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Assessment and good technique are key to effective compression therapy

Karen LayFlurrie, RGN, DPSN.

Staff Nurse and Tissue Viability Support Nurse at West Herfordshire Hospitals NHS Trust

With the extension of nursing roles to encompass specialist skills, wound-care nurses are among those who have been given greater responsibility. Their role now covers the application of compression therapy, which has been cited as the most desirable treatment for managing patients with venous leg ulceration (Mear and Moffatt, 2002).

With the extension of nursing roles to encompass specialist skills, wound-care nurses are among those who have been given greater responsibility. Their role now covers the application of compression therapy, which has been cited as the most desirable treatment for managing patients with venous leg ulceration (Mear and Moffatt, 2002).

Compression therapy involves the deliberate application of pressure to the body and is most frequently used in treating venous disorders of the lower limb, for example venous ulceration, varicose eczema, oedema and varicose veins (Charles and Lindsay, 2004). It is also used in the maintenance phase of treating lymphoedema. This condition may be primary in origin, that is, congenital, or secondary, where it is caused by damage to the lymphatics as a result of surgery or radio- therapy (Mallett and Dougherty, 2000).

Compression is used for patients with venous disorders to help reduce blood pressure in the superficial venous system and to promote venous return by increasing blood flow in the deep veins. The reduction in pressure differences between capillaries and tissues also helps to reduce oedema (Dowsett, 2004). Thus, in a patient with lymphoedema, compression therapy will help maintain a limb's normal shape (Mallett and Dougherty, 2000).

Sub-bandage pressure
Sub-bandage pressure is a measurement of compression applied to a limb at the point of bandage application, which can be calculated using Laplace's law, which states that:

Sub-bandage pressure = Tension of bandage x Number of bandage layers / Circumference of limb x Width of bandage.

The pressure generated is achieved by a combination of factors: the tension of the fabric, the bandage width, the number of layers applied, and the circumference of the limb (Thomas, 2003).

Sub-bandage pressure will be greater in people with smaller ankles and less in those with larger ankles. Likewise, a bandage of smaller width will create a greater pressure than one that is wider (Mear and Moffatt, 2002). The skill and technique of the nurse applying the bandage and the nature of any physical activity undertaken by the patient will also have an effect on the degree of compression provided (Clark, 2003).

Indications and cautions
High-compression systems are advocated for patients with uncomplicated venous ulceration - that is, the application of graduated compression with the highest pressure of between 30mmHg and 40mmHg at the ankle, reducing by at least 50% at the knee in a normally shaped limb (Charles and Lindsay, 2004).

However, great care must be taken to ensure that high compression therapy is not applied inappropriately. For example, compression in the treatment of arterial ulcers is dangerous (Stacey et al, 2002) and can lead to pressure damage to the tissues, which will result in further ulceration or may even necessitate amputation (Mear and Moffatt, 2002).

Caution should also be exercised when applying compression to patients with neuropathy, as their reduced protective response may increase the risk of tissue damage. Patients with cardiac failure should also be closely monitored. A rapid shift in fluid from the tissues back into the circulation could overload the heart. Patients with delicate skin, such as those with lymphoedema, may also be at risk of skin damage from high-pressure bandages (Marston and Vowden, 2003).

Assessment
Patient assessment before the application of compression therapy is vital and should include the measurement of the ankle brachial pressure index (ABPI) using a hand-held Doppler (Stacey et al, 2002).

The methodology for recording ABPI has been described in various texts (Ruff, 2003). However, it should be remembered that ABPI cannot confirm venous ulceration, it will merely exclude significant arterial disease (Vowden and Vowden, 2000). Furthermore, in patients with diabetes, the readings may be falsely elevated owing to calcification of the medial layer of the artery, which will prevent arterial compression (Ruff, 2003). Falsely elevated readings may also be attained in patients with renal failure, heart disease, oedema or in the elderly (Stevens, 2004).

In these groups of patients, Doppler waveform analysis and toe pressure measurements are considered to be more reliable methods of assessment (Stacey et al, 2002).

Normal ABPI measurement is '1.0 but no greater than 1.3 (Charles and Lindsay, 2004). An ABPI of 0.8-1.0 will indicate mild peripheral vascular disease, in which case standard compression therapy may be used.

A recording of 0.5-0.8 is an indicator of moderate arterial insufficiency and ulceration of mixed venous arterial aetiology. Reduced compression of between 15mmHg and 25mmHg may be used in these patients, who should also be referred to a vascular specialist.

It is essential, however, that such compression is applied only under the direction of an appropriately qualified specialist, such as a clinical nurse specialist or leg ulcer specialist, and that the patient is closely monitored because of possible restriction of the arterial circulation. Practitioners who are uncertain whether or not to use compression should consult their regional or trust guidelines for directions on appropriate patient management.

A patient with an ABPI of '0.5 will have severe arterial impairment. Any form of compression in these patients is contraindicated and an urgent vascular review should be sought (International Leg Ulcer Advisory Board, 2003).

