Jackie Stephen-Haynes. Compression therapies- Does. Jackie Stephen-Haynes 2011

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1 Jackie Stephen-Haynes Compression therapies- Does compression meet the patients needs? 2011

2 Aims For practitioner to be able to consider compression options and the impact for the patient

3 Leg Ulcer Definition A discontinuity of an epithelial surface (Harding Rains and Mann 1988) Tissue breakdown on the leg or foot due to any cause (Cullum1994) A leg ulcer is loss of skin below the knee on the leg or the foot that takes more than six weeks to heal (Dale et al 1995) A leg ulcer is a breakdown of epidermal and dermal tissue, below the knee on the leg or foot, due to any cause, which fails to heal ( Moffatt & Harper 1997)

4 Vascular Disease Epidemiology 46% adults in UK have some degree of venous disease (Weddell 1996) Up to 1% of adults in UK will suffer from leg ulceration (Nelson 2000) Costs to NHS million per annum (Laing 1992) Treatment of leg ulcers accounts for 22% of District Nurses time (Hampton 2003) Recurrence rates reported at 26-69% (NHS 1997)

5 Age 60 years and over. Percentage increase in population 10% 8% 6% 4% 2% 0% 3% 5% 7% 9% 10% Year

6 Venous leg ulceration?

7 Summary Venous Ulceration with Oedema

8 CEAP: Clinical, aetiologic, Anatomic classification, Pathophysiologic C0 = No signs of venous disease C1= Telangiectasies or reticular veins C2 =Varicose veins C3= Oedema C4=Pigmentation or eczema C5=Healed venous ulcer C6=Active venous ulcer

9 Cochrane Compression vs no compression (Cochrane 2005).Reviews 22 trials Results = compression is better than no compression MLGC most effective treatmentdebated that Short stretch bandaging is equally effective

10 RCN Guidelines 2006 Recognised gold standard treatment for VLU Aetiology must be determined before commencing compression therapy 0.8 and above is ABPI suitable for compression Compression should be applied by a trained and skilled practitioner Inexperienced practitioners can apply inappropriate and varying pressures Incorrectly applied compression can be ineffective and even harmful

11 Graduated External Compression Compression squeezes the limb, reduces oedema and aids venous return and is for patients with confirmed venous disease Is measured in mmhg. Aids venous return by increasing the velocity of blood flow in the deep veins. Reduces oedema by reducing the pressure difference between the capillaries and the skin Transfers tissue fluid back to appropriate system i.e. lymphatic and veins.

12 Effects of 2 weeks compression Thinning of the fibrous exudate on the ulcer base. Formation of granulation and angiogenesis and an increase in macrophages Reduction in the number of red blood cells cuffed with fibrin around the ulcer base Thickening of epidermis and evidence of increased hyperkeratosis

16 Damaged or incompetent valves in the deep and perforating veins are the major cause of venous hypertension in the lower limb High back pressure causes venous stasis and oedema

17 Accountability As a professional-the NMC Accountable to the public-criminal law Accountable to the patient-civil law Accountable to the NMC Accountable to the employer Employer vicarious liability. Human rights Acts

18 Responsibility and accountability (NMC 2008) Respect the client as an individual You are personally accountable for your practice- actions as well as omissions. You are entitled to receive safe and competent care. You are expected to co-operate as a team. You must keep your skills and knowledge up to date. Minimise risk to patients/clients- delegating appropriately. Be trustworthy Respect the client as an individual

19 Compression

20 Laplace s law P=(TN x4630) divided by CW P= Sub-bandage pressure(mmhg) T=Bandage tension (kgf) C=Circumference of the limb(cm) W=bandage width(cm) N=Number of layers applied

21 Aims of Compression Bandaging Improve venous return (Partsch 2003) Promote a healthy wound environment (Bradley 2003) Improve condition of skin/patient comfort (Edwards 1998) Reduce oedema (Charles 1999) Control exudate and odour (Moody 2001) Reduce pain (Prytherch 2003)

22 Measure the ankle Padding Essential to measure ankle to get the best healing rates cm average limb size Measure after padding If ankle > 25 cm pressure reduced with a cm kit If ankle < 25 cm pressure increased with a cm kit

23 Considerations prior to application of compression Measure ankle circumference Foot deformities Check skin condition History of sensitivities History of compression History of compliance Leg shape

24 Padding Absorbency Re-shape leg Protect from pressure damage Dorsum Tibial crest Achilles tendon Malleoli Bunions/bunionettes

25 Bandage application Holistic assessment. Vascular assessment. Education of the practitioner. Hands on practice improves bandaging skill- (Magazinovic 1993). Patient /professional concordance. Appropriate bandages.

