Compression Bandaging in Adults Cared for Outside of Specialist Areas within LTHT - The Use of

Publication: 19/10/2015  
Next review: 05/09/2022  
Clinical Guideline
CURRENT 
ID: 4364 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The use of compression bandaging in adults cared for outside of specialist areas within LTHT

Background

Lower limb oedema in hospitalised patients may occur as a result a variety of medical conditions, such as chronic venous disease, lymphoedema, cardiac failure, hypoalbuinemia or renal failure. If untreated the oedema can lead to lymphorrhoea (leaking legs), blistering and ulceration. Chronic oedema patients can also suffer from repeated episodes of cellulitis.
Currently it is estimated that up to 1% of the population have ulcerated legs[1-3], and they can take a long time to heal, can cause pain and distress to patients as well as being very costly to the NHS [4, 5]. Venous leg ulcers can occur when blood returning to the heart from veins in the legs is slow or obstructed.  Compression bandages help blood return to the heart from the legs and have been found to lead to better healing rates when compared to no compression. [4]  There is currently a wide variance in the treatment provided for patients with lower limb oedema and/or uncomplicated venous leg ulcers cared for outside of specialist areas within LTHT. Therefore care pathways for the management of un-complicated venous ulceration (Appendix 1), management of oedematous legs (Appendix 2) have been devised to assist practitioners working outside of the specialist settings. There is also a lack of clarity on when a patient needs referring to a specialist service and which service they require, which these guidelines aim to aid with this.  

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Diagnosis

Prior to commencing treatment with compression bandaging for the first time all patients must be assessed in terms of their clinical history, physical examination and investigation of arterial patency by a health care professional who has received training in the management of chronic oedema and leg ulceration. Information relating to training courses can be obtained via the Tissue Viability intranet site

Clinical history should be assessed for:

  • Symptoms of venous insufficiency: leg pain, aching, heaviness, itching, oedema, exudate, skin changes such as hyperpigmentation and eczema
  • Risk factors: immobility, obesity, varicose veins, VTE, family history leg ulceration, surgery or fractures to the affected limb [5-7]
  • Other possible causes of ulceration
    • Peripheral arterial disease: smoking, hypertension, IHD, hypercholesterolaemia, intermittent claudication and rest pain
    • Diabetes mellitus
    • Rheumatoid arthritis
    • Skin malignancy
  • Establish if the patient is already under the care of a speciality (e.g. dermatology, vascular, district nurses) - if there are no signs of infection or DVT then continue with the pre-existing plan

Physical assessment should then be undertaken and should include examination of the lower limbs observing for [5-8]:

  • Pitting oedema
  • Venous eczema (itchy redness usually without heat)
  • Hyperpigmentation (haemosiderin deposits giving the legs a brown appearance)
  • Assess for signs of peripheral arterial disease:
  • Look for: hair loss, coldness, dusky appearance on lowering the leg
  • Capillary refill >4 seconds
  • Absence of foot pulses

If there is an ulcer present this should be assessed for:

  • Size and depth, the ulcer may be shallow, epithelializing or punched out.

Measure size of the ulcer including approximate measurements of the greatest depth

  • Where possible, appropriate and with consent of the patient take photographs and upload to medical notes
  • Wound bed – look for granulation, fibrous or necrotic tissue and any exposed underlying structures (bone, tendon)
  • Look at exudate amount to help determine dressing selection

This information will assist the practitioner in identifying the underlying aetiology and tissue integrity thereby effecting treatment choices.

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Investigation

Clinical investigation should include:

  • ABPI – rule out arterial insufficiency (see Appendix 3)
  • Weight – Provides baseline enabling assessment of weight loss and nutritional risk factors that could affect healing

Bacterial swabs – to be taken if any clinical indications of infection (erythema/cellulitis/increased wound pain/rapid deterioration in wound/ purulent or odorous exudates/pyrexia). Please refer to guidelines for the management of infected wounds.

 

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Treatment / Management

On confirmation of the patients’ suitability for compression bandaging, it is recommended that a cohesive short stretch bandage be applied as per the manufacturer’s instructions by an appropriately trained practitioner.     

