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					   Clinical PRACTICE DEVELOPMENT



Understanding compression
therapy to achieve tolerance
Compression bandage therapy may be poorly tolerated by patients and can be a frustration for both
patients and practitioners. This article presents the view that practitioners need to increase their
knowledge and assessment skills to enable patients to tolerate a rather difficult treatment. The use of
compression bandages will be discussed in relation to their type, sub-bandage pressures, application
technique and the role of the Ankle Brachial Pressure Index. It is hoped that some of the ideas
presented will promote debate.

                                                            Alison Hopkins, Fran Worboys


                                                             compression they use or is on offer to       diverse needs of their patients are
                                                             the patient. This was echoed in a study      to be met. Yet, despite using a range
   KEY WORDS                                                 by Edwards (2003); she discovered            of bandages, nurses appear generally
   Leg ulcers                                                that it was the patient’s perception         unaware of bandage classification and
   Compression bandaging                                     that they had to put up with the             where each bandage they use sits
   Compliance                                                compression bandage on offer, despite        within this (Table 1).
   Sub-bandage pressure                                      their problems, because this was the
                                                             treatment provided by the district              There is also a confusion of terms
   Doppler ABPI                                              nurse with little evident flexibility.        used, e.g. long-stretch, elastic, inelastic or
                                                                                                          short stretch, compression or support.
                                                                Yet if practitioners understand           The British National Formulary’s
                                                             compression therapy, its role and how it     inclusion of Type 3a compression


I
   t has been firmly established that                         can be achieved successfully through a       bandages in the section on support
   compression bandage therapy                               variety of compression techniques, the       bandages adds to this confusion.
   increases the healing rates of                            practitioner’s skill will be increased and
venous ulceration (Cullum et al, 2001).                      thus also the tolerance of the patient       Classifying extensible bandages
Compression therapy reverses the                             for the therapy. Promoting tolerance is      Extensible bandages (also referred
effects of venous hypertension. Venous                       a complex interplay of issues and this       to as short-stretch, inelastic, long-
blood velocity is increased through the                      article presents a few of them.              stretch, elastic) have been classified
reduction of superficial capillary and
venous pressure (Mear and Moffatt,                           Knowledge of bandage type                     Table 1
2002), augmented by increasing the                           The management plan must ensure
efficiency of the calf muscle pump                            a thorough assessment of the                  Bandage classification
(Partsch, 2003).                                             patient, limb, and ulcer history before       Type 1: Retention or
                                                             compression therapy can be selected                    conforming bandages
   Multi-layer systems are more                              (Royal College of Nursing Institute,          Type 2: Light support
effective than single layer compression                      1998; Scottish Intercollegiate Guidelines
(Fletcher et al, 1997). It is also clear that                                                              Type 3: Compression bandages,
                                                             Network, 1998). Good knowledge
practitioners vary in their techniques                       about one compression system is not                    pressure dependant on
and the subsequent sub-bandage                               enough. It is the authors’ experience                  18–25cm ankle
pressure being applied (Moore, 2002);                        that knowledge about the traditional          Type 3A: Light compression, 14–17mmHg
thus consistency with any system is                          four-layer system does not necessarily        Type 3B: Moderate compression,
difficult to obtain. From the authors’                        mean the nurse understands the key
experience, it appears that nurses                                                                                  18–24mmHg
                                                             principles behind it or the individual
can become fixed on which type of                             properties of each bandage. It is             Type 3C: High compression, 25–35mmHg
Alison Hopkins and Fran Worboys are CNS Tissue Viability,    essential that proficient practitioners        Type 3D Extra high compression
East London Wound Healing Centre, Tower Hamlets PCT,         know about all the differing types of
London                                                       compression bandages available if the

  26      Wounds       UK
                                                                                             Clinical PRACTICE DEVELOPMENT

based on their ability to safely apply        Documentation of the bandages              law, i.e. number of layers, bandage
and maintain a predetermined level            used and their proprietary name            tension, circumference of the limb, and
of compression on limbs of known              is essential, as is the rationale for      bandage width. The equation is clinically
dimensions (Thomas, 1998). There are          choice. Practitioners also need to feel    relevant to the practitioner because
fundamentally two types of bandages.          competent with the system that they        it should affect their bandage choice
                                              are using and be aware of the cost         and technique. Thus it is important
Long-stretch or elastic bandages              implications of the different types of     to recognise that the following will
Long-stretch or elastic bandages apply a      bandages, weighing up the bandage          increase the sub-bandage pressure:
predetermined amount of compression           costs with nursing time, patient           8Smaller limbs
if applied following the manufacturer’s       acceptability, and lifestyle.              8Narrow bandage width. Thomas
instructions and to certain ankle widths.                                                    (2003) states that a 10cm bandage
They change shape with the limb;                 Bandage properties have been                is applied with the same amount
when oedema is reduced, the bandage           discussed in detail elsewhere                  of force as a 5cm bandage, but the
follows in on the limb. The sub-bandage       (Thomas, 1998) and it is important             pressure is distributed over twice
pressure changes little when the patient      that practitioners are familiar with           the area
is active or inactive. Elastic bandages are   the various terms. They are clinically     8Bony or tendon prominence. This
classified as type 3.                          relevant and application of this               increase in pressure can be reduced
                                              knowledge will have a major impact             with the use of sub-bandage
Short-stretch or inelastic bandages           on the tolerance of the therapy. For           wadding by increasing the width of
Short-stretch or inelastic bandages           example, the bandage’s density and             the limb at that point and spreading
do not have any elasticity; the stretch       extensibility govern its conformability.       the load
is caused by the weave only, thus             This is possibly why a type 3a bandage     8Number of bandage layers. (A figure
forming an inelastic covering to the          has better acceptability and comfort           of eight application applies 1.5 times
limb. This resists changes in the limb or     value than a cohesive bandage (type            the pressure of a spiral technique
calf muscle shape. Thus, when walking,        3b); the latter has less extensibility         [Barbenel et al, 1990], thus is only
the efficacy of the calf muscle pump           and can be problematic for patients            used in a type 3A bandage or for
is increased, with pressures being            especially over the dorsum of the ankle        a short stretch in lymphoedema
redirected back into the deep veins.          where the bandage must be applied              management.) Also, a strict 50%
This is described as a ‘high working          with care.                                     overlap will ensure only two
pressure’ present on walking. However,                                                       bandages at any one point. A 66%
when oedema reduces, the bandage              Sub-bandage pressure                           overlap will ensure three bandages
cannot follow the limb in, becoming           Sub-bandage pressure (the pressure             at that point (Thomas, 2003) and
loose and thus this type of bandage           the limb receives from the bandage)            will contribute to compression
requires more frequent application            is more than a theoretical concept             intolerance and damage
initially until the oedema has reduced.       and needs to be understood and             8Increased bandage tension. Bandage
The advantage of this bandage is the          utilised at assessment and evaluation.         guides will help prevent the
‘low resting pressure’ when supine.           Practitioners need to understand its           excessive use of force.
This may be useful for those who have         relevance. Laplace’s equation can be
particular problems with pain at night.       ‘used to calculate or predict sub-         The importance of limb circumference
Also, it is difficult to apply inelastic       bandage pressures and hence the            A review by Cullum et al (2001)
bandages with too much pressure,              level of compression applied to the        found that the aim is to achieve a sub-
making it easy to teach patients or           limb’ (Thomas, 2003). This has been        bandage pressure of approximately
carers to apply. Inelastic bandages are       discussed and debated elsewhere            35–45mmHg at the ankle. Graduated
classified as type 2 support bandages,         (Mear and Moffatt, 2002; Clark, 2003;      compression is the term used to
yet when applied correctly they               Thomas, 2003). Laplace’s law reveals       describe the presence of greater
augment the calf-muscle pump thereby          how the sub-bandage pressures are          compression at the ankle, reducing
reversing venous hypertension.                altered by the variables within the        up the calf. This will be automatically
                                                                                         applied if the bandage is applied with
   Table 2                                                                               constant tension up the limb, as long
                                                                                         as the limb is of a normal shape, i.e.
   Multi-layer compression systems                                                       narrower at the ankle and wider at the
   Ankle width          Bandage layers                                                   calf. If the shape is abnormal, i.e. lacking
   <18cm                X2 sub-bandage wadding, crepe, 3b bandage                        in calf bulk, then sub-bandage wadding
   18–25cm              Sub-bandage wadding, crepe, 3a bandage figure 8, 3b bandage       must be used to restore a normal
                                                                                         shape and reduce the likelihood of
   25–30cm              Sub-bandage wadding, 3c bandage, 3b bandage
                                                                                         compression damage. Similarly where
   >30cm                Sub-bandage wadding, 3a+3c+3b bandages                           the calf muscle is reduced producing
                                                                                         a long thin lower limb, varying the

