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RNweb - Compression stockings

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Compression stockings Aug 1, 2006 By: Barbara Acello, RN, MS RN A patient I'll call Jane Peterson received compression stockings in the OR shortly after hip surgery. Although she had a history of severe peripheral vascular disease and was recovering from a stroke, the nurse failed to look into Ms. Peterson's complaint of toe pain before he applied the hoseor to measure her legs for a proper fit. A few days later, with no circulation checks done, Ms. Peterson screamed in pain whenever anyone touched her toes. By the time the stockings were removed, her toes had turned black and a dark purple spot had formed on the top of one foot. Her physician documented what he believed to be the cause: illfitting compression stockings. The patient died a few weeks later, without ever leaving the hospital. Not surprisingly, the case led to a lawsuit. As this story illustrates, compression stockings are associated with seriouspossibly even fatal complications, and their application and continued use demand skilled nursing care. Ill-fitