In the United States, venous ulcers can affect up to 2.5 million people every year.1 Venous ulcers are lesions of the skin and subcutaneous tissue of the lower extremities, mainly occurring over the medial malleolus. The lesion is typically shallow and moist, with moderate to large amounts of drainage. Edema and/or hemosiderin deposits are visible; itching and pain are common complaints Figure 1.
Venous ulcers are believed to be caused by venous hypertension as a result of venous obstruction, incompetent valves,2 or an abnormal calf muscle pump.3 Chronic venous insufficiency develops as a result of venous hypertension and venous reflux.4
Several theories have been proposed for the development of venous ulcers. These include the development of a fibrin cuff5; white cell trapping6; and the trap theory, with fibrin leaking out of the capillaries and trapping growth factors and other substances necessary for healing.7
The most common treatment for venous ulcers is compression therapy. It serves to reduce edema by increasing the local hydrostatic pressure and decreasing the superficial venous pressure. The result is less leakage of fluid and macromolecules.2 Compression of 30 to 40 mm Hg will counteract capillary pressure present in the tissues.4 It is vital for the health care provider to check for the presence of arterial disease before initiating compression therapy because arterial insufficiency is a contraindication for the therapy.4
Compression therapy consists of both inelastic and elastic compression. Inelastic or rigid compression therapy has low resting pressures with inactivity and high pressures with activity, as muscle contraction is utilized to provide a working pressure. Examples of rigid compression include the Unna boot, which goes on wet and becomes rigid as it dries. Because of its rigidity and inability to conform to a decrease in edema, it must frequently be reapplied. Comprilan (BSN-Jobst, Charlotte, NC), a rigid short stretch bandage, can be rewrapped daily, and CircAid (CircAid Medical Products, San Diego, CA) has hook-and-loop closure straps for adjustment.2,3
With elastic compression therapy, sustained pressures are maintained. Elastic bandages are available in high and low compression pressures, and they conform to the leg. Examples of high compression include Setopress and SurePress (ConvaTec, Skillman, NJ). They can provide pressure of 40 mm Hg at the ankle.2,3
Compression therapy can consist of 1 layer or multiple layers. Single-layer wraps provide sustained pressure. Multilayer wraps provide graded compression, with 40 mm Hg pressure at the ankle and 17 mm Hg pressure at the knee Figure 2. An example is Profore (Smith & Nephew, Largo, FL).2,3
Pneumatic compression has been used to deliver high pressure intermittently for short periods. Pressures as high as 180 mm Hg can be delivered.3 A systematic review of compression therapy in 1997 found it to be a useful addition to compression therapy.8
Several studies have looked at the various types of compression therapy. Ukat et al9 compared multilayer compression with short-stretch compression. They found that patients treated with multilayer compression healed faster than those treated with short-stretch compression and that treatment costs were lower. Franks et al10 found that there was no difference in the healing times in those treated with short stretch versus a generic 4-layer compression bandage. In another randomized trial of 4-layer and short-stretch compression bandages, no significant difference was found in median time to healing. However, when factors that could influence healing were included in a Cox proportional hazards regression model, the researchers concluded that venous leg ulcers healed more quickly when a 4-layer compression bandage was used, as opposed to a short-stretch one.11 Polignano et al12 compared venous ulcer healing rates with 4-layer compression versus the Unna boot. They found no difference between the groups in the time to closure. There was, however, a significant difference (P = .013) in the ease of application of the 4-layer compression at the final application. The Cochrane Group conducted a meta-analysis and concluded that high-compression and multilayered bandages were best in the treatment of venous ulcers.13
The research shows that compression is effective. Continued studies on ease of application, economics, and healing times are needed.
Three posters presented at the 2004 Clinical Symposium on Advances in Skin & Wound Care evaluated the effects of compression therapy on patients.
Evaluation of a Newly Developed Multilayer Compression Bandaging System: Is the New 2-Layer System as Effective as the 4-Layer System?