                                                                                                                  Wounds    UK    27
  Clinical PRACTICE DEVELOPMENT

                                                                                              When bulk or heat is a tolerance issue
                                                                                              Sub-bandage wadding must be used
                                                                                           beneath any compression bandage,
                                                                                           regardless of the compression levels
                                                                                           applied, because of the risk this may pose
                                                                                           to skin integrity. However, if footwear is
                                                                                           a problem, driving is difficult or irritation
                                                                                           a problem, one option is to modify and
                                                                                           reduce its use with the proviso that
                                                                                           the ankle width is wider than 18cm;
                                                                                           the practitioner can do this safely if the
                                                                                           rationale for its use is understood.

                                                                                               The sub-bandage wadding is used
                                                                                           to protect the bony prominences
                                                                                           and Achilles’ tendon from excessive
                                                                                           pressure by redistributing the high
Figure 1. Guttering on the limb.
                                                                                           pressures away from these areas
application technique of a type 3a               While the development of the              (Moffatt, 2005). It is also used for the
bandage from a figure of eight to              four-layer bandage system was based          absorption of exudate. By keeping
spiral, will allow for a better pressure      on the requirement for a sustained           these key principles in mind, bulk or
distribution for the thin leg. A standard     high compression at 40mmHg                   heat can be minimised by reducing
four-layer bandage, which takes no            (Moffatt, 2004), there is debate             the amount of wadding over the base
account of limb shape, may not be             about the precise levels required            of the foot and up the calf: strips of
producing graduated compression.              (Thomas, 1998). Practitioners would          wadding are applied down the tibial
                                              also recognise that for those with           crest to the toes, and around the ankle,
    Despite authors (Clark, 2003; Thomas,     extensive venous disease, often a            protecting the malleoli, the dorsum of
2003; Moffatt, 2005) drawing attention        greater amount is required in order          the ankle, and Achilles tendon (Figure
to the need to measure the limb and           to prevent recurrent infection and           2). Despite this suggestion appearing
choose bandages accordingly, from the         aid healing.                                 controversial, it is a simple measure
authors’ experience of reviewing patients                                                  that can produce a dramatic increase in
within a tertiary referral unit, it seems         One way of evaluating this               tolerance for the bandage system and
that many nurses do not understand            requirement is through the presence          allow for more footwear choice.
its significance. It is thus common for        of ‘guttering’ on the limb (Figure 1). The
patients with very wide limbs not to          author has not been able to find this            The crepe layer can initially apply high
receive the compression they require in       term described in the compression            pressures, but these reduce quickly over
order for healing to take place (Table 2).    literature despite its recognition in        time. However, this initial high pressure
                                              clinical practice. Guttering can be          must be recognised and the bandage
   Again, nurses need to have confidence       described as longitudinal grooves            applied with care. Again, it is important
in Laplace’s law and be reassured that,       down the gaiter and above, which are         to remember that crepe is used for
by applying extra high compression, they      3–5mm in width, revealing oedema             smoothing of the wadding and adding
will not cause damage to a limb with a        reduction. Its presence demonstrates         absorbency but can be considered the
31cm ankle width. This knowledge will         that the compression therapy is having       least effective layer (Moffatt, 2005).
also ensure that the small limb (<18cm)       a therapeutic effect on the limb. Thus       Thus the authors suggest that if bulk is
will be protected from high sub-bandage       guttering needs to be looked for when        causing intolerance, then the crepe layer
pressure by the use of extra sub-bandage      evaluating effectiveness. If it is not       can be omitted and the reason for this
wadding. The use of compression               present and the wound is non-healing,        documented.
therapy is about both competence and          then the supposition is that the
confidence. A recent study found nurses        compression therapy is not effective.        The significance of the application technique
erred on the side of caution, fearful of      The practitioner will need to review         When a compression bandage or
applying incorrect compression (Field,        either the choice of compression             system is not tolerated and thus
2004). This echoed work undertaken by         system or the practitioner’s technique.      removed, the patient is frequently
Ruckley (2001) who found that reduced         It is important that guttering is not        described as non-compliant. They are
compression was often used, despite the       confused with bandage creases that           thus dismissed as interfering with, or
presence of guidelines, when support for      are transverse ridges that are red on        negating the effects of, this correct and
practitioners was lacking. Thus this points   their apex. These are brought about by       beneficial treatment. This view is both
to the need for explicit referral pathways    poor application or slippage and need        detrimental to the patients’ care and
for specialist review and support.            to be avoided.                               the therapeutic relationship. A patient

