Working in partnership with patients to promote concordance with compression bandaging.

‘i felt comfortable and slept well’ Working in partnership with patients to promote concordance with compression bandaging Dr Anne F. Williams © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.012 on December 7, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.

Contents Achieving comfort and concordance when selecting and applying compression bandages

S3

Venous ulceration

S3

Chronic oedema

S4

Differentiating between chronic oedema and lymphoedema

S4

Pain

S4

Effects of pain on sleep

S5

Pain assessment and management

S6

Compression therapy

S6

The science of compression bandaging

S7

Practice considerations

S8

Case studies

S10

Concordance

S11

Self-management

S12

Conclusion

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References

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Declaration of interest This supplement was commissioned and supported by Activa Healthcare Anne Williams is an independent consultant who received a fee for her contribution

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B r i t i s h J o u r n a l o f C o m m u n i t y N u r s i n g Vo l 1 7 , N o 1 0

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Achieving comfort and concordance when selecting and applying compression bandages Patients may be tempted to remove their compression bandages if they find them uncomfortable, particularly at night. Working in partnership with patients to select bandages that they find tolerable and then applying them in a way that promotes comfort will encourage concordance with this therapy

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or many individuals, venous leg ulceration is a chronic, debilitating condition (Briggs and Flemming, 2007), particularly if they also have chronic oedema. Multi-component compression bandaging is a key element of the management of these conditions. However, problems such as pain and discomfort can influence the extent to which individuals tolerate compression bandaging (Moffatt et al, 2009; Taverner et al, 2011a), affecting treatment outcomes. When choosing a compression bandaging system, it is necessary to take into account both the underlying disease aetiology and the need for patient comfort. This involves recognising that sometimes the treatment itself can lead to pain and discomfort, which can reduce the ability to perform activities during the day and cause loss of sleep at night (Hareendran et al, 2007; Herber et al, 2007). If this persists, patients may remove their bandages (Ebbeskog and Ekman, 2001), and so may be perceived as being non-concordant with their treatment. This supplement explores the link between painrelated loss of sleep and non-concordance in patients with venous ulcers and chronic oedema of the lower limb. A key challenge nurses experience when selecting and applying a compression system is ensuring that it will be acceptable to the patient. This supplement explains that patient satisfaction and thus concordance are more likely to be achieved if nurses undertake a comprehensive assessment that identifies problems with pain and sleeplessness; educate patients about their condition and its treatment; select compression systems that both address the underlying aetiology and suit the individual’s lifestyle; and apply bandages correctly (Moffatt, 2008). Concordance is also more likely to be achieved if nurses establish empathetic relationships with patients that incorporate holistic assessment, shared decision-

Ac t i va S u pp l e m e n t

Dr Anne F. Williams, PhD, RN, DN, Dip.Nurs.Ed Nurse Consultant/Researcher Esk Lymphology Dalkeith, Midlothian, Scotland and NHS Highland Lymphoedema Project Consultant

making, education and support. This involves regarding patients as partners in care, and thus encouraging them to self-manage their condition. This will enhance quality of life, as patients are more likely to stay active (Moffat et al, 2009) and get a good night’s sleep.

Venous ulceration

It is estimated that 60–80% of all leg ulcers result from venous disease, with many being chronic, following a cyclical history of healing and skin breakdown, often in patients with several comorbid conditions such as diabetes, obesity and arthritis (Scottish Intercollegiate Guidelines Network [SIGN], 2010). Venous disease occurs when the flow of blood from the legs to the heart becomes impaired. In people with normal circulation, when the patient is walking the calf muscles and feet pump the blood, allowing it to flow through the veins of the leg upwards toward the heart. Meanwhile, valves present in the vein close, preventing blood flowing back down (Hampton, 2010). When the valves in the deep and/or superficial veins in the leg become incompetent, backflow of blood occurs, resulting in a build-up of pressure in the veins (venous hypertension) (SIGN, 2010). Prolonged periods of standing and/or immobility, as well as trauma, surgery and a history of deep venous thrombosis (Ågren and Gottrup, 2007) can impair the valves. S3


This venous hypertension causes the vein to become weakened and stretched. Over a prolonged period of time, this leads to chronic venous insufficiency, also known as venous disease. Venous disease results in a variety of skin and tissue changes, such as varicose veins, venous eczema, ankle flare and atrophie blanche (Todd, 2012). These changes should be looked for and identified when washing patients’ legs and feet, and changing dressings or bandages. The presence of these signs is indicative of underlying venous disease, which, without intervention, may progress to skin breakdown and ulceration. Early intervention in the form of good skin care and wearing hosiery can delay, or even prevent, the disease from progressing in this way.

