 40 mm Hg at the ankle.
Examples include: DYNA-FLEX (J&J, Somerville, NJ), Profore (Smith and Nephew, Largo, Fla), Proguide (Smith and Nephew, Largo, Fla). (See Figure 3).
A newer option to a pre-packaged multilayer wrap provides seemingly sustained short-stretch equivalency. This system includes a foam layer that molds to the shape of the lower leg and provides a more rigid compressive layer and is followed by a pre-stretched cohesive bandage layer. The overall effect is less bulky; even at greater stretch on application, patients find it comfortable and non-constricting. These wraps can remain in place up to 1 week although some patients may require twice-weekly applications. The length of wear of the outer wrap will drive the choice of primary ulcer dressing used.
Examples: DYNA-FLEX (J&J, Somerville, NJ ), Profore, Proguide (Smith and Nephew, Largo, Fla), and Coban 2 Layer (3M, St. Paul, Minn).
Paste bandages. Historically referred to as the Unna Boot, these paste bandages consist of roll gauze impregnated with zinc oxide, gelatin, and in some cases calamine. A self-adherent elastic wrap is applied over the paste wrap and the entire bandage dries to a semi-rigid bandage, providing approximately 30 mm Hg at the ankle. Unna boots can remain in place for up to 1 week and cannot be removed at night or for bathing.
Examples: Viscopaste (Smith and Nephew, Largo, Fla) and Unna-Flex (Convatec, Skillman, NJ) (See Figure 4).
Short-stretch bandage. Like the bandages previously mentioned, the short-stretch variety are applied from the base of the toes to the knees or above. Padding is applied directly to the skin, overwrapped by layers of dressing. Short-stretch wraps work well with the calf pump during ambulation and exercise. Although comparatively expensive, they are reusable and washable. Because of the rapid edema loss typically noted, they often need more frequent reapplication than other compression options.
Examples: Comprilan (BSN Medical, Hamburg, Germany) and LoPress (Hartmann, Rock Hill, SC).
Problems with wraps. Long-term management of edema often requires the patient to wear compression socks or stockings. Worn faithfully, the stockings can mean the difference between maintaining and not maintaining ulcer healing. Compression stockings come with inherent difficulties, not the least of which is cost. Ironically, the Center for Medicare and Medicaid Services (CMS) will pay for stockings only when the patient has an ulcer, as part of the Surgical Dressing Policy. Further, because compression can be adjusted as the edema reduces and the nature of the treatment lends to drainage and soilage, a disposable system may be preferred.
Stockings are a lifetime necessity. More than one pair is required, not unlike personal socks or stockings. This may cause patients to enter a cycle of repeated ulcerations if they cannot afford the stockings. Additionally, another more enduring challenge with stocking use is that appropriate application requires flexibility and dexterity, making use difficult for some patients.
Orthotic devices. Another long-term alternative for compression are orthotic devices consisting of inelastic straps that overlap and are secured with Velcro®. These devices are easier to apply, are durable, and therefore may be more cost effective than stockings.
Examples: Farrow Wrap®(Farrow Medical Innovations, Bryan, Tex), CirCaid®, (Coloplast Corp. Minneapolis, Minn).
Caveats for Care
Managing the patient requiring compression demands a definite level of competency and skill on the part of the staff and necessitates close attention to detail and patient follow-up. The following are important considerations in the management of the compressed patient.
Constant assessment. Changes in edema levels and the potential for high ulcer exudate (especially early in the treatment) require frequent assessment of the patient, leg, and ulcer. Care visits may need to be scheduled twice weekly early on, progressing to weekly unless the patient has home health care and the agency providing the care can provide the appropriate type of wrap as well as the skill level of the nurse changing the wraps in the home setting. Calf and ankle measurements should be assessed at each visit to confirm the adequacy of the edema management.
Hygiene and skin care. With each visit, the leg should be thoroughly washed and moisturized. This step is essential not only for the skin health, but also the patient’s sense of well being.