 28      Wounds     UK
  Clinical PRACTICE DEVELOPMENT

                                                                                                                 utilising a combination of spiral and
                                                                                                                 St Charles application technique
                                                                                                                 with good effect, thereby preventing
                                                                                                                 slippage. These techniques will need
                                                                                                                 to be used by the specialists to help
                                                                                                                 people in difficult circumstances.

                                                                                                                 Pain should not be tolerated
                                                                                                                 Pain is the main cause of abandoning
                                                                                                                 compression therapy. Again, exactly
                                                                                                                 what this means to the patient needs
                                                                                                                 to be investigated. It is clear that most
                                                                                                                 venous ulceration causes pain (Krasner,
                                                                                                                 1998; Persoon et al, 2004) thus new
                                                                                                                 or additional pain is more significant.
                                                                                                                 Most importantly, pain needs to be
                                                                                                                 reduced through adequate analgesia,
Figure 2. Bulk or heat can be minimised by reducing the amount of wadding over the base of the foot and
                                                                                                                 using opiates as necessary. Compression
up the calf: strips of wadding are applied down the tibial crest to the toes, and around the ankle, protecting
                                                                                                                 therapy cannot be tolerated if pain relief
the malleoli, the dorsum of the ankle, and Achilles tendon.
                                                                                                                 is not addressed. Some ulceration may
                                                                                                                 be particularly painful and is not related
knows, if asked, which nurse they would                  8No bandages are applied with                           to the size or depth of the ulceration
prefer to apply the bandage. A patient                    tension until the turn coming out of                   but is caused by painful atrophe blanche.
in Edwards’ (2003) study describes this                   the ankle                                              Oedema or lymphoedema can also be
well, making it clear that ‘appropriate                  8Bandage layers are kept to a minimum.                  painful and debilitating.
application of compression causes less
pain and discomfort’. Thus, the technique                   This will also ensure that ankle                         The type of pain needs to be
used by the nurse and the bandage                        mobility is not reduced, allowing the                   established and whether it is increased
chosen must be the first point of review                  calf muscle to maintain its important                   or changed with the compression
when a bandage is not tolerated.                         function in promoting venous return.                    therapy. It is imperative that the
                                                                                                                 practitioner ascertains whether the pain
While it is essential, as stated, to                         If a patient has found the bandage                  is the result of ischaemia, neuropathy,
protect the prominent bony and                           system uncomfortable, the reasons for                   infection or application technique. If
tendon areas of the lower limb, one of                   this needs to be investigated. Simply                   ischaemic, symptoms would be pain
the most common problems for the                         documenting that it was too painful                     or tingling in the toes, or claudication
patient is tightness over the dorsum of                  is not adequate, and certainly is not                   (cramping) pain; it is essential that
the ankle. This cannot be tolerated and                  enough to abandon a proven therapy.                     patients are forewarned of these signs
the bandage is often removed before                      Mear and Moffatt (2002) discuss                         and know to remove their bandages.
any damage can be seen. The key                          the importance of using the correct
reasons for this are:                                    technique when applying a bandage.                         Unresolved pain can also lead
8Too much compression too soon                           Practitioners need to be competent.                     to hypersensitivity or hyperalgesia
   when pain management has not                          A practitioner noticing the poor                        (Consensus document, 2004) and
   been instigated or is ineffective                     technique of a colleague is called to                   unfortunately this is poorly understood
8Too many bandage layers, that is,                       be an advocate for the patient and                      by practitioners leading to a lack of
   the bandage has not been applied                      to identify and minimise risk (Nursing                  belief in the extent of a patient’s pain.
   utilising a 50% overlap                               Midwifery Council, 2004). One way in                    Understanding the pathophysiology of
8Bandages applied with tension over                      which this can be dealt with is through                 pain could have an enormous impact
   the foot and ankle                                    adequate training of practitioners                      on a patient’s quality of life (Briggs,
8On application, the foot is in a relaxed                (RCN, 1998; SIGN, 1998).                                2005) and pain needs to dealt with
   or plantar-flexed position, so on walking                                                                      actively, not with indifference.
   there is bulking of the bandages.                         Difficult-shaped legs often require                  Having stated this, it appears that a
                                                         a different application technique or                    common issue for the patient is simply
These problems are easily prevented by                   bandage choice. Using a cohesive                        that they lack belief that this therapy
ensuring that:                                           bandage as the top layer may prevent                    will not cause any adverse effects to
8The foot is dorsi-flexed when                            slippage. Charles et al (2003) describe                 their limb; they become worried, a
  bandages are applied. The patient                      the benefits of using a cohesive short-                  worry made worse at night, resulting in
  must learn the catch-phrase ‘toes to                   stretch bandage for the ‘champagne                      them removing their bandage. Through
  your nose’                                             bottle’ shaped legs; they describe                      discussion, the provision of analgesia and

  30     Wounds     UK
  Clinical PRACTICE DEVELOPMENT

the application of reduced compression,      group. In addition, those who had an          accounted for and recorded. Moreover
their confidence and tolerance is built       ABPI within a normal range (0.8–1.2),         the measurement and calculation is
up enabling them to progress onto high       but also had evidence of some arterial        subject to practitioner competence and
compression bandaging.                       disease, had light compression applied.       practice with inter-rater and intra-rater
                                             As Bowering (1998) states:                    reliability creating a challenge (Fisher
   Attention to co-morbidities is also                                                     et al, 1996; Kaiser et al, 1999). This
important. Paracetamol for a sickle cell        ‘Although (ABPI of <0.8)                   poses a question as to what training is
patient or an intravenous drug user             are legitimate concerns,                   available for nurses to facilitate them
may be ineffective: the challenge is to         global avoidance of all levels             into competency in ABPI assessments
find effective analgesia with sometimes          of compression therapy in                  and whether there enough guidance for
‘imaginative’ bandaging combinations            mixed venous and arterial                  complex assessments.
that will be tolerated.                         ulcers [….] eliminates one
                                                of the best modes of venous                   However, using the ABPI ratio is only
Role of the ankle brachial pressure index       ulceration treatment’.                     one aspect of the Doppler ultrasound
The use of the Doppler ultrasound in                                                       that should be used in decision making.
providing a simple vascular assessment          Thus although cut-off values provide       The waveform output and pulsatile
as part of determining leg ulcer             a useful tool perhaps they should             sounds are also important. Being
management and therefore compression         not be seen as an end in themselves           able to differentiate the difference
bandaging is advocated (SIGN, 1998;          but part of the assessment, just as           between tri-phasic, bi-phasic and
RCN, 1998). An ankle brachial pressure       the ABPI is part of the process in            monophasic sounds will help to assist
index (ABPI) is considered a reliable        determining leg ulcer management.             the practitioner in discerning vascular
and reproducible measurement                 Indeed using the ABPI as sole indicator       status. The patient might have an
sensitive to arterial occlusive disease      of whether compression can safely             apparently healthy ABPI of 1.0 but with
(Osmundson et al, 1985). The cut-off         be applied to the limb can limit the          a whooshy and monophasic pulse. This
value for applying full compression has      use of compression therapy and be             points to evidence of arterial disease
been based on evidence which places a        detrimental to the patient. Relying upon      and needs to be excluded with a
normal ABPI value as being equivalent        the ABPI for compression decisions is         Duplex Ultrasound. Any compression
to or greater than one (Yao et al, 1969),    also limiting if the patient is unable to     must then be reduced and applied with
with others locating it at 0.97 (Carter,     tolerate the procedure: compression           care. It also appears that in the authors’