Chronic oedema

In patients with longstanding venous hypertension, the capillary walls become more permeable, with excess fluid and macromolecules leaking into the interstitial tissues (increased capillary filtration) (Mortimer and Levick, 2004). Normally, the lymphatics transport such excess fluid back to the venous system. However, if the increased capillary filtration continues unabated, the lymph system will be overwhelmed and its function impaired. It is now recognised that lymphatic drainage is compromised to some extent in all chronic oedemas (Partsch and Moffatt, 2012). Chronic oedema is a broad term used to define oedema that has been present for more than 3 months (Moffatt et al, 2003). Often, several coexisting factors contribute to its development and exacerbation. These include chronic venous insufficiency; skin problems and cellulitis (Wingfield, 2009); right-sided heart failure; renal or liver disease; poor mobility; weight gain; limited ankle movement due to arthritis; and use of medications such Figure 1: Stemmer’s sign

as calcium-channel blockers, which affect the pumping action of lymphatic smooth muscle, compromising lymph drainage (Keeley, 2008). As stated above, venous hypertension is a precursor of leg ulceration and chronic oedema. Chronic oedema will also impair venous ulcer healing (Anderson, 2012), highlighting the chronic nature of ulceration for many individuals.

Differentiating between chronic oedema and lymphoedema

Chronic oedema can be differentiated from lymphoedema by identifying the initial cause of the swelling. Chronic oedema is associated with venous disease, and is compounded by prolonged immobility, obesity, chronic organ failure or use of medications with fluid-retention side effects, whereas lymphoedema is a direct result of failure/damage of the lymphatic system. Therefore, in lymphoedema, the capillary filtration may be normal, but the lymphatics will be damaged or absent. If primary, it involves structural and functional changes to the lymphatic system that may be present at birth or become obvious later in life. Secondary lymphoedema results from damage to the lymphatics, which can be due to surgical removal of lymph nodes, tissue fibrosis (thickening and scarring) following radiotherapy or an injury such as a burn, or infection or malignant disease (Browse, 2003; Lymphoedema Framework, 2006). Lymphoedema can coexist with venous ulceration. Stemmer’s sign, an inability to pinch up the skin on the second toe, is often described as a definitive sign of lymphoedema (Lymphoedema Framework, 2006) (Figure 1). In a prevalence study of a defined geographical population of 252 000 in London, a positive Stemmer’s sign was identified in 39/113 of patients (35%) with venous leg ulcers (VLUs) (Moffatt et al, 2004), suggesting that many had compromised lymphatic function. In the early stages of oedema in patients with existing VLUs, the swelling may reduce on elevation — for example, in bed at night (Timmons and Bianchi, 2008). As the condition progresses and becomes chronic, the swelling becomes more persistent and signs of lymphatic insufficiency develop (Lymphoedema Framework, 2006). The skin becomes thicker due to tissue fibrosis, and skin folds may arise or, where already present, may become more pronounced (Todd, 2012).

Pain

There is considerable evidence that pain is a common problem for people with leg ulcers (Royal College of Nursing [RCN], 2006; Briggs and Flemming, 2007; SIGN, 2010). It can have various pathophysiological causes (Table 1), and be exacerbated when chronic oedema causes localised pressure within and around the ulcer site. It may also be associated with medical conditions such as rheumatoid arthritis (Margolis et S4



Table 1: Possible causes of pain in people with leg ulceration (adapted from Briggs and Closs, 2006; Beldon, 2009; Anderson, 2012) Inflammation or infection leading to nociceptive pain Arterial insufficiency and tissue ischaemia Neuropathic processes — hyperactivity of damaged nerves Allergic reactions Treatments such as wound cleansing, debridement, compression products Excoriation and/or maceration of skin due to excessive exudate

al, 2004) or infection (Miller et al, 2011), or be a direct result of treatments including wound cleansing and compression therapy (Briggs and Closs, 2006; Herber et al, 2007). Pain or discomfort may be made worse by hot weather (Herber et al, 2007). Pain can restrict activities such as walking (Herber et al, 2007) and is likely to affect how much a patient can participate in his/her care (Beldon, 2009). Long-term pain can affect emotional wellbeing, and is associated with stress, depression, low self-esteem and poor wound healing (Jones et al, 2006; Solowiej et al, 2009). Pain has psychosocial and emotional dimensions, and is influenced by an individual’s past experience of it, his/her social situation, and understanding of the condition and its treatments (Briggs, 2006). There is evidence that nurses may underestimate the degree of pain experienced by patients with VLUs (Briggs et al, 2007), or make assumptions about the reason for it (Taverner et al, 2011b). Nurses must therefore establish empathetic relationships with individuals with venous ulcers and/or chronic oedema of the leg(s), and fully assess and understand the causes of the pain, what it means for each individual and how it affects aspects of his/her life, such as sleep.

