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Practice question

A patient keeps loosening her compression bandages, so her ulcers are not healing. What can I do?

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Poor tolerance to compression bandaging is well documented (Van Hecke et al, 2008, Edwards, 2003). 

  • Exclude any underlying disease
  • Undertake a reassessment of the patient as a whole to ensure ulcer diagnosis is correct
  • Look for signs of dermatitis, which could be related to an allergy
  • Try switching to a different bandage system

Patients have cited pain and discomfort and lack of valid lifestyle advice as the main reasons for non-concordance (SIGN, 2010).  Clinicians are tasked with the job of establishing the cause of the discomfort.  To maximise good clinical outcomes, it is important that sufficient time is allocated to this process. 

Bandage discomfort can be attributed to a number of factors.  The first priority is to exclude any underlying disease processes, such as peripheral arterial disease, which could explain pain following the application of compression.  A Doppler assessment including calculation of the ankle brachial pressure index is advisable.  Referral to a vascular specialist is necessary if the cause of the pain is thought to be secondary to peripheral arterial disease.

Reassessment

It is helpful to undertake a reassessment of the patient as a whole to ensure the ulcer diagnosis is correct.  For example, an ulcer originally diagnosed as venous, may in fact be secondary to other aetiological factors such as vasculitis, which was perhaps overlooked at the first assessment.  In most cases, this would require compression to be discontinued and referral for specialist input. 

During the reassessment, attention should be directed to the clinical appearance of the affected limb.  Are there any “tell-tale” signs of pressure damage?  This may present as signs of erythema, blistering or purple discolouration.  Common anatomical sites include the tibial crest, malleoli, Achilles tendon and the dorsum of the foot.  For example, a reddened shin should prompt the clinician to apply additional wadding to offer greater protection.  It could also indicate that the bandages have been applied with too much stretch, resulting in excessive levels of compression.  Continued examination of the limb should include looking for any signs of dermatitis, which could be related to an allergy to constituents of the bandages.  This can be addressed by switching to a latex free bandage and protecting the skin with a cotton tubular stockinette bandage.

Application technique

If there is evidence of bandage slippage, the compression system and the application technique should be reviewed.  The correct placement of the wadding layer is essential to successful therapy.  For example, if the patient has an unusual limb shape where there is a steep gradient between the calf and the ankle, additional padding or foam is vital to achieve graduation of compression.  Bandage slippage can be uncomfortable as excessive bandage gathers around an area of the limb, sometimes causing ridging and skin irritation.  Failure to address poor limb shape can also result in uneven pressure distribution resulting in tourniquet effects.

Switching from one bandage system to another may also prove successful, for example selecting a system with less layers, an inelastic bandage or one that provides less compression overall.  Trying a staged approach to compression is sometimes successful, where the amount of compression is gradually increased over time.  Another option is to consider a hosiery kit.

It is helpful to question patients about the extent to which their legs are in the dependent position.  For example, are they struggling to get to bed and resorting to sleep in a chair?  Failure to elevate the limb effectively can result in increased venous congestion and discomfort. 

In some instances it may be useful to consider alternative therapies, such as intermittent pneumatic compression if the patient cannot tolerate bandaging or hosiery.

Pain associated with venous ulcers should not be under-estimated.  A comprehensive assessment process should address the presence, intensity, location and cause of pain and ensure an effective management plan is in place and evaluated on a regular basis.  Consider a referral to a pain team.

If despite a thorough reassessment, the clinician still requires further help, referral to a specialist practitioner such as a leg ulcer specialist nurse would be wise.

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