Christine Barkauskas RN, BA, CWOCN, APN; Linda Galvan RN, BSN, CWOCN, APN; and Andrea McIntosh RN, BSN, CWOCN, APN, Silver Cross Hospital, Joliet, IL
PURPOSE: The purpose of this poster is to assess the performance of a 2-layer compression bandaging system, to determine whether the 2-layer system is as effective as the 4-layer compression bandaging system, and to determine whether the use of a 2-layer system increases patient compliance. A new 2-layer compression system is now available in a range of system packs to suit different ankle circumferences. The first layer absorbs exudate and helps to evenly distribute pressure. The second layer is a new technology that consistently delivers 40 mm Hg at the ankle.
OBJECTIVES: Until recently, a 4-layer compression bandage system was the most effective way to obtain sustained 40 mm Hg compression for 1 week. The 4-layer system can be bulky, which may be displeasing for the patient and possibly pose a problem regarding footwear for the patient. A relatively new 2-layer compression bandaging system is available, which is user-friendly, allows the patient to wear his or her own shoes, and, compared with the 4-layer system, requires less time to apply.
OUTCOMES: In these case studies, the use of the 2-layer compression bandaging system was very effective for management of edema, decreased application time, and supported wound closure. Patient compliance was increased secondary to comfort, decreased wound pain and itching, and the patients' ability to wear their own shoes.
Cost-Effective Lower Extremity Edema Management
Denise Elber, RN, CWOCN, Idaho Elks Rehabilitation Hospital Wound Clinic, Boise, ID
The Idaho Elks Wound Clinic in Boise, Idaho, has been successfully managing most lower extremity edema with the use of tubular elastic bandages (TEB).
The cornerstone or gold standard for venous ulcer management is edema reduction/management. Literature suggests graduated compression (after assessment) is therapeutic in prevention and treatment of venous ulcers. Although TEB is generally recommended for general edema management, our patients have responded well when this product has been utilized in the management of lower extremity wounds when the patient either rejects or is unable to tolerate standard compression therapy. TEB provides tension compression considering limb circumference, whether a single layer or double layer is applied, and/or if a combination length is applied.
The patient's ability to comply with wound protocol therapy is related to the patient's acceptability of the ease of application, low cost, and comfort; therefore, TEB has helped improve wound healing results.
Clinic staff highlight advantages of TEB in management of mixed-disease. The patients are able to don TEB in acute conditions where more compression may increase inflammation. It is also easy for any level of care provider to fit and apply and has the ability to provide a wide range of compression, making it an excellent choice for initial compression to check tolerance.
Some disadvantages include that it is not as effective in management of well-established brawny edema and that it is not latex-free.
Some of the patients choose to continue to use TEB posthealing for long-term management.
Future study is planned to measure TCPO2 before and after donning TEB.
Healing Venous Stasis Ulcers in Third-World Countries with the Help of Technology
Ann Marriott RN, BSN, CWCN, COCN, Provena Covenant Medical Center, Urbana, IL
OBJECTIVES: Demonstrate proper medical treatment for venous stasis ulcers for people in third-world countries using videotape and printed brochures in Spanish. Develop and promote international good will for health care to people in third-world countries. Recognize the talents and capabilities of persons in third-world countries to follow detailed instructions for wound healing of venous stasis ulcers.
STATEMENT OF THE PROBLEM: There are few resources available for treatment of chronic venous stasis ulcers in third-world countries as compared with the United States and other first-world countries. What do people in other parts of the world do?
RATIONALE: With today's technologic advances, access to information and treatment for people in third-world countries is improving.
METHODOLOGY: A highly motivated Honduran man was seeking his family's support for options to heal his leg ulcer. It was by chance that his daughter, a US university student, shared this with a classmate whose mother was a wound care specialist. The classmate referred the Honduran student to her mother. With a digital photograph of the wound and health history, the nurse's impression was that this wound was from venous hypertension and would benefit from compression therapy. Subsequently, a meeting was arranged with the students, the nurse, and a wound product company representative. The representative provided a brochure in Spanish and a videotape in English, which the daughter translated into Spanish. Initial supplies of wound cleansers, silver dressings, and compression dressings were provided. Additional supplies were obtained from Internet sources. Digital photographs were sent by e-mail to monitor progress.
RESULTS: The Honduran man was able to heal his leg ulcer in 3½ months without complications and is now wearing compression hose for prevention.
CONCLUSION: Third-world residents can use technology to help treat venous stasis ulcers.
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