1969; Stoffers et al, 1996). Thus an ABPI    may be postponed in favour of a wait          experience, some practitioners are
of < 0.9 is taken to indicate a degree of    and see policy while the wound or             reluctant to apply compression when
arterial disease.                            condition deteriorates.                       an ABPI is greater than 1.2, fearing
                                                                                           calcification, despite significant clinical
   An ABPI of > 0.8 is therefore                 The ABPI is not a fixed phenomenon.        need. Again, this does not account for
considered safe for the application of       Just as the pressure index varies with        the fit, younger patients with triphasic
high compression therapy (SIGN, 1998)        the systolic pressure it is also subject to   pulses for whom this ratio, or even
and Vowden and Vowden (2001) note            a number of variables which influence          above this, is normal.
how this has become the pivotal figure        the result and interpretation. Limitations
for determining high compression             to the Doppler method of measuring               Thus these points reveal the
bandaging with a ‘mixed ulcer’ being         systolic pressure have been noted,            complexities of what is often
defined at this point. An APBI of             particularly related to calcification of       considered a simple tool. Practitioners
>0.8 allows the application of high          the arteries as in diabetes (Emanuele et      need to have courage and confidence
compression. Light compression can be        al, 1981; Goss et al, 1989). Similarly the    to apply compression, but this is not the
applied to a limb that has an APBI of        ABPI will not be helpful in microvascular     same as taking undue risks. Guidance
0.5 – 0.8. Practitioners need reminding      or vasculitic conditions and hypertension     regarding the ABPI and compression
of the benefits of reduced compression        and hypotension may also affect               therapy is clear, and should be
and the EWMA Position Statement on           pressure ratios (Hugues et al, 1988;          supported by specialist support and
Compression Therapy (Marston and             Carser, 2001) producing results which         local referral pathways to vascular
Vowden, 2003) has clarified this.             may lead to over or under compression.        teams. These complexities are part
                                                                                           of risk management within a clinical
   In a group of diabetics with venous          The procedure for obtaining an             governance framework.
disease, Bowering (1998) did not             ABPI is directly related to the accuracy
solely use the ABPI to determine the         of the results produced. Guidelines           Not just for venous disease
degree of compression to be used but         advise following a strict procedure           With the classic definition of a leg
evidence of peripheral arterial disease.     and are well documented (Anderson,            ulcer being a loss of skin below the
Light compression was applied to             1995; Vowden and Vowden, 1996;                knee on the leg or foot, taking more
limbs with an ABPI of 0.5–0.8 which          Stubbing et al, 1997). Any deviation          than 6 weeks to heal (Dale, 1995), it
produced positive results in this difficult   produces results which should be              appears that practitioners forget that

