Question from practice: Compression dressing for a leg ulcer
A. Treatment of leg ulcers frequently consists of two different strategies: wound management and treatment of the underlying causes. Whether there is cause for concern here depends on the type of ulcer and the dressing regimen being used.
Although approximately 70 per cent of leg ulcers are venous, ulcers can also occur due to arterial disease (eg, atherosclerosis), rheumatoid arthritis or diabetes. It is important to find out what type of ulcer is being treated. It is also important to establish whether compression therapy is being used, or whether the tightness is due to the wound dressing itself or additional bandaging over a primary wound dressing.
The dressings used will depend on the health of the wound and the quantity of exudate being produced. For example, management of a highly exuding wound might include foam or absorbent pad dressings and the fixings (eg, adhesive borders, tape) can cause some local tightness.
The form of constriction described in this case suggests that there is bandaging over the area, which may either be compression bandaging or retention bandaging.
Compression therapy is often used in the treatment of venous leg ulcers. The aim is to produce pressure at the ankle that decreases moving up the leg, in order to reduce venous pressure and increase venous return, so that healing is promoted. Compression therapy can include:
• Graduated compression hosiery
• High compression bandages
• Short stretch compression bandages
• Multi-layer compression bandaging systems
Graduated compression hosiery is used in active ulcer management as well as in chronic venous insufficiency or oedema and to prevent venous ulceration. Hosiery is available in three compression classes, providing a specific range of pressures at the ankle. Once the ulcer has healed a lower degree of compression may be used as a preventive measure.
It is important that the leg is measured as specified by the manufacturers to ensure that the gradient is maintained. An incorrect fit or localised pressure on skin and underlying tissue can result in a number of problems, from exacerbation of underlying conditions (eg, worsening of venous insufficiency) to necrosis. If the gradient is reversed — so that the pressure is greater at the calf than the ankle — serious complications can also result.
Inappropriate constriction can occur, even with correctly fitted compression stockings, if rucks are allowed, causing localised areas of high pressure. A study of anti-embolism stockings used in hospital found rucking to be a more common problem with thigh-length stockings. Although rucking has not been studied specifically in compression hosiery in chronic care, fit should be considered as a potential issue (particularly if a patient is using thigh-length hosiery) because there is risk of not getting the compression evenly distributed when the hosiery is put on each day.
High compression bandages (eg, Setopress, Tensopress) are applied at full stretch to produce a high compression gradient, overcoming venous insufficiency. The target pressure at the ankle is at least equivalent to class 3 compression hosiery (25–35mmHg), and patients not used to compression therapy can find the sensation strange.
Issues related to inappropriate, localised or uneven compression can arise after each dressing change depending on the nurse’s level of experience and bandaging technique.
Short stretch compression bandages (eg, Actiban, Silkolan) are also applied at full stretch and experience is just as important to ensure correct use. Localised pressure is less of an issue because the bandages are applied over padding (which is used to smooth the contours of the leg and distribute pressure more evenly over a greater area, eg, K-Soft) but the issue of compression gradients going in the wrong direction may still be a cause for concern.
Multi-layer compression systems are a commonly used alternative to compression bandaging. They consist of two, three or four layers and complete kits are available on prescription (eg, System 4, K-Four, Profore). The four-layer system consists of padding, crepe, a compression layer and a cohesive bandage layer. The padding is retained and compressed by the crepe bandage. The cohesive bandage layer provides additional compression and retains the compression bandage layer as well as preventing slippage of the bandaging. Although there is wide experience of the use of multi-layer systems good application technique is still critical for effectiveness and safety.
Non venous ulcers
Compression therapy is contraindicated in ulcers caused by underlying arterial disease because it can lead to skin and tissue necrosis, potentially resulting in limb amputation. Lightweight conforming bandages (eg, K-Band, Acti-Wrap) or elasticated tubular bandages (eg, Tubigrip) may be used to retain dressings being used on the ulcer. If this patient’s leg ulcer is not venous, it is possible that inappropriate compression is occurring due to the use of retention bandaging.
Slippage and gathering of the bandages may cause a tourniquet effect, which will produce compression at specific points on the leg. Localised compression can occlude blood flow in the skin and lead to necrosis in serious cases, particularly if there are other underlying issues such as diabetes.
It is important to check the patient’s understanding of the type of ulcer being treated. The wound management plan can be evaluated and this can be discussed with the community nurse or GP. For example, not all dressings require retention bandaging. If the leg is inflamed, even a light retention bandage can cause constriction. It is also important to ensure that no nerve damage is occurring due to underlying disease. For example, the pins and needles sensation may be caused by diabetic neuropathy and such cases need specialist input.
Whether the patient’s wound management consists of compression therapy or not, it is important that the health of the areas of the legs most likely to suffer pressure damage (ie, those with minimal soft tissue coverage, such as the shin or the top [dorsum] of the foot) is assessed. It may be possible to ask whether any additional sores or tender areas of skin are apparent at dressing changes. Emerging damage in bony areas may suggest inappropriately applied bandaging, whether for compression or retention and, with the patient’s consent, his GP should be alerted to such concerns.
Ultimately, if the patient is being treated for venous ulceration and you are confident that the compression is being appropriately managed, the discomfort may be an unavoidable factor of treatment.
Failure in compression therapy is sometimes caused by patient intolerance and lack of compliance, which may lead to the decision to reduce or discontinue it. This can compromise the healing rate of the ulcer and can also impact on ulcer prevention. Care should be taken in these cases to ensure that patients do not miss dressing change appointments.
If compression therapy is a recent addition to the patient’s management plan, reassurance that the pressure is a desired outcome and an explanation of why pressure is needed may be sufficient to put this woman and her husband’s minds at rest.
Citation: The Pharmaceutical Journal URI: 11093700
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