Written by Madeleine Matthews
Lower leg ulceration is a major health issue in New Zealand. This chronic condition is debilitating for patients’ and has many symptoms such as pain, infection and odor. It also affects the patients’ physical, psychological and social health (Todd, 2011a). Leg ulcerations are a financial burden to the patient and health services, as they require complex and long-term nursing and specialist care (Simon, Dix, & McCollum, 2004). Using evidence-based practice is the most effective way to treat and heal leg ulcerations; therefore this discussion will look into compression bandaging, the different types, and its use and effectiveness in healing leg ulcerations.
While on my primary health placement I noticed there were a large variety of dressings used on leg ulcerations in the community. The nurses had completed training in wound care and compression bandaging however, compression was not commonly used by this particular service. After attending the wound clinic day with a wound care specialist nurse I was unsure what method was best practice. The specialist used compression bandaging on all the chronic wounds, which made me wonder, how does it work, when is it an appropriate intervention, are there different sorts of bandaging, and who can apply the compression. This topic is relevant in today’s society as chronic leg ulcers are prevalent in the older population, they require a large amount of resources, they take up a lot of nursing time and they are very distressing for the patient. Currently, community nurses are caring for patients with chronic leg ulcers and this ensures patients have independence, can continue living their ordinary life, and because hospital services could not accommodate the large number of patients with this condition.
In order to formulate a clinical question from my clinical issue, I used the PICO acronym to structure my question. PICO stands for; patient or problem, intervention of interest, comparison, and outcome. (Schneider & Whitehead, 2013). The problem I have identified is chronic leg ulcerations, the intervention is compression bandaging, the comparison is between different types of compression and the outcome is which compression therapy is more efficient.
The question remains:
Is compression bandaging the most effective treatment for venous leg ulcerations in adults in the community, and if so, is long stretch, short stretch or combination bandaging more efficient at healing?
Leg ulcerations are caused by vascular, neuropathic, hematological, traumatic and neoplastic difficulties. The most common type is a venous ulcer and is primarily caused by venous hypertension (Simon, Dix, & McCollum, 2004). Blood in the legs opposes gravity and is returned to the heart by contraction of skeletal muscles and by valves that prevent backflow. These mechanisms prevent pooling in the veins however; immobility, prolonged standing and genetic factors prevent blood return, which then leads to venous hypertension (Todd, 2011a). The pressure exerted on the veins causes loss of elasticity in veins, distention of the veins, and cells leak into the tissues causing oedema. The blood flow slows down and causes white blood cells to clump together and cause congestion in the veins. These factors together make it difficult to supply adequate nutrients to maintain healthy cells. Skin cells begin to break down and a venous ulcer is formed (Anderson, 2008).
The aim of ulcer management is to heal the wound and prevent the reoccurrence of future ulcers. Compression bandaging corrects the cause, which is oedema and decreased blood supply. By applying external pressure to the leg, the compression acts as a skeletal pump and helps push the blood back up to the heart, close the valves and prevent backflow. When there is less pooling of blood in the veins, and blood is being effectively returned to the heart, then accumulated fluid in the tissue and clumped white blood cells are able to return to the circulatory system (McKenzie, 2010). Blood flow can then speed up to a normal rate and supply the tissues with adequate nutrients. Therefore, compression bandaging facilitates an environment for effective wound healing and as many studies show, compression bandaging has proven to be best practice for the management of venous leg ulcers (Anderson, 2008).
Compression bandaging needs to be successful at reducing oedema, tolerated by the patient and adaptable to the patients needs in order to be effective (Anderson, 2008). There are many different types of compression bandaging in order to cater for these different needs. These include, long stretch, short stretch and multi layer. Long stretch bandages can be stretched up to 100% and they move with the body ensuring sustained compression (McKenzie, 2010). This means that the client can mobilise, muscles can contract, and the compression bandaging adapts and returns to the original shape. Short stretch bandages are the opposite. They are usually made from cotton and the way the fibers are woven it allows air permeability and very little stretch. This type does not move with muscular activity, which means there is higher compression during activity, and this is when compression is at a therapeutic level. However, during rest compression is reduced due to the inelastic properties, which means it is more comfortable for the patient, but it does not provide adequate compression to help the oedema or prevent pooling of blood in the legs (Todd, 2011b). Multi layer compression bandaging aims to provide graduated compression by using three of four layers. Each layer alone is not sufficient, but the accumulation of layers provides beneficial compression (McKenzie, 2010). The first layer is the padding and is usually made from wool. This layer protects the skin, gives shape, and is also absorbent if the ulcer has heavy exudate. It is important to protect the skin and the bony prominences, as they may be vulnerable during compression (Anderson, 2008). The next layer is a crepe bandage, which will smooth out the wool fibers and provides light compression. The third and forth layers provide the majority of compression and is often cohesive and sticks to itself, this helps maintain sustained and graduated compression (Anderson, 2008).