 32    Wounds    UK
compression bandages are not just
useful for treating venous ulcers. For          Table 3
pre-tibial lacerations, occurring in an        Checklist for when compression bandaging is not tolerated
area with poor vascular supply, healing
can be slow, especially if complicated
                                               1. Check ABPI result is recent. What are the absolute values?
by oedema. While pre-tibial lacerations
would benefit from compression                  2. Has it ever been tolerated? If yes, when and who applied it?
therapy (Moffatt, 2005), the authors           3. Check application technique, especially over dorsum of ankle.
would contend that lower limb graft               Is there pressure damage or pain on walking?
sites and suture lines from coronary           4. Check where and when the pain occurs
artery bypass grafts would also heal
                                               5. Is the pain the result of arterial insufficency or is it based on fear/apprehension
faster with the application of light
compression. Unfortunately, Stevens               or claustrophobic feeling?
(2004) notes that some trusts are              6. What type of compression has been tried?
reluctant to allow practitioners to apply      7. Does the patient know immediately whether the bandage will be comfortable?
therapeutic compression for ulceration            If yes, then apply correctly and find out. If comfortable, then application technique
that is not venous. This can be limiting
                                                  needs to be addressed.
and will lead to some patients having
ineffective treatment. The latter still        8. Does the patient/nurse ensure correct ankle position at application (toes to nose)?
require a full leg ulcer assessment and        9. Is footwear an issue? If yes, reduce sub-bandage wadding over base of the foot.
arterial assessment before compression            Choose a single-layer bandage regime
therapy (RCN, 1998; SIGN, 1998).               10. Is the bandage slipping? Is this because of oedema reduction, shape of leg
                                                  or application? Use cohesive bandage as a top layer or short-stretch technique
Evaluation of compression therapy
Evaluation of compression therapy                 that supports the calf
should occur on a regular basis.
This involves assessment of comfort,
toleration, efficacy (ulcer healing and       understanding of their perceptions’              the difficult to heal and those with
oedema reduction), and sustainability.       (Edwards, 2003). This will allow the             complex aetiologies. While generalists
If the bandage is not staying secure for     nurse to negotiate a treatment regime            still require clear guidelines in which to
the allotted time, then time is being        that is both comfortable and effective,          work, specialist practitioners are now
wasted on inefficient treatment and           thereby increasing tolerance with this           working on the edge of what can be
healing will be delayed. If a wound          difficult therapy. Creativity is essential        termed as evidence-based practice.
is non-healing despite adequate              or some patients will be left with little        In these circumstances we need to
compression, then the original diagnosis     hope of healing (Table 3). Thankfully,           be creative in our craft, interpreting
of venous ulceration needs to be             with new materials and the recent                guidelines while holding on to key
questioned and the patient referred          addition of two-layer hosiery systems            theoretical principles. Some readers
for specialist advice. Consistent            (Hampton, 2003), ingenuity should be             may find several of the suggestions
compression therapy is a key feature         less difficult to attain.                         in this article worrying; others will
and needs to be appreciated by both                                                           recognise practices that they already
practitioner and patient.                    Conclusion                                       carry out. It is hoped that by raising
                                             The complexities of compression                  these challenging issues debate will be
    This article has not explored the        bandaging are recognised and a good              stimulated.WUK
complexities of non-compliance but has       technique brings together the art and
focussed on the need of practitioners        science of nursing. Practitioners require        References
to increase their skill and knowledge. It    guidelines to follow that are evidence           Anderson I (1995) Doppler ultrasound
is clear that there will be a few patients   based and relate to local needs. Clear           recording of ankle brachial pressure index in
                                             referral pathways are vital for wounds           the community. J Wound Care 4(7): 325–7
for whom compression therapy cannot
be tolerated. Yet, it is also evident        that are non-healing despite what is             Barbenel JC, Sockalingham S, Queen D, et al
that application varies widely (Moore,       perceived to be correct management.              (1990) In vivo and laboratory evaluation of
                                             Practitioners also need to know how              elastic bandages. Care Science Pract 8(2): 72–4
2002) and practitioners need to review
their knowledge and skills. When             to proceed when there is anxiety                 Bowering CK (1998) Use of layered
a practitioner understands the key           over Doppler results and associated              compression bandages in diabetic patients.
                                             interpretation.                                  Adv Wound Care 11: 129–35
principles of compression bandaging,
the types and their properties, their                                                         Briggs S (2005) Leg ulcer management:
                                                 With the increased knowledge and             how addressing a patient’s pain can improve
ability to meet the patient’s needs is
                                             skills of practitioners, the classic venous      concordance. Prof Nurse 20(6): 39–41
enhanced. Practitioners need to listen
to their patients and ‘gain a better         leg ulcer often heals quickly, leaving           Carser DG (2001) Do we need to reappraise

                                                                                                                         Wounds    UK      33
  Clinical PRACTICE DEVELOPMENT

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