Effects of pain on sleep

Regardless of the wound type or aetiology, ongoing and poorly managed pain is likely to result in disturbed sleep, whether someone finds it difficult to get to sleep, or wakens at intervals, such as when the effect of analgesia diminishes (Herber et al, 2007; Taverner et al, 2011a). An international survey of 2018 patients with chronic wounds, of whom 46.3% had leg ulcers, reported pain at night and on waking as particularly problematic (Price et al, 2008). A review of 22 papers on patients with VLUs concluded that pain was the most frequently cited factor affecting quality of life and resulting in sleeping difficulties (González-Consuegra and Verdú, 2011). In their meta-synthesis, Taverner et al (2011a) summarised the evidence on pain and insomnia in people living with leg ulcers, citing several studies, and including quotes from individuals (see box right). Ac t i va S u pp l e m e n t

Furthermore, our ability to sleep through the night reduces as we get older. During sleep, the brain goes through distinct patterns of activity. An adult usually experiences five complete sleep cycles in an average night (Martin, 2003). However, as we get older, our sleep patterns change: the proportion of rapid eye movement (REM) sleep and our ability to sleep soundly diminish, and we are more likely to wake in the night (Martin, 2003). This suggests that older people may be at risk of disturbed sleep when wearing compression bandaging, which may lead them to remove the bandages or be ambivalent about their treatment, particularly if the bandages are bulky and restrict movement. Similarly, individuals with a history of chronic pain, anxiety and depression may experience insomnia, so may find bandaging difficult to tolerate. Pain-related impaired sleep is likely to be associated with anxiety and depression, although it is hard to pin down cause and effect (Taverner et al, 2011a). When selecting a compression bandaging system, the medical, social and emotional context of each individual must therefore be considered. This will, in turn, help identify the potential impact of the compression system on the individual, his/her sleeping pattern, and the possibility of non-concordance with treatment.

‘I was awake nearly all night due to the pain’ (Kitching, 2004)

‘I kept it (the compression bandage) on for a week and never slept for the whole week. It was terrible’ (Mudge et al, 2006)

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Table 2: Questions to consider in a pain assessment (adapted from Beldon, 2009) What pain or discomfort do you experience with your leg ulcer, or for other reasons such as arthritis? Describe the pain (eg, sharp, nagging, stabbing or burning, pins and needles?) When does it occur and how long does it last? How does the pain affect you; for example, does it affect your ability to sleep? What makes the pain or discomfort worse? What improves the pain or discomfort? What analgesic medication(s) do you currently take, when and what is its effect? In what ways does the compression bandage affect any pain or discomfort? Any other comments?

Pain assessment and management

It is clear that the assessment of pain and sleep must be a priority for nurses. Key good practice points for pain assessment are summarised below: • Assess the condition of the ulcer: this involves assessing the ulcer depth and size, whether or not the wound is critically colonised or infected, and the nature and amount of exudate present, as these may all contribute to or exacerbate pain • Assess the peri-wound skin and local tissues: excoriation or maceration can result in pain, or exacerbate it, as can the degree of oedema present • Identify any evidence of possible arterial insufficiency as pain may be a sign of underlying arterial disease (RCN, 2006). This requires measurement of the ankle brachial pressure index (ABPI) or referral for further vascular assessment • Identify other medical conditions, such as osteoarthritis, rheumatoid arthritis or gout, that cause pain or discomfort and may be exacerbated by chronic oedema • Discuss with the patient his/her current use of analgesia and other relevant medications, and their effectiveness • Identify what outcomes will be measured and how, involving the individual in ongoing assessment. Table 2 outlines questions that patients should be asked during pain assessment. A person-centred approach involving open, empathetic discussion is required. This should explore the patient’s current experience of pain and sleeping difficulties, and his/her expectations of treatment. The management plan, which should be developed by both the patient and nurse, should include strategies for evaluating the effectiveness of ulcer treatments and pain-management interventions (Beldon, 2009; S6

Anderson, 2012). However, healing may be an unrealistic expectation in patients with chronic wounds and persistent, poorly controlled oedema. Here, management of problems such as pain, exudate and infection may be the priority, with the objective being to improve quality of life. It is difficult to predict what impact compression bandaging will have on an individual and his/her experience of pain (Taverner et al, 2011b) as this varies so much between patients. According to Taverner et al (2011b), establishing the exact cause of the intolerance to compression bandaging reported in the literature (Briggs and Closs, 2006; Heinen et al, 2007) is a challenge, suggesting that it could be due to both poor toleration of appropriate levels of compressions and badly applied bandages. Nevertheless, an understanding of the science of compression will enable nurses to better understand how to use compression bandages in ways that promote comfort, particularly at night, and thus encourage concordance (Miller et al, 2011). This will, in turn, help achieve good clinical outcomes.