Footwear. Many wraps may prohibit patients from wearing not only the shoes worn into the clinic on the day of the initial wrap, but possibly all of their shoes. An inexpensive alternative to have on hand are standard post-op shoes. These can provide safe ambulation and foot protection and can last for the entire episode of care. (See Figure 5).
Prevent Sliding. Multilayer wraps tend to be thicker and heavier and as a result can tend to slide as one unit, especially in the case of very irregularly shaped legs. (See Figure 6). This effect can be lessened by wrapping the leg with adequate tension and can be reduced or avoided completely by applying a thick ointment to the leg such as Aquaphor®, (Bieresdorf AG, Hamburg, Germany), Dermabase®, (Paddock Laboratories, Minneapolis, Minn), or a non-gritty barrier ointment. This will cause the cotton layer to stick and reduce slippage. Additionally, this practice provides excellent moisturization.
Avoid wrinkles. Compression wraps may cause rubbing, discomfort, and possibly blistering, resulting in iatrogenic injury and further ulceration. Instructing the patient to dorsiflex the foot during the application of the wrap will place the foot in an ambulatory position that allows smoother wrap application. Additionally, the use of foam dressings to pad areas such as the anterior ankle and tibial areas, Achilles tendon, and metatarsal heads can provide protection and an added level of comfort. (See Figures 7&8).
Moisture-related skin damage. Wound exudate can cause maceration at the very least and skin breakdown at worst. A barrier ointment such as Calmoseptine®(Calmoceptine, Inc. Huntington Beach, Calif) for protection or Xenaderm® (Healthpoint, Fort Worth, Tex) can be applied before the dressing and the wrap. (See Figure 9).
Showering and bathing. The wrap applied for a week or even several days at a time makes personal hygiene a challenge because the wrap needs to be kept dry. Consideration must be given to the patient’s stability and strength and specific suggestions should be included in the patient education for bathing. Bathing at a sink is always an option, although not particularly acceptable one depending on the patient’s occupation and daily activity. Getting in a bathtub while keeping the leg out is another option but requires considerable upper body strength and mobility. Many patients will choose to shower with the wrap on and covered. Devices designed to keep dressings and casts dry have the added benefit of a non-slip surface at the foot. For the patient who chooses to shower with a plastic bag taped over the wrap, very pointed safety education must be provided to prevent falls. Having another person available for assistance or placing towels on the floor of the shower or tub to eliminate the slick surface can reduce the risk of falls.
Cohesive wraps can be sticky. The cohesive layer outer wrap tends to be a bit “tacky” at times, causing pant legs to cling, dirt and lint to adhere, and bed linens to restrict movement during sleep. Applying a plain stockinette can alleviate this problem and make it easier to put on shoes without catching the wrap and causing it to bunch-up at the foot. (See Figure 10).
Always have a contingency plan. Patient education is vital when compression therapy is used. A critical success factor is whether the patient will wear the wrap for the prescribed length-of-time and maximize the therapy. The patient who removes the wrap “since I was coming into the clinic anyway” can undermine several days’ worth of therapy. By the same token, the patient who does not remove the wrap when pain or injuries are occurring also may have problems.
Mr. Swollen indeed may be a candidate for compression therapy. Only a comprehensive patient history and assessment will determine if he should receive compression and, if so, the type of compression treatment and the length-of-time for the treatment verses support. As previously discussed, the patient’s physical/medical needs, occupational and social situation, functional abilities, and financial means must be considered in the compression decision. If any one of these factors is omitted from the equation, the patient may be doomed to failure. The clinician needs to remember that compression therapy is rarely a short-term treatment. Most patients with chronic lower extremity edema will require long-term compression therapy followed by life-long compressive support to prevent the recurrence of limb threatening ulcerations.
In wound healing clinics, there is a popular mantra: “Treat the whole patient, not the hole in the patient.” Clinicians always must remember that we are treating not just the wound or the edematous limb but also a disease process. n