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Practice comment

Nurses need more training to ensure effective compression therapy for venous leg ulcers

  • 6 Comments

Nurses lack confidence in applying full compression and need to improve their skills, says Irene Anderson

 

Effective compression therapy is key to healing venous leg ulcers. However, practitioners must be properly trained and assessed as competent in applying compression bandages to ensure the treatment is effective and safe.

The term “evidence-based practice” is widely used and should be a goal for all treatments and methods of managing patients. Evidence should underpin all interventions, but for this to happen practitioners need to know what that evidence is and how to apply it.

When I talk to specialist nurse colleagues and to non-specialists attending study days, workshops and courses, it becomes apparent that there is sometimes a lack of confidence about applying full compression therapy. This may be due to lack of assessment data such as Doppler assessment of the ankle brachial pressure index, or a lack of confidence when applying compression therapy. The explanation given is that it “feels safer” to apply reduced compression just in case damage is caused to a patient’s leg, or because damage has occurred.

In some acute trusts, guidelines may indicate that compression therapy is suspended for inpatients. This pragmatic stance is based on the difficulties of ward staff gaining and maintaining bandaging competencies when there may be few opportunities to practise such skills.

Often patients are in hospital for a short time, their acute condition may impact on their vascular system and they are on bedrest or able to maintain leg elevation for longer periods than they would at home, which helps to control oedema. If oedema increases, the need for compression therapy to be resumed should be revisited.

Most people with leg ulcers are treated in the community and this is where the focus of staff education and training should be, although some acute trusts have extremely effective systems for managing inpatients.

Evidence-based practice should be optimum practice (based on the best knowledge at the time). To withhold treatment, such as by not applying full compression, means patients may have their leg ulcer and the unpleasant symptoms associated with it for longer than necessary. This delay also adds to service costs.

If full treatment is withheld because damage has been caused to the patient’s skin, assessment, diagnosis and application skills must be revisited.

‘It is unacceptable to reduce compression as a matter of course for patients because staff are not adequately trained and supported to deliver safe and effective treatment.’

Of course nurses should be concerned about patient safety but it is wrong to deprive patients of the best chance of healing. Compression levels may be reduced in response to patient pain or discomfort, and certainly in a concordant relationship there must be negotiation and understanding of each patient’s individual perspective.

Reduced compression is indicated in mixed aetiology ulceration, particularly in the presence of significant arterial disease, to ensure that arterial flow is not unduly compromised. Some patients may have reduced compression if there is some doubt about ulcer aetiology and further advice is being sought, but this reduction must not become a final solution unless the decision is based on sound clinical criteria.

There are many compression systems available, which gives scope for patients to choose the one that suits them best. It is, however, unacceptable to reduce compression as a matter of course for patients because staff are not adequately trained and supported to deliver safe and effective treatment.

IRENE ANDERSON is programme tutor, tissue viability, School of Nursing and Midwifery, University of Hertfordshire.

 

  • 6 Comments

Readers' comments (6)

  • Ian Mansell

    Even when using "full compression" it is often under applied. The use of laplaces law which helps to determine the ampount of compression required depending on the ankle circumference ie "The sub-bandage pressure is inversely proportional to the circumference of the limb" ie the bigger the leg the greater amount of pressure required to reverse venous hypertension. Most legs will fit in the 18cm -25cm ankle circumference category, but they would still require full compression ie 40mmHg at the ankle graduated to 20mmHg below the knee. This may not be achieved as nurses tend to underbandage rather than over bandage as highlighted in the article. "reduced compression" is often used on the basis of "just in case" its too tight, or I may cause trauma. But if the venous hypertension is not reversed you're unwittingly causing potential problems by inhibiting the natural physiological processes to restablish themselves. We provide mandatory training in leg ulcer management and mandatory updates both of which include sub-bandage pressure checks, whilst I admitt these systems aren't perfect they never the less provide a more objective reference point for nurses to evaluate their technique and adjust accordingly along wiht laplaecs law and the theory & practice of bandaging. I must point out that there is an over emphasis on vascular assessment by Doppler ultrasound. Whilst the procedure elimates any significant ischaemic disease which would preclude the use of compression it still does not indicate the aetiology of the ulcer. Although a mandatory requirement of leg ulcer assessment it will not determine the type of ulcer. A thorough understanding of the A&P of the leg, & signs & symptoms of venous/ arterial disease, and how that is manifested both in the condition of the leg and the presenting ulcer.

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  • This isn't the real world of nursing is it?
    Confidence has very litte to do with it.
    I cannot rememember a patient complaining about the bandaging being too slack but plenty complain that it is too tight. This leads to a lack of concordance and a negative attitude to compression therapy in general . Some patients remove the bandages or cut them open with scissors, risking additional wounds.

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  • I agree with the above statement. We are treating people with feelings and different pain tolerances. Many elderly patients especially, do not understand the reason for tighter bandages, therefore ask for the pressure to be reduced. Usually you find that during the night they complain of burning and itching and they will rub the bandage off causing more damage than they originally had.

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  • It's not just bandages that matter- an entire programme of education, from the value of protein and adequate fluids to the need to get the legs elevated for bed rest at night need to be combined with adequate compression. Although I agree to some degree with posters who say we have to respond when people cant tolerate the compression, it can't just be "Oh, sorry, I'll take off the outer later"... If we could get to people before they needed the most intense compression and help prevent the development of the ulcers that would be best but if faced with nasty ulcerations, an individualised whole person approach to care planning that includes education, environmental/social/ADL/nutritional/ etc interventions, based on a responsive assessment and using a multidisciplinary approach coupled with with some accountability for care on the part of the indivdiual being cared for, is necessary.

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  • ((not outer later, outer layer, sorry))

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  • Ian Mansell

    Whilst I fully endorse most of the comments above and accept holistic approach. When faced with a venous ulcer the pathophysiological consequences are inescapable. Unless you reverse venous hypertension you can engage as much as you like with the social environment but it'll mean diddly to the healing of the ulcer. 40mmHg of pressure is required to reverse venous hypertension (stemmer1969), multi-layer compression has been identified as the gold standard to achieve that. A number of alternative 2 -layer systems have also been shown to be of benefit. Pain is certainly problem but that can be as a result of the venous hypertension and the pressure exerted by an oedematous limb, so compression can also relieve pain in a number patients. to further emphasise the importance of compression the well used cliche assciated with venous leg ulcer patients is "once a leg ulcer patient always a leg ulcer patient". This focuses the care that continues after the ulcer is healed is life long, with the use of compression hosiery. recurrence rates with good after care yes education diet, lifestyle mobility can be reduced to as little as 24% without proper aftercare as high as 74%. The term tight is very subjective, if we are attempting to achieve 40mmHg with our bandaging around a limb with good technique & sufficient padding with protection of vulnerable areas such as the achilles tendon, pre-tibial area malleoli & foot this will reduce the likehood of problems. With some proactive support and planning problems with concordance can be foreseen. How we approach the situation procatively can go along way to supporting the patient coming to terms with bandaging

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