A Guide To Compression Dressings For Venous Ulcers
- Volume 25 - Issue 2 - February 2012
- 18295 reads
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Other Considerations To Keep In Mind
Venous insufficiency is very common and is the most likely cause of lower extremity edema.38 However, it is imperative to consider other causes of edema, especially in a population with multiple significant comorbidities.39,40 Prior to initiating compression therapy, one must ensure adequate arterial circulation. Studies have shown that up to 30 percent of people with lower extremity ulceration have concomitant peripheral arterial disease.41
Physical assessment including an ABI is often indicated. An ABI > 1.3 suggests poorly compressible vessels and an arterial Doppler with segmental and toe waveforms/pressures may be necessary.42 Most experts agree that an ABI < 0.8 contraindicates the use of high (35 to 40 mmHg) compression therapy and an ABI of < 0.5 or ischemic rest pain contraindicates compression completely.16,35,43 Patients with ABI readings between 0.5 and 0.8 may benefit from modified bandaging that offers a reduced compression of 15 to 25 mmHg.44
One must tailor compression therapy to the patient. Due to the initial discomfort that may occur with compression therapy, it may be necessary to begin with less compression and gradually increase to the indicated pressure. Patients who have a negative first experience with compression may be less willing to continue the treatment.35
Multiple factors have been implicated as contributing to poor therapy adherence.45 One of the inconveniences with compression bandages is the necessity to keep the dressing dry. There are devices that one can slip on over the leg to seal from the shower water. However, application may be difficult in patients with poor dexterity, strength or balance. Many patients are creative with large garbage bags.
Addressing this issue at the initiation of therapy will assist with maintaining a safe environment for the patient. Once therapy is established and progressing, it may be possible to coordinate visits with the patient and have them remove the bandage and shower prior to the visit. If there is assistance in the home, the patient might use short stretch bandages and one can teach the family how to remove and reapply these bandages safely after bathing. Remember to validate competence prior to allowing unsupervised application.
One should initiate patient education regarding the necessity for compression — both for ulcer treatment and for lifelong maintenance — at the first visit. An understanding of the pathophysiology of the disease helps with therapy adherence.46 However, ulcer recurrence is often associated with failure to wear the compression socks or use the venous pump as directed. Continued reinforcement at every visit is essential.
Podiatrists frequently encounter venous ulcerations and chronic venous insufficiency in the clinical setting. The standard of care for management includes graduated compression therapy. It is important to rule out other potential causes of lower extremity edema and ensure vascular adequacy prior to the initiation of therapy. One should also consider the individual needs of each patient prior to choosing a compression plan of care.
Ms. Rivera is an instructor at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. She is also a nurse practitioner with a specialty in wound and foot care at the Center for Lower Extremity Ambulatory Research (CLEAR).