Compression therapy

Compression therapy is the mainstay of treatment for people with venous leg ulceration and chronic oedema (European Wound Management Association [EWMA], 2005; World Union of Wound Healing Societies [WUWHS], 2008), and should be combined with skilled skin and wound care, and support with self-management (RCN, 2006; SIGN, 2010). The use of compression therapy is informed by local guidelines and protocols. In addition, some patients may require referral to specialist vascular, tissue viability, dermatology or lymphoedema services, as appropriate. Compression bandaging systems used on people with chronic oedema and leg ulcers are predominantly B r i t i s h J o u r n a l o f C o m m u n i t y N u r s i n g Vo l 1 7 , N o 1 0


multilayer and multi-component. Most incorporate padding materials such as foam or wadding under layers of compression bandage. Toe bandages are also sometimes used (Todd, 2011). The acronym PLACE is now often used to describe the characteristics of a compression system: it represents the degree or ‘dose’ of Pressure; the number of LAyers; the different Components used; and the Elastic properties of the textiles used in the compression bandage (Partsch and Moffatt, 2012) of the system. The effects of compression therapy on the venous and lymphatic systems are summarised in Table 3. As stated above, nurses are more likely to promote concordance if, when choosing a compression system, they not only take into account the patient’s needs, but also understand how different bandaging systems achieve their therapeutic effect. This requires an understanding of the science of compression.

The science of compression bandaging Elastic and inelastic bandages Bandages are categorised in various ways (WUWHS, 2008). For example, the extensibility of a bandage refers to the extent to which it can be stretched. The

degree of elasticity relates to its ability to return to its original unstretched length. Bandages are generally classified as either elastic or inelastic. Elastic bandages incorporate elastomeric fibres, and so are extensible and can be stretched to 120% of their original length. They are sometimes referred to as ‘longstretch’ bandages and will accommodate changes in limb shape, providing fairly similar pressures when the patient is resting, moving or standing. Inelastic bandages are commonly composed of cotton or a cotton/polyamide mix and provide minimal stretch. They are referred to as ‘short-stretch’ bandages. When applied to the limb over a layer of padding, inelastic bandages provide ‘stiffness’ as they remain ‘rigid’, and do not yield or change shape when the leg muscles expand or contract during movement. The pressure exerted by a bandage can be estimated by recording the interface pressure (the pressure between the bandage and skin [Mosti et al, 2009], also known as sub-bandage pressure) using a pressure monitor. Interface pressures are influenced by a variety of factors (Table 4) and are often constantly changing, particularly during the day while the patient is moving.

Table 3: Effects of compression therapy (adapted from Partsch, 2003; Földi et al, 2005; Mosti et al, 2009; Partsch and Moffat, 2012) • Accelerates microcirculatory blood flow • Reduces capillary filtration • Increases the venous flow velocity and reduces venous reflux, thereby reducing venous hypertension • Reverses micro-lymphatic hypertension and improves reabsorption into the lymphatic system • Reduces levels of post-inflammatory substances in the tissues • Increases tissue pressure, encouraging initial lymphatics to open and softening tissue fibrosis

Table 4: Factors that may influence sub-bandage pressure Materials • Padding: foam or wadding may create different pressures • Compression bandage: extensibility and elastomer properties; bandage width Application • Number of layers used • Application technique: a figure-of-eight technique provides greater overlap than spiral and so will exert a higher pressure • Tension of bandage when applied: may be at full tension/stretch or less • Time since bandage application • Experience of the person applying the bandage The person • Q uality and nature of his/her skin and tissues: the sub-bandage pressure over hard, fibrotic skin may differ to that over soft, fatty areas • D egree of mobility and function: as the patient moves, sub-bandage pressure is likely to reduce over time, particularly if oedema starts to move from the area and the limb circumference reduces