In order to enable skill development and maintain competencies at clinical level, ward based training for the application of short stretch bandaging can be organised by contacting the Tissue Viability Team or L&R Medical (formerly Activa) directly. Wound management study days provided by the Tissue Viability Team include bandaging training - bookings can be made via ESR.

Following application of compression bandaging regular limb observations and skin inspection are required. If circulatory compromise is suspected compression bandages should be removed and referral made to a medical practitioner.    

Patients should be encouraged to report any pain, numbness or tingling sensations following the application of compression bandages. If this is reported then observations of the limb should be recorded involving:

  • Observe the toes for :
    colour,
    temperature,
    capillary refill
  • Record the patients’ pain score using a scoring system of 0-10.

If there are any concerns that the circulation is being compromised then immediately remove the bandages and report to a medical practitioner [4, 5, 9].


Follow up/on-going management
For chronic lower limb oedema and venous disease the continued use of compression in the form of bandaging or hosiery is advocated in combination with regular follow up to assess skin condition and ulcer size.
In order to promote concordance with compression therapy patient education is required relating to the rationale for long term compression, appropriate skin care regimes, prevention of trauma, avoidance of the use of over the counter treatments, encourage early self-referral in the case of skin breakdown, the need to maintain mobility and exercise, along with elevation of the effected limb when seated [10].

Referral Criteria

Referral to the following specialist services may be required for: 

Vascular

  • Reduced ABPI <0.8
  • Increased ABPI >1.3
  • Rapid deterioration of ulcers
  • Newly diagnosed Diabetes Mellitus
  • Ulcers which have received adequate treatment but have not improved after 3 months
  • Recurring ulceration
  • Ischemic/infected foot

Dermatology

  • Ulcers of non-venous aetiology (e.g. rheumatoid, pyoderma, vasculitic)
  • Suspected malignancy
  • Signs of dermatitis and/or suspected contact dermatitis (spreading eczema, erythema and demarcation, increased itch)

Lymphoedema

  • Long term self-management of chronic oedema (>3 months) which has not resolved with diuretics and the following have been ruled out:
    • malignant neoplasms
    • cellulitis
    • DVT
    • uncontrolled heart failure
    • arterial insufficiency
    • renal failure

Tissue Viability

  • New ulceration
  • Infected ulceration
  • Current care plan does not meet the need

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Provenance

Record: 4364
Objective:

Aims
To improve the diagnosis and management of adults with lower limb oedema and/or uncomplicated venous leg ulcers cared for outside of specialist areas within secondary care.

Objectives
To provide evidence-based recommendations for appropriate diagnosis, investigation and management of lower limb oedema and/or uncomplicated venous leg ulcers and improve the use of compression bandaging within LTHT

Clinical condition:

Lower limb oedema and or uncomplicated venous leg ulcers

Target patient group:

Adult in-patients with lower limb oedema and or uncomplicated venous leg ulcers requiring the application of compression bandaging, cared for outside of specialist areas such as Dermatology, Vascular, Tissue Viability and Lymphoedema services within LTHT. For the purpose of these guidelines, “uncomplicated venous leg ulcers” are defined as patients admitted to hospital where their venous leg ulcers are not the reason for admission. If they have a current management plan in place this should be continued whilst as an inpatient. This guideline excludes patients under the age 18 years, those patients already under the care of specialist services (Dermatology, Vascular, Tissue Viability, Lymphoedema), wounds where an underlying malignancy is known or suspected and patients with wounds other than leg ulceration.

Target professional group(s): Secondary Care Nurses
Adapted from:

Evidence base

  1. Moffatt, C.J., et al., Prevalence of leg ulceration in a London population. 2004. 97(7): p. 431-437.
  2. Alberta Heritage Foundation for Medical Research, A study of the impact of 2001-2002 health technology assessment products – final report. 2003, Alberta Heritage Foundation for Medical Research: Edmonton.
  3. Hall, J., et al., Point prevalence of complex wounds in a defined United Kingdom population. 2014. 22(6): p. 694-700.
  4. O'Meara, S., et al., Compression for venous leg ulcers. 2012(11).
  5. Wounds UK, Best Practice Statement: Holistic management of venous leg ulceration. 2016, Wounds UK: London.
  6. Franks, P.J., et al., Management of patients with venous leg ulcers: challenges and current best practice. Journal of wound care, 2016. 25(Sup6): p. S1-S67.
  7. Moffatt, C.J., Understanding the causes of chronic oedema. Wounds UK Supplement, 2007. 3(2): p. 5-10.
  8. Billingham, R., Assessment and diagnosis of chronic oedema. Wounds UK, 2007. 3(2 Suppl): p. 11-15.
  9. Wounds UK Best Practice Statement: Ankle brachial pressure index (ABPI) in practice. Wounds UK, 2019.
  10. Lymphoedema Framework, Best practice for the management of lymphoedema. International consensus, 2006: p. 3-52.