26 Leg Shape No calf muscle- chicken legneed to make a false muscle Large calf-inverted champagne bottle leg-require extra padding at ankle Large ankle-due to swellingextra padding needed around calf to achieve normal leg shape

27 Compression options MLGC- multi component rather than multi layer as a layer may be applied more than once. Short stretch 2 piece hosiery 2 layer

28 Practical considerations Encourage safe and accurate application is it the correct system? Is it easy to apply? Can it be applied accurately and consistently Comfortable & conformable Stays in place Copes with exudate Hypoallergenic materials Minimise skin irritation Easily available On FP10

29 Getting it right Help the patient to feel experience normal life and activities Leg washes Aids to facilitate a shower or bath Appropriate bandage selection-one size does not fit all! Appropriate dressing selection and frequency of dressing changes Treat hyperkeratosis and skin conditions Facilitate holidays

30 Challenge of compression Wide range of options Variations in terminology Lack of clear understanding re sub-bandage pressure Limb shape Difficult ulcer site Frequent recurrence Reduced mobility ( Harding 2008)

31 Adverse effects of compression Tissue Loss Increased pain Reduction of blood supply if arterially compromised Amputation

Patients give the following rationale for not continuing with compression therapy Painful Too

33 Non-concordance with treatment Patients are often labelled as non-concordant but what we should really be considering is have we got it right? Patients give the following rationale for not continuing with compression therapy Painful Too tight Poorly applied bandages Bandage slippage Lack of understanding of ulcer aetiology Lack of information about the treatment for the ulcer

34 Patient advice Verbal and written leaflets Include indications of need to remove compression Change in colour of toes Change in sensation Increase in pain Increase in swelling

35 Concordance

36 Caution Care with patients with heart failure. Care with Rheumatoid arthritis Care with Sickle cell disorder Care with diabetes

37 Self assessment Selects appropriate patient Measure ankle Apply padding, shape as necessary Applied starting at base of toes, heel lock, control bandage Applied correctly on foot Applied correctly on limb Advise re :change in colour of toes, change in sensation, increase in pain & increase in swelling

38 Comp options Leg shape Size range Mixed aetiology Clinically proven Footwear Compatible with dressing MLGC SSB Coban 2 Hosiery Kits Hosiery

39 Comp options Promotes independence bathing Appearance Bandage slippage Training & skills required Patient can self apply Cost

40 TREATMENT PROCESS IDENTIFICATION ASSESSMENT TREATMENT PRESCRIBED REASSESSMENT APPLICATION OF PREVENTATIVE MEASURES AND HOW THE PATIENT CAN HELP

41 Working with patients

42 Clinical need, efficiency and effectiveness. Future care.?greater emphasis on prevention..? Greater emphasis on education and training for staff Greater emphasis on effectiveness

43 Leg Care Venous hypertension Venous oedema Lymphovenous Lymphoedema

44 References Moffat C (1995) The organisation and delivery of leg ulcer care. In: leg ulcers, nursing management a research based guide. Cullum N, Roe B (Eds) Scutari Press. Middlesex. Logan R, Thomas S, Harding E et al. (1992) a comparison of sub bandage pressures provided by experienced and inexperienced bandagers. Journal of Wound Care Vol 1 pge Moffat C. J. et al randomised trial comparing two four layer bandage systems in the management of chronic leg ulceration. Phlebology, (1999); 14: Morrel C J. Stephens J Walters et al. Cost effectiveness of community leg ulcer clinics: randomised control trial. BMJ (1998); 316: Nelson E A. C.D. Iglesias, N. Cullum, D.J. Torgeson, et al Randomised clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers (VenUS 1). A UK NHS HTA programme-funded study. Brit J Surg. (2004); 91: Stephen-Haynes, J. (2006) Compression therapy. Nursing standard. Vol 20, No 32, p68-76 Tuckwood-SmithJ,(1996).Which compression therapy? Journal of Communnity Nursing. Nov.Vol.10. Iss. 11; Ukat A. M.Konig, W. Vansheidt, et al. Short stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. J Wound Care. (2003); 12(4):

45 Jackie Stephen-Haynes, Stourport Health Centre, Worcester Street, Stourport on Severn, Worcs DY 13 8EH

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