Static stiffness index The stiffness of an inelastic bandage refers to its ability to withstand any change in limb shape when the limb moves. The static stiffness index (SSI) is the difference between the sub-bandage pressure when the patient is resting and standing (Partsch, 2005; Partsch et al, 2006; Mosti et al, 2008a). A pressure increase of 10mmHg or more between lying and standing is classified as a high SSI (Partsch, 2007). Evidence shows that significant variations in pressures occur under an inelastic bandage system as the individual walks, or moves from a resting to a standing position (Charles, 2012). Generally, compression products with a high SSI, such as inelastic bandages, combine a high working pressure, which is necessary for therapeutic effectiveness, with a relatively low and tolerable resting pressure (Partsch et al, 2006; Partsch and Moffatt 2012). As a result, they can be more comfortable than elastic bandaging systems at night, and may still continue to have a therapeutic effect. Lindsay et al (2003) reported that, in their clinical experience, inelastic bandages promote ulcer healing in immobile patients, suggesting that they provide therapeutic pressures even when the wearer is resting. This may be because their higher SSI makes inelastic bandages more effective than elastic bandages in decreasing the degree of venous reflux (backflow of blood in the vein) (Partsch et al, 1999; Mosti et al, 2008b).

It can be hypothesised that the variation in pressure that occurs under an inelastic bandaging system has a rhythmic massaging effect on the lymphatics and surrounding tissues (Partsch, 2007). This may be similar to the action of manual lymph drainage, which is a gentle type of massage used to promote the movement of lymph from the tissues (Williams, 2010).

Practice considerations

Effects of inelastic bandages on the lymphatic system Inelastic bandages have been shown to improve lymphatic function and reduce oedema. There are indications this can alleviate pain in some patients (Wong et al, 2012). Inelastic compression appears to counteract capillary filtration in patients with chronic oedema and influence the contraction of lymphangions (segments of lymph vessels), thereby reducing the pressure in the lymphatics and improving lymph flow (Partsch and Moffatt, 2012). Inelastic bandages also have been shown to help reduce lymphoedema (Badger et al, 2000; Moffatt et al, 2012). A Dutch study involving 20 patients with lymphoedema in the leg found that the median subbandage pressure under an inelastic bandage system reduced from 64mmHg to 32mmHg due to a reduction in the volume of oedema, when measured 2 hours after application (Damstra et al, 2008). Lamprou et al (2011) reported similar reductions in pressure under lymphoedema bandages. This rapid reduction is often reflected by bandage slippage, and emphasises the need for frequent bandage changes in the early stages of treatment in individuals with significant swelling (Williams, 2006; Damstra et al, 2008; Partsch and Moffatt, 2012).

Patients who find their compression therapy uncomfortable or painful are at increased risk of nonconcordance (Moffatt et al, 2009). When selecting a compression bandaging system, it is vital, therefore, to balance the need for clinical effectiveness with patient comfort, acceptability and tolerability. Bandages must be comfortable, particularly at night, or there is a risk that patients might remove them or be reluctant to continue with treatment. Open communication between patient and nurse, with both working in partnership, is particularly important if someone appears unable or unwilling to tolerate compression bandaging, or is anxious about how it will curtail his/her lifestyle, or cause loss of sleep. It is important to avoid labelling these individuals as ‘poorly compliant’, and instead to explore their fears, anxieties or apparent ambivalence about treatment. It can be frustrating when patients do not follow advice, but building a relationship with them over time will enable clinicians to better understand their motivations and so overcome some of these problems. Education is key, and patients need clear information about the reasons for using compression. Time should be taken to explain the different components of a bandaging system and how they work, with discussion on how an individual might avoid discomfort at night. In addition, support and advice on self-management should be consistent and discussed at regular intervals. Patients who find compression therapy uncomfortable or painful are often less motivated to self-manage their condition, and may become discouraged and unwilling to attend clinic appointments, particularly if symptoms are not well managed or treatments produce intolerable side effects (Herber et al, 2007). When selecting a compression bandage system, it might be possible to avoid this by considering the following factors: • The identified clinical outcomes and the patient’s expectations of them • The patient’s symptoms • The patient’s previous experience of treatmentrelated pain and loss of sleep • The patient’s lifestyle • Individual patient choice. Once a system has been chosen, the next step is to ensure that it is applied correctly, as this will increase both its efficacy and comfort.

