TR E AT MEN T
COMPRESSION:
HOW MUCH IS
NEEDED TO BE
THERAPEUTIC?
Elizabeth O’Connell-Gifford
and Jackie Young
Mrs. PJ enters your facility with a
family-reported vague diagnosis of
“poor circulation and a lot of swelling
in both of her legs.” You note a small
shallow wound in the gaiter area of
her left lower extremity. She is 76
years old and obese; she has stress
incontinence that is managed by panty
liner; she has dementia; and she is no
longer able to perform her ADLs.
After the initial assessment, you realize
that more information is needed to
initiate appropriate treatment.You call
the primary care physician’s office and
learn that Mrs. PJ has been diagnosed
with venous hypertension or lower
extremity venous disease (LEVD). Her
arterial perfusion is adequate.
Let’s discuss the treatment for LEVD
and the best plan for Mrs. PJ.
Improving Quality of Care Based on CMS Guidelines
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TREATMEN T
COMPRESSION: HOW MUCH IS NEEDED TO BE THERAPEUTIC
T
he gold standard of treatment for LEVD is to
use adequate compression. Before any form of
compression is applied, the arterial perfusion
status must be evaluated. If the lower
extremity has either arterial or mixed (arterial
and venous) disease, applying compression is usually
contraindicated and could lead to negative results. A fairly
simple diagnostic test, the ABI or ankle-brachial index, is
often all that is needed to decide if compression is
appropriate or not. (1)
This article focuses on compression, but it is important to
realize that the wound itself may also need to be dressed.
The dressing is chosen based on multiple factors including
wound characteristics, frequency of dressing change (a daily
dressing is not the best choice with a seven-day
compression wrap, for example), the ability of the patient or
caregiver to apply the dressing, as well as reimbursement
and availability issues. There are no studies showing that
one type of dressing or specific frequency of dressing
change is appropriate for all LEVD wounds. A short course
(approximately two weeks) of a topical antimicrobial may
be considered if the ulcer has a high level of bacteria. (1)
About the ankle-brachial index (ABI):
ABI = ankle blood pressure divided by brachial (arm) blood
pressure.The result will be close to 1 (meaning they are about
the same) in a normal person.
Results of 0.8 to 1 are within the normal range. Residents
with an ABI of less than 0.8 may have peripheral arterial
disease, in which case compression would be contraindicated.
In a diabetic, because of small vessel calcification, this test is
not as reliable.
42 HEALTHY SKIN
Applying compression in any form to a patient with venous
hypertension can be challenging! One of the most common
complaints from clinicians is, “My patients are
noncompliant; they won’t leave their compression system in
place because they say it hurts.” Realize that edema
associated with LEVD can be very painful. The challenge is
to get the patient to leave the product on until the edema is
reduced. Once that happens, it is likely the pain will lessen
or be nonexistent. Discuss with the patient that this pain is
not uncommon and usually lessens over time with
treatment. Talk with the physician about prescribing
appropriate analgesics for the first several weeks of therapy.
There is research that supports therapeutic compression as
an effective means of treatment. But how much compression
is enough? It is documented that some compression therapy
is more effective than no compression therapy for the
treatment of LEVD wounds. High compression (30–50
mmHg) is more effective than low compression, but there
are no differences in the effectiveness of the different types
of products available for high compression. (1)
The most commonly used products for compression are
wraps or stocking-like products. Application of wraps
should not be performed by an inexperienced person.
Proper technique is crucial and requires training. Wraps that
are applied incorrectly can create too much compression,
leading to limb loss or damage, or too little compression,
causing a delay in healing or even a decline in condition.
There are several different ways to address wounds on the
lower extremity. As with Mrs. PJ, the initial assessment leads
to further investigation and some detective work on the part
of the nurse. Obtaining all the information from the family
as well as the primary care physician’s office allowed Mrs.
PJ to receive the best treatment for her LEVD. The wound
was small and had some drainage that needed to be
managed. Because there was a concern about bioburden, a
silver alginate dressing and a four-layer compression wrap
was the dressing of choice. The entire dressing was changed
every five days.
Easy Guide to Compression Therapy
Type of
Compression
Examples
Amount of
Compression
Application of
Compression
Performance
Characteristics
Long stretch
elastic bandages
*Matrix, *Swift-Wrap®,
*Sure-Wrap®, Ace®,
Curity®
17 mmHg pressure
Applied in a figureof-eight from toe to
knee with a 50%
overlap on an ankle
circumference of
18–25 cm (3)
Not washable or
reusable, loses stretch
after first application
Zinc paste bandages
(inelastic compression)
*Primer® Boot, Unna
Boot, Dome Paste
Bandage
Applies initial pressure
of 29.8 mmHg at the
ankle but falls to 10.4
mmHg at 24 hours (2)
Applied in an overlap
fashion from the toe
to the knee with a
50% overlap
Not reusable
Light compression,
support
*Medigrip, Tubigrip®
If the product is
“shaped,” it applies
12–15 mmHg pressure
in a single layer (3)
Cannot apply
graduated compression
because it does not
conform to the leg.
May fit at the calf
but be too loose at
the ankle.
Washable (not dryersafe) for up to
6 months
Multilayer
*FourFlex, Profore®,
Dynaflex, Four-Press
Can maintain 40
mmHg pressure on an
ankle circumference of
18–25 cm for up to
one week (2, 4)
Various layers are
applied differently.
Please refer to
package insert for
instructions.
High compression.
Cut off entire
dressing at change.
Cohesive or selfadherent bandage
*Co-Flex®, Coban®,
*PowerFlex®,
Flex-Wrap®
23 mmHg pressure
Applied at mid
stretch with a 50%
overlap in a spiral
from toe to knee on
an ankle circumference
of 18–25 cm (3, 4)
Used with other
products to produce
therapeutic
compression. Not
washable or reusable.
High elastic
compression
Setopress®, Surepress®
Can apply up to 40
mmHg pressure (3, 4)
Please refer to
individual package
Therapeutic
compression to treat
LEVD
* These products are available through Medline.
References:
1. Johnson J and Paustian C. Guideline for Management of Wounds in Patients with Lower Extremity Venous Disease. Number four in WOCN Clinical Practice Guideline Series.
Wound Ostomy and Continence Nurses Society, 2005, Glenview IL, p. 13.
2. Blair SD, Wright DDI, Backhouse CM et al. Sustained compression and healing of chronic venous ulcers. British Medical Journal 1988:297:1159–1161.
3. Moffatt CJ. Compression bandaging—the state of the art. Journal of Wound Care 1992:1:1:45–50.
4. Moffatt CJ, Dickson D. The Charing Cross high compression four-layer bandage system. Journal of Wound Care 1992:2:2:91–94.
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