Doppler ABPI is only one element of patient assessment before instigating the application of compression therapy and has no value when considered in isolation. Patient assessment should also include, where appropriate, ulcer history; general medical condition; an examination of the legs to include ankle circumference; social circumstances; and patient knowledge and understanding (RCN, 1998; SIGN, 1998). In addition, in patients with lymphoedema, any distortion in limb shape, change in degree of mobility or any neurological impairment should be noted, and limb volume measured (Mallett and Dougherty, 2000).

A thorough assessment will enable the practitioner to determine the most appropriate bandaging regimen for a patient. EWMA (2003) has outlined benchmark criteria for an ideal compression system in patients with uncomplicated venous ulceration. These state that effective compression therapy must be:

- Based on evidence-based research

- Capable of providing sustained pressure, maintaining clinically effective levels of compression for at least one week during walking and at rest

- Able to enhance calf muscle pump function

- Non-allergenic

- Easy to apply; training practitioners in the technique must also be straightforward

- Conformable and comfortable

- Durable.

Types of compression therapy
A variety of bandage systems is available. Choice will be governed by the following:

- Ulcer aetiology or degree of oedema

- Level of patient mobility and range of movement within the ankle joint

- Purchase and availability of bandage systems (Mear and Moffatt, 2002; Charles and Lindsay, 2004).

Short-stretch bandages

These are minimally extensible bandages that are applied at full stretch - the 'resting pressure'. The pressure beneath the bandage increases when the calf muscle is exercised - the 'working pressure'. This type of bandage is thus more appropriate for mobile patients who have some ankle movement.

It is important to assess a patient's ambulatory capabilities before applying the bandages to ensure that the therapy is appropriate for the individual (Charles and Lindsay, 2004). An ambulatory assessment chart has been devised although, as yet, it is not widely available (Lindsay et al, 2003). Practitioners should use their trust assessment form as a basis for obtaining the required information.

Short-stretch bandages are the bandages of choice for treating lymphoedema (Mallett and Dougherty, 2000). They may require more frequent application initially as they tend to loosen with the reduction in oedema (Charles and Lindsay, 2004). Examples of short-stretch bandages include Actiban and Actico (Activa Healthcare), and Comprilan (Beiersdorf).

High-compression elastic bandages

These are extensible bandages that expand or contract to accommodate changes in leg muscle expansion during the working phase. Caution should be taken not to overstretch this type of bandage (Charles and Lindsay, 2004). Examples are Setopress (SSL), Tensopress (Smith & Nephew) and SurePress (ConvaTec).

To date, there has been little research to compare the differences in outcomes in patients with uncomplicated venous ulceration treated using short-stretch bandages and those using elastic bandages (Stacey et al, 2002). Further research is indicated.

Multi-layer systems

These consist of three or four layers and usually contain a mixture of wool, crepe, elastic or non-elastic and cohesive or adhesive bandages (Charles and Lindsay, 2004). They may be available in 'kit' form; for example K-Four (Parema) or Profore (Smith & Nephew). The total pressure exerted is the combined pressure exerted by each bandage layer (Mear and Moffatt, 2002). The use of multi-layer compression systems has been shown to improve healing rates in patients with venous ulceration by comparison with single-layer reduced compression systems - it should therefore be the treatment of choice (Stacey et al, 2002).

Reduced compression systems

These systems provide 15-25mmHg of compression using a one- or two-layer bandage system (Stacey et al, 2002). A light compression bandage such as Elset (SSL) or Litepress (Smith & Nephew) will provide about 17mmHg to patients with an ABPI of 0.6-0.7.

Patients with an ABPI of 0.7-0.8 can be treated with a moderate compression bandage, for example, Coban (3M) or Co-Plus (Smith & Nephew), to provide 23mmHg of compression (Stevens, 2004). However, practitioners are advised to seek direction from their tissue viability or dermatology team or consult their trust's guidelines before applying such systems.

Patients who are unable to tolerate high-pressure regimens may benefit from reduced compression (Stevens, 2004).

Compression stockings

These provide between 35mmHg and 45mmHg of compression and are used largely for the preventive treatment of varicose veins or for venous ulcer recurrence (Mear and Moffatt, 2002). High compression of 40-50mmHg is usually advocated in the treatment of lymphoedema (Mallett and Dougherty, 2000).

Intermittent pneumatic therapy

Devices for this type of therapy provide short-term pressures of up to 100mmHg and can be used as an adjunctive therapy with multi-layer compression systems (Stacey et al, 2002). However, evidence for the routine use of this therapy is weak and studies to date have been small scale (Charles and Lindsay, 2004).

Application
Most compression bandages are applied using a spiral or figure-of-eight technique from the base of the toes to below the tibial plateau (Mear and Moffatt, 2002). Each turn of the bandage should be applied with equal tension and with a 50% overlap of the previous layer. Ankle circumference will need to be ascertained to determine the number and type of bandage layers used (Charles and Lindsay, 2004). Extra padding should be applied to bony prominences to reduce sub-bandage pressure and the risk of local tissue damage or necrosis (Mear and Moffatt, 2002).

Whatever bandaging regimens are chosen it is essential, if treatment is to be successful, that the patient is concordant with the regimen. Research has shown that there is a link between the level of pain experienced by a patient and their concordance with therapy (Edwards, 2003).