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Padding Padding materials are used to protect bony prominences and vulnerable areas of the foot, ankle and leg (Hopkins and Worboys, 2005) and provide an even shape under the compression layer, particularly in a poorly shaped limb (Williams and Keller, 2005). It is thought that the compression is more likely to be applied at an consistent compression gradient when the limb is evenly shaped. Padding is also used to absorb exudate (Figure 2), although correct compression bandage application will soon reduce any leakage in certain cases and/or if appropriate treatment is given to address the underlying aetiology. Care must be taken to evaluate how the use and degree of padding influences comfort, tolerability and general mobility. Excessive padding will dissipate and reduce pressure (Partsch and Moffatt, 2012) and can create heat and bulk, restricting movement (Hopkins and Worboys, 2005). Compression systems are now available that require minimal padding (Moffatt et al, 2012). However, poorly applied or inadequate padding may result in pain and skin damage. The characteristics of a padding material can also influence pressure and comfort. For example, a thicker foam material creates a soft and flexible space between the skin and compression layer, which some patients find more comfortable than thinner cellulose wadding. It may be surmised that some types of padding provide greater variations in pressure (and a higher SSI) than others, although research evidence on this is lacking. The type and degree of padding required for each individual should be carefully assessed. Use of strips of wadding to protect areas such as the tibial crest, the dorsum of the ankle, the malleoli and/or Achilles tendon can help promote comfort and tolerance (Hopkins and Worboys, 2005), minimising the need to apply excessive padding around the limb. Patients may be embarrassed by a bulky bandage that may be difficult to hide under trousers. They will therefore appreciate the opportunity to discuss considerations relating to clothing and footwear, body image and self-esteem (Herber et al, 2007). Compression bandage application technique Compression layers must be applied with the patient (and nurse) in a comfortable position, in which the patient feels relaxed and is able to dorsiflex his or her ankle in a ‘toes-to-nose’ position (Hopkins and Worboys, 2005). The number of bandage layers should be kept to a minimum, and the application technique used, including the level of overlap, should be based on individual need. Usually, this involves 50% overlap on a spiral or figure-of-eight application. If chronic oedema or lymphoedema are present, additional layers may be indicated — for example, to increase interface Ac t i va S u pp l e m e n t

Figure 2: Padding can be used to protect bony and vulnerable areas, and to absorb exudate pressure in a fibrotic and swollen limb. Clinicians require adequate training in bandage application, and education and supervision should be sought when required. An experienced bandager will adjust the application tension in relation to the limb circumference, shape, and the density of the elastic fibres in the bandage (Partsch, 2007). For patients with oedema, the potential for a reduction in sub-bandage pressure soon after application provides a possible rationale for application with full stretch. However, when working with patients who are old or frail, those beginning a course of bandaging, or individuals with arterial problems, it is wise (and often necessary) to reduce the application tension. Over time, as patients adjust to the experience of being bandaged, the application tension may be increased when indicated and safe to do so. However, care must be taken to ensure that excessive tension is not used over the dorsum of the foot and ankle (Hopkins and Worboys, 2005) and that the tension is as even as possible throughout the limb. Patients should be advised what to expect and who to contact for advice or to discuss concerns with, for example, about pain or discomfort. It is vital that patients experiencing ulcer-related pain and discomfort are involved in treatment decision-making and are fully informed so that they understand the rationale for the choice of materials. It may take time for individuals to adapt to wearing bandages and learn how to selfmanage their condition. S9


Case study 1 Edwin Tapiwa Chamanga Tissue Viability Nurse Homerton University NHS Foundation Trust, UK

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79-year-old woman with bilateral chronic oedema had been treated with a four-layer bandage system that was causing her problems soon after application. As she walked around her house doing housework and other day-to-day activities, the bandages would cut into the skin, causing blistering and tissue necrosis. They also caused pain and discomfort at night, resulting in her Figure 1

taking analgesia before going to bed. Figure 1 shows bandages in place as presented at a clinic visit. She told staff there that ‘… a few times I had to wake my son up and cut them off … I didn’t want to remove the bandages but the pain was too much’. Figure 2 shows skin damage, on the dorsum of the foot, which had been caused by incorrect application of the previous bandaging system. The clinic staff replaced the bandage system with Actico (Activa Healthcare). The stiffness of this inelastic, short-stretch bandage, applied with the recommended technique, eliminated the blistering and necrosis on the dorsum of the foot within one week. The patient also found the bandages more comfortable, and no longer required analgesia at night. Figure 2

Case study 2

r C was a 73-year-old widower who had a bilateral hip replacement 2 years previously, after which he needed a stick to assist with walking. He had varicose eczema, which led first to wet irritant dermatitis and then ulceration. At presentation, the ulcer measured 4 x 3cm and was 0.5cm deep. His ankle brachial pressure index was 0.82.