This guidance is evidence based. The grading scheme used for the recommendations A, B, C, D, or Good Practice Point (GPP) This is the grading scheme employed with NICE Guidelines adapted from SIGN 50 Evidence levels:

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs

B. Robust experimental or observational studies

C. Expert consensus.

D. Leeds consensus. (where no national guidance exists or there is wide

disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1 - Pathway for the management of adult in-patients with uncomplicated venous leg ulcers

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Appendix 2 - Pathway for the management of adult in-patients with lower limb oedema

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Appendix 3 - Calculating the Ankle Brachial Pressure Index (ABPI)

This can be done by using an automated device (e.g. MESI – follow manufacturers guidance) which does not involve resting the patient and allows for simultaneous measuring of all limbs[9]. 
Instructions for using a hand held doppler as follows:


STEP 1.    Explain the procedure to the patient and provide reassurance.
Once verbal consent gained:

  • Offer analgesia
  • Lay the patient flat (use only one pillow).
  • Leave the patient to rest for 20 minutes.

NB - If the patient does not consent document in patient records that procedure not performed, stating why. Inform the practitioner who initially requested an ABPI be undertaken.

STEP 2.    Measure the brachial blood pressure using a manual sphygmomanometer and a hand held Doppler.

  • Place an appropriate sized cuff around the upper arm of the patient.
  • Apply gel to the anti-cubital fossa and locate the brachial pulse with the Doppler.
  • Inflate the cuff until the audible signal disappears,
  • deflate the cuff slowly and record the pressure at which the audible signal returns (systolic pressure) taking care not to move the probe.
  • Make a note of this pressure reading.
  • Repeat the procedure for the other arm.
  • Use the highest of the readings when performing the calculation below.

STEP 3.    Measure the ankle systolic pressure.

  • Remove any bandages and dressings present on the leg.
  • Apply a clear film dressing to protect any areas of ulceration on the leg.
  • Place an appropriately sized cuff around the ankle just above the malleoli.
  • Apply gel to the dorsum of the foot and locate the dorsalis pedis pulse with the Doppler.
  • Inflate the cuff until the audible signal disappears,
  • deflate the cuff slowly and make a note of the pressure at which the signal returns (systolic pressure) taking care not to move the probe.
  • Repeat the procedure for the posterior tibial pulse.
  • Use the highest reading (either dorsalis pedis or posterior tibial) to calculate the ABPI for that leg.
  • To obtain readings for both legs then repeat the procedure above using the opposite leg.

STEP 4.    Calculate the ABPI using the formula below:

   ABPI                =       Highest of the ankle pressures for that leg
                                      Highest of the two brachial pressures.

ABPI

INTERPRETATION OF RESULTS

 

0.8 -1∙3

Normal – please follow pathway for the management of adult in-patients with uncomplicated venous leg ulcers

<0∙8

Not suitable for compression without specialist management – please refer to Tissue Viability or Vascular Services for further patient management

>0∙5 and <0∙8

Can be associated with claudication, if symptoms warrant patient should be referred for vascular assessment – please refer to vascular team for further patient management.

<0∙5

Indicates severe arterial disease, may be associated with gangrene, ischemic ulceration or rest pain -  urgent referral for a vascular opinion must be undertaken.

NB - Errors may occur if:

  • The cuff is repeatedly inflated for long periods, (causes the ankle pressure to fall).
  • The pulse is irregular or the cuff deflated too rapidly, (the true systolic pressure may be missed).

The Vessels are calcified (Diabetic patients), the legs are large, fatty or oedematous, the cuff size inappropriate, the legs elevated or dependant, (results may be inaccurate).

 

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