Furthermore, poor bandaging techniques have led patients to complain of increased pain, and patients have associated bandage tightness with the nurse's application of the therapy (Edwards, 2003). Bandaging that is too tight will affect concordance and therefore effectiveness, as patients may resort to cutting the bandages to relieve the tightness (Edwards, 2003). This may lead to further problems, and the patient being labelled as non-compliant.

Training
Only appropriately trained practitioners should apply compression therapy and undertake Doppler ABPI measurements (Mear and Moffatt, 2002). Training may take the form of university courses, study days or conferences (Charles and Lindsay, 2004). However, there may be little standardisation between courses. National guidelines also fail to clarify what 'suitable training' entails.

Trust or regional guidelines should specify the standards of competency a practitioner must achieve. Assessment will usually be in the form of supervised practice following theoretical study. The Hertfordshire Consensus Guidelines (West Hertfordshire Health Authority, 1998), for example, suggest supervised practice of five measurements using Doppler ultrasound and five compression bandage applications. This is the minimum requirement; some practitioners will require more practice. Tissue viability support nurses can assist clinical nurse specialists in training, mentoring and helping nurses to become competent in these skills.

Reynolds (1999) highlighted the difficulty of ensuring that nurses maintain their bandaging skills, and the propensity for nurses to overestimate their competency. Those practising compression therapy need to maintain their skills if they are to continue to practise competently. It is essential to target training at nurses in areas where the compression therapy is frequently used.

Tissue viability support nurses can help specialist nurses to identify and encourage practitioners to attend not only initial training, but also update sessions, and to use education providers such as universities and societies such as the Leg Ulcer Forum (www.legulcerforum.org).

Conclusion
The application of compression therapy is the mainstay of treatment for patients with uncomplicated venous leg ulcers. Inappropriate application of compression can be dangerous and a full clinical assessment including Doppler ABPI should be undertaken before therapy is initiated (Stacey et al, 2002).

There is a range of bandaging regimens, and any nurses applying compression should be aware of the latest guidelines and the standards of competency they are required to achieve.

Furthermore, practitioners should be aware that compression therapy is not effective on its own; they should therefore consider other issues, such as patient education, and providing advice on smoking cessation, exercise or nutrition.

Referral to dermatology or vascular teams should also be considered if the patient presents with any of the following: varicose veins, arterial ulceration, eczema or dermatitis that may indicate an allergy, or if they have ulceration that fails to heal within 12 weeks of compression therapy (West Hertfordshire HA, 1998).

Latest policy
National, European and local guidance on compression therapy

- The RCN (1998) and the Scottish Intercollegiate Guidelines Network (1998) have issued guidance on the application of compression therapy. These advocate the use of graduated multi-layer high compression systems for the treatment of uncomplicated venous ulceration. They emphasise that ankle brachial pressure index (ABPI) must be recorded using a hand-held Doppler before instigating any treatment. The APBI must be '0.8 to make patients eligible for treatment.

- Understanding Compression Therapy is a position document issued by the European Wound Management Association (2003), which contains a recommended management pathway.

Practitioners involved in applying compression therapy are advised to familiarise themselves with these documents, as they provide a detailed evidence base, particularly on using reduced compression therapy and referral criteria.

You are also advised to consult your local trust wound-care policies or local leg ulcer guidelines as these will give more specific advice on training needs and the assessment and maintenance of competency in compression application skills.

Case study: The management of leg ulceration
Presentation

Mary Brown, a 73-year-old woman patient, presented with bilateral cellulitis of her legs, reduced mobility and confusion. She had a two-year history of recurrent ulceration to her left leg and deteriorating ulceration to her right one. She was treated initially with a course of intravenous then oral antibiotics for the cellulitis.

An examination revealed superficial granulating ulceration to the shin and gaiter area of her left leg with surrounding eczema. The right leg had areas of 'punched out' sloughy ulceration to the lateral and medial gaiter, big toe and second toe. Eczema was also present on the right leg, and this was thought to be a possible allergy to the use of paste bandages. Ms Brown also complained of night and rest pain and having to hang her leg off of the side of the bed to reduce the pain.

Assessment and treatment

The patient's ankle brachial pressure index (ABPI) was recorded using a hand-held Doppler, which showed an ABPI of 0.94 to the left leg. Three-layer-bandage compression initially involved using wool, crepe and Elset (to give 17mmHg compression), with a view to increasing to four layers, if Ms Brown was able to tolerate the therapy. The right leg showed an ABPI of 0.67, prompting a vascular review.

A decision was made to investigate further using an angiogram. Compression was withheld until surgical intervention was completed, with a view to applying the therapy at a later date. Referral to the dermatologist was also instigated for patch testing in view of the presentation of eczema and possible allergy.

Ms Brown will be followed up in the leg ulcer clinic.

The patient's name has been changed.

Author's contact details
Karen LayFlurrie, Tissue Viability Team Office, Level 2, Verulam Wing, Hemel Hempstead General Hospital, Hillfield Road, Hemel Hempstead, Herts HP2 4AD. Email: karen.lay-flurrie@whht.nhs.uk

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