Mr C had originally been managing the ulcer himself. Following assessment, his district nurses applied reduced multilayer elastic compression bandaging to the ulcerated leg. Unfortunately, Mr C found the bandage uncomfortable over the dorsum of the foot, and had difficulty tolerating it at night. During discussion with a vascular nurse specialist, Mr C indicated that he was thinking of no longer wearing the compression bandage. The nurse suggested he try an inelastic system (Actico, Activa Healthcare). Mr C found this more comfortable at night, and was able to tolerate (and therefore continue with) compression bandaging. At the time of writing, he has been using this compression system for approximately 5 months.

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Margaret Armitage Vascular Liaison Nurse Specialist NHS Greater Glasgow and Clyde, UK

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Reducing pain Case studies 1 and 2 (see page 10) give examples where dual consideration of the science of compression and the patient experience resulted in a reduction in pain and better sleep at night. These complement evidence, presented as posters, by Prytherch et al (2003) and Prytherch (2005). Prytherch et al (2003) described two case studies, one concerning a patient with VLUs and the other a patient with mixed aetiology leg ulcers. Use of inelastic compression was associated with increased comfort, resulting in concordance with treatment and good healing outcomes. The patient with the VLUs, who had previously been unable to tolerate four-layer bandages at night, reported that he was pain-free when using the inelastic bandages, which made a ‘tremendous difference’ to his physical, psychological and social wellbeing. As a result, Prytherch increased the use of inelastic bandages in her tissue viability team. In a poster presented two years later, Prytherch (2005) described two further case studies showing that patients with leg ulcers who were unable to tolerate multilayer bandaging at night found an inelastic compression system comfortable, and so continued with the treatment and progressed towards healing. Other methods of reducing ulcer-related pain and neuropathic pain (nerve damage, often manifesting as constant burning and/or ‘pins and needles’) in particular,

include the use of a dressing that absorbs exudate and/ or has analgesic properties, such as an ibuprofen foam dressing or a topical opioid gel (Young and Hampton, 2005; Beldon, 2009), although the evidence in this field is limited (Briggs and Nelson, 2010). Similarly, oral analgesia may be indicated, in which case its effectiveness will need to be monitored. Gabapentin (an anticonvulsant medication) should be considered for managing neuropathic pain, particularly in older people, and can help to promote sleep (Taverner et al, 2011b). Systemic antibiotics should only be used when there is clinical evidence of infection (SIGN, 2010).

Concordance

This supplement has provided evidence that pain is a key predictor of non-concordance, influencing whether patients can comfortably tolerate and adapt to wearing a compression bandage, particularly at night. Similarly, patients with chronic, slow-healing ulcers may be reluctant to continue with bandaging if they perceive treatment to be ineffectual (Herber et al, 2007), and will require ongoing support with managing symptoms such as pain and loss of sleep. Table 5 summarises influences on concordance in people with VLUs (Brown, 2011). Table 6 identifies methods of promoting concordance with compression bandaging at night. It should be noted that concordance is fundamentally different to the concepts of compliance or adherence

Table 5: Factors influencing concordance (adapted from Moffatt et al, 2009; Van Hecke et al, 2009; Brown, 2011)

• R estrictions on clothing and footwear affecting self-esteem and body image • Pain or discomfort during the day and/or at night

Person

• Difficulties with personal hygiene and bathing • E conomic factors, such as type of work and difficulty attending appointments • P sychological factors e.g. anxiety, depression, poor relationships and support

• Inadequate assessment of the patient, his/her condition, lifestyle and factors potentially influencing concordance • Poor management of pain, infection and chronic oedema

Professional

• Inappropriate choice or ineffective application of bandaging materials • V ariable skills and experience; lack of education and supervision • Inflexible health-care structures — which can lead, for example, to lack of support or follow-up for patients



as it focuses on the consultation process rather than on a specific patient behaviour, and has an underlying ethos of a shared approach to decision-making (Chambers et al, 2006). McCormack and McCance (2011) showed how, as social beings, we exist in the context of our relationships with others, as we need our hopes,

