Wound Care Professional - Multicomponent compression system (2, 3, 4 layers)

Abstract

Purpose:

To provide appropriate high level compression of lower extremities to improve venous return, decrease venous hypertension, reduce and control edema, promote wound healing and prevent disease progression.

Policy:

Documentation confirming lower extremity venous disease (LEVD) with edema, and/or with or without venous leg ulcer/s.

Compression therapy wrap to be applied by skilled and trained clinician.

Prior to application of compression therapy, perform ABI to exclude lower extremity arterial disease

Compression (30-40 mmHg at the ankle) if ABI is greater or equal to 0.80 mmHg

Modified compression (23–30 mmHg at the ankle) if ABI is less than 0.80 and equal to or greater than 0.50

Do not apply compression if ABI is less than 0.50

Multicomponent compression systems may remain in place for up to 7 days

Precautions:

Do not apply compression if ABI is less than 0.50, ankle pressure is less than 70 mmHg, or toe pressure is less than 50 mmHg

Compression wraps should be promptly removed if patient develops pain or pale, cool or numbness of extremity distal to the dressing and/or slippage of wrap

If patient has very thin ankle or very prominent tibial crest, extra padding should be applied to these areas to prevent pressure necrosis

Measure ankle circumference to confirm 18 cm or 7¼ inches (add foam padding per need)

Assessment to rule out arterial disease is vital. Failure to detect significantly reduced arterial blood flow can result in pressure necrosis, amputation of limb or death

Review contraindications for multicomponent compression wrap therapy systems (2, 3, 4 layers)

Steps

Bring equipment to the patient's room and knock on door before entering. Introduce yourself. Call the patient by their name and confirm by checking armband. Provide privacy to patient. Explain the procedure to the patient.
Prepare a clean, dry workspace. Use disinfectant solution to prepare. Place trash bag within easy reach of the working area.
Wash hands and apply gloves.
Assess current compression wrap: secured as previously applied or slippage and/or cut by to relieve discomfort; strike-through drainage; distal skin discoloration, edema, numbness, tingling. Report abnormal findings to the patient's nurse, physician or heathcare provider.
Remove compression wrap. Discard in trash bag.
If the patient has a lower leg ulcer, remove wound dressing and discard dressing and gloves in the trash bag.
Wash hands. Apply clean gloves. Assess the wound. Cleanse wound according to policy and procedure. Remove and discard gloves in trash bag.
Apply clean gloves. Measure ankle circumference. If less than 18cm, apply foam padding.
Follow each product manufacturer instructions for application of multicomponent compression systems.
Observe skin distal to compression wrap for adequate circulation (pain, color, pulse, warmth).
Initial and date compression wrap.
Discard gloves and all used supplies in trash bag. Wash hands.
Place the patient in a comfortable position.
Document in patient's medical record:
Wound assessment and dressing change.
Compression wrap removal and application of new multicomponent compression system (name and type)
Patient's tolerance of compression wrap application.

Key points

Multicomponent compression systems are available with 2, 3, and 4 layer bandages. Follow specific application instructions for each product.
If applied too tightly, the bandage may cause patient discomfort, and/or act like a tourniquet. If applied too loosely, the compression wrap is ineffective.
Apply bandages with foot dorsiflex position. Wrap from lateral to medial for accurate compression.
Upon reaching the knee, do not wrap down the leg with any remaining bandage wrap.
Always assess associated pain with compression wrap systems.