Before compression can be applied, a thorough and holistic assessment needs to be completed to ensure that the patient can have compression bandaging (Regmi & Regmi, 2012). A full health history needs to be taken first to record any other health problems and any possible complications. The history of the ulcer and an examination is also important, as it helps identify the underlying cause of the wound (London & Donnelly, 2000). During this assessment it is vital that all contraindications and barriers to effective compression therapy are detected and addressed. Patient tolerance and compliance is an important contraindication as a study conducted by Annells, O’Neil and Flowers (2006), shows that the willingness of the patient is essential in effective compression. To ensure that there is no arterial insufficiency or arterial disease, the Arterial Brachial Pressure Indexes (ABPI) need to be assessed by using a hand held Doppler. This measurement must be between 0.9 and 1.2 to be eligible to have compression bandaging (Simon, Dix, & McCollum, 2004). In order to evaluate the progress of oedema reduction and wound healing, the circumference of different parts of the limb and wound should be recorded (Todd, 2011a).
If, after an holistic assessment, compression is an appropriate intervention, then a suitable type of bandaging needs to be selected. According to Cullum, Nelson, Fletcher and Sheldon (2008), compression bandaging for healing of venous ulcers is superior to no compression, higher compression is more successful than low compression and multi layered bandaging is more effective than single layered. This evidence shows that multi layered high compression is the most effective and efficient intervention, however, there are other factors that must be taken into consideration when deciding on a bandage type (Cullum, Nelson, Fletcher, & Sheldon, 2008). A patient who would not be suited to the multi layered compression may be allergic to the fibers in the padding or crepe layer, they may prefer and be more compliant with the thinner and less bulky single layered bandage and they may also find the multi layered bandage too hot. The long stretch bandage gives continuous high compression, but it can be painful and some patients cannot tolerate it, especially at night time. Short stretch bandages are another option, but they rely on patient compliance because this form of bandaging is only effective if the patient is mobilising, so therefore it should not be used on an immobile patient. There are many factors to take into consideration when choosing an appropriate bandage, and these factors will determine the effectiveness of treatment.
Compression bandaging is the gold standard for healing venous leg ulcers. Community nurses predominantly manage this condition so, to provide the best care; nurses must understand the basic principals of compression bandaging, be able to conduct a thorough assessment before and during treatment and be able to skillfully apply compression bandaging (Todd, 2011b). Application of any type of compression bandaging should be by a competent practitioner as correct application is essential. Incorrect application could result in pressure ulceration over bony prominences, tissue damage and even necrosis (Simon, Dix, & McCollum, 2004). In order for all practitioners to be competent at compression bandaging, appropriate resources, support and education needs to be available to nurses who require it.
Compression bandaging is the most effective and efficient treatment for venous leg ulcers. The evidence from this literature review clearly shows, though some compression may be better than others, that any compression is better than none. Long stretch, short stretch and multi layer compression bandages are all effective modes of compression if used correctly and for the right patient. Community nurses are capable of implementing compression and managing patients with venous leg ulcers, however, to ensure they are confident and accurate, training programmes and resources should be readily available.
Compression bandaging can improve patient outcomes by facilitating normal venous function and allowing wounds and ulcers to heal.
This discussion has answered the question, is compression bandaging the most effective treatment for venous leg ulcerations in adults out in the community, and if so, is long stretch, short stretch or combination bandaging more efficient at healing? Compression bandaging has been shown to be the best, most efficient treatment for venous leg ulcerations. The pathophysiology behind compression bandaging has been backed up by numerous studies and they all have very similar findings. All three forms of bandaging are beneficial if used in the right situation. Venous leg ulcerations are a chronic and common condition and New Zealand and by keeping up to date and following best practice guidelines, this condition could be better managed in the community by using compression bandaging.
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