Table 6. Key methods of promoting concordance with compression bandaging at night • U ndertake a comprehensive, person-centred assessment that includes pain assessment, how the pain affects an individual and is influenced by his/her compression bandaging • D iscuss sleeping patterns with the patient and any specific problems with sleep. Give advice on how to ensure a good night’s sleep while wearing compression bandages (NHS Direct, 2012). This may include advice on caffeine intake, methods of relaxing before going to bed, positioning in bed and use of analgesia in the evening and overnight. Patients should also be encouraged to sleep in bed, rather than in a chair with their leg in a dependent position as the latter can compromise venous blood return and lymph drainage • In collaboration with the patient, choose a compression bandaging system that suits him/ her and his/her lifestyle. This should enable him/ her to be as mobile as possible during the day and comfortable at night when in bed • R egularly review the use and effect of compression treatments, wound-care products and analgesia. Discuss any practical difficulties such as pain, and lifestyle and psychosocial challenges with the patient • T alk to patients about their expectations of treatment outcome, as these may differ from yours • W hen applying a bandage, use this opportunity to teach patients how to recognise potential changes (for example, signs of dermatitis, infection, or an exacerbation of symptoms) and discuss how to respond should this happen • C onsider developing an action plan with the person to encourage them to take responsibility for self-management • R ecognise that patients who appear ambivalent about their treatments, or ‘non-concordant’, may require time to talk about their motivations and difficulties. Explore opportunities for changing their health-related behaviours (Dart, 2011) • D evelop your knowledge and experience of different compression bandaging systems

S12

beliefs and values to be recognised and respected. They suggested that ‘tasks’, for example selecting and applying compression bandaging, provide an important opportunity to engage with individuals, and should involve identifying their wishes and expectations, being sympathetic and sharing decision-making. When patients experience frustration and difficulties in coping with treatment and symptoms such as pain, skilled communication and careful questioning can help enhance collaboration. Finally, it should be remembered that concordance is not a static concept (van Hecke et al, 2011) as individuals change their perceptions and behaviours over time for various reasons. One study found that fewer than half the patients included knew that leg ulceration was caused by problems in the veins or were able to identify activities that helped prevent recurrence (Finlayson et al, 2010). This suggests that providing patients with ongoing and accessible information about their condition, the treatment plan and the bandaging materials may increase their motivation to continue with treatment, undertake self-management activities such as exercise, and cope with problems such as pain and discomfort, including at night. Providing patients with opportunities to make an informed choice about their compression therapy, for example regarding the frequency of bandage application or type of system used, may enable people to feel more empowered, despite the chronic nature of the condition. This means that clinicians must be knowledgeable about the different options available, discuss the patient’s needs and wishes, and find a solution that is acceptable to both.

Self-management

In patients with venous ulceration and chronic oedema of the leg, self-management may relate to a range of issues besides managing sleeplessness. These include diet and nutrition, bathing, exercise, negotiating intimate and work relationships, recognising and responding to changes in symptoms, and dealing with pain. Supporting patients with self-management may involve one-to-one discussions about mobility, exercise and difficulties that occur when wearing bandages (both during the day and at night), giving practical advice on skin care, lifestyle, clothing, footwear, and offering emotional support. Some nurses also run support groups, such as Leg Clubs, which teach patients about their condition, and how to adapt and take control of it. This is another way of empowering patients with the aim of increasing concordance (Stephen-Haynes, 2010). Most patients welcome the opportunity to learn about compression therapy, as it is an essential and long-term aspect of treatment. It is also important not to label patients as noncompliant if they prioritise their social roles as parent, B r i t i s h J o u r n a l o f C o m m u n i t y N u r s i n g Vo l 1 7 , N o 1 0


carer or employee over their medical and self-care needs (Townsend et al, 2006). Similarly, nurses must take care not to become unduly medically focused during consultations (Rees and Williams, 2009; Williams, 2011) or when supporting patient selfmanagement (Berman and Iris, 1998). It is also helpful to be aware of how your professional group may influence your approach to providing support. For example, Kennedy et al (2011) showed that practice nurses tended to focus on helping people manage their specific medical condition, while district nurses took a broader life- and personcentred approach.

Conclusion

Inappropriate use of compression bandaging systems can be devastating for the individual who experiences pain and sleeplessness as a result of their condition and treatment. We must consider how our treatment choices and approaches to care influence an individual’s ability to self-manage his/her condition (Long-term Conditions Alliance Scotland, 2008) and motivation to continue with compression bandaging. Understanding both the patient experience as well as the science of compression bandaging will enable us to make appropriate choices as to which bandaging system will be effective, readily tolerated and comfortable for the patient.

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...throughout the day and night. Unlike elastic systems, Actico gives you low resting pressures at night - making bedtime a lot more tolerable.[1,2] ®

1. Prytherch, J. (2005) Not a stretch too far. Poster Presentation, Wounds UK, Harrogate, November 2005. 2. Wilson, J. (2005) The introduction of Actico® cohesive SSB into a specialist leg ulcer clinic; Poster presentation, EWMA Conference, Stuttgart.

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