EDEMA AND COMPRESSION IN WOUND CARE

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EDEMA AND COMPRESSIONIN WOUND CARE

• University of Washington
• Doctor of Physical Therapy Program
• June 24 and 26, 2008
• Kathleen L. Allen, PT, DPT

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Edema and compression in wound care

• OBJECTIVES
• Understand potential etiologies of edema.
• Be familiar with indications, precautions, and
  contraindications for treatment with compression.
• Be able to describe options for managing edema.
• Be able to perform hands-on four-layer
  compression bandaging.

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Edema and compression in wound care

• Edema dynamic insufficiency, not mechanical.
• Swelling of the interstitial tissues decreases
  the cellular response and removal of cellular
  debris.
• Compression facilitates movement of the excess
  fluid from the lower extremities.
• Venous disease occurs in 1 of the general
  population, 3.5 over 65 years of age.

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Edema

• Etiologies of edema
• Chronic venous insufficiency.
• Cardiac disease (manage with the cardiologist).
• Pelvic tumors.
• Morbid obesity (abdomen restricts venous and
  lymphatic return).
• Medications (e.g., antihypertensive agents).
• Increased interstitial volume (cirrhosis, renal
  failure).

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Edema measurement

• Measure edema by depth of pitting
• 1 Mild 0 to ¼ pitting
• 2 Moderate ¼ to ½ pitting
• 3 Severe ½ to 1 pitting
• 4 Very severe 1 pitting
• Pitting can also be measured by the time it takes
  for the skin deformation to normalize.

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Interventions for edema

• Leg elevation.
• Exercise.
• Compression.
• Diuretics should never be used as a primary
  treatment for edema.
• MANAGEMENT OF EDEMA REQUIRES AN INVESTMENT OF
  TIME, ENERGY, AND DEDICATION BY THE PATIENT, WITH
  MULTIPLE LIFESTYLE ADJUSTMENTS.

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Interventions for edema

• Leg elevation
• Elevate legs above the level of the heart 20 to
  30 minutes at a time for a total of 2 hours per
  day.
• OK to exercise feet and ankles while elevating
  legs.
• Contraindications arterial occlusive disease,
  CHF, morbid obesity, other medical conditions
  which preclude lying horizontal.
• Exercise
• Work the calf muscle pump while using a
  compression garment or wrap.

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Interventions for edema

• Compression includes
• Short- and long-stretch bandages.
• Tubular bandages.
• Paste bandages (Unna boot).
• Graduated compression stockings.
• Intermittent sequential compression devices.

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Compression

• Questions to ask before applying compression
• Is the ABI above 0.8?
• Does the patient have an allergy to latex?
• Does the patient need edema reduction before
  being fitted for permanent compression garments?
  Should insurance authorization be initiated?
• Does the patient have sufficient ROM to don the
  garments? Will a caregiver need to be trained?
• Is the patient committed to the process?

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Classes of compression

• Class 1 14-18 mmHg
• Class 2 18-24 mmHg
• Class 3 25-35 mmHg
• Class 4 40-50 mmHg
• Non-ambulatory patients or those not able to work
  the calf muscles need 16-18 mmHg pressure.
• Dependent edema requires low compression at 18-24
  mmHg.
• Venous insufficiency requires 24-35 mmHg (some
  say 40 mmHg, if patient is able to walk) in OTC
  or custom compression stockings or four-layer
  bandages.

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Compression hints

• Check the ABI!
• Choose the compression option that suits the
  degree of exudate.
• Increase compression if edema persists with lower
  compression, or with an chronic ulcer of 6
  months duration.
• Be careful of uneven tension causing skin
  irritation and/or ulcerations.
• Apply compression within 20 minutes of waking.

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Compression options

• Elastic wraps
• Long-stretch bandages are best simply to secure a
  bandage (or with burn patients at HMC).
• Short-stretch bandages are recommended, so
  sufficient external compression isi applied to
  cause movement of excess fluid.
• Tubular bandages for light compression - Should
  be tapered at the ankle otherwise, compression
  is higher at the calf than at the ankle. Tubular
  bandages come in many sizes. Demo of
  measurement.

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Compression options

• Paste bandages
• Developed in the 1880s by Dr. Unna
• Fine gauze impregnated with zinc oxide, gelatin,
  glycerine, (?) calamine.
• As the boot dries and stiffens, the leg cannot
  continue to swell.
• Apply it without tension or wrinkles (cut and
  pleat).
• If too tight after a period of activity, elevate
  legs at least 30 minutes.

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Compression options

• Paste bandages (cont.)
• Application of a compression wrap over the boot
  will increase compression and protect clothing.
• Usually changed every 4 to 7 days.
• Shower if able to cover with plastic and tape.
• Ownership of care is placed on the provider.
• Contraindications Is the patient allergic to
  any ingredients? Is the ABI below 0.8? Does the
  patient have poor personal hygiene, frail/friable
  skin, active cellulitis, or infected ulcers?

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Compression options

• Four-layer bandages (plus wound contact layer)
• Provide 40 mmHg pressure at ankle, 17 at calf.
• Provide graduated, sustained compression with
  layers providing protection, padding, and
  compression.
• Layering anchors the wrap, stays in place longer.
• Patient should not report toe numbness/tingling.
• PT should be able to place one finger under the
  bandage.

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Compression options

• Four-layer bandages (cont.)
• Rewrap if it telescopes down the leg.
• Change the bandages every 4 to 7 days, more
  frequently if heavy exudate is present.
• Inspect the skin after removing wrap, document.
• Patient should not report severe pain, excessive
  drainage, or foul odor.
• Ownership of care is placed on the provider.

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Compression options

• Compression pump
• Divided into multiple chambers, inflating first
  at ankle. Each successive chamber inflates to a
  lesser degree.
• Used 1 to 2 hours daily, daytime use only.
• Will require LE compression when not on the pump.
• Strict Medicare guidelines.
• Contraindications Untreated CHF, cellulitis,
  active wound infection, sleeves that do not fit.

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Compression options

• Compression stockings
• Multiple manufacturers, OTC and custom. Examine
  examples and various compression levels.
• Measure early in the a.m. or after pumping for 1
  to 2 hours. Or refer to compression specialist
  when PT deems it appropriate following bandaging.
• Depending on compression level, may be difficult
  to don. Demo of the butler. Make sure there
  are no wrinkles.

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Compression options

• Compression stockings (cont.)
• May be removed for sleeping.
• Not recommended for patients with extensive leg
  ulcers or circumferential wounds.
• Order two pairs at a time -- for laundering.
• Patient compliance is a high priority, especially
  in the summer! Patients should not arrive with
  their stockings in a bag.
• Not universally covered by insurance, certainly
  not by Medicare.

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Compression options

• Compression stockings (cont.)
• Contraindications ABI at or below 0.8, allergy
  to latex (choose the appropriate brand), plus the
  other usual contraindications for compression.

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Criteria for referral back to provider

• Arterial occlusive disease (pain and calf
  cramping with walking, absent peripheral pulses,
  localized lack of hair growth, thickening of
  toenails, delayed capillary refill).
• Persistent edema for 1 month s/p compression
  wrapping, leg elevations, and exercise.
• New ulcerations or enlargement of existing
  ulcer(s).
• Pain with leg elevation and exercise.

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Patient education in self-care

• Patient needs to acknowledge that edema
  management is owned by the patient, not the
  practitioner.
• If compliance is questionable, consider a
  contract.
• If initially using paste bandages and four-layer
  wraps, attempt to move the patient into an
  increased role in their own care as soon as
  feasible.
• Now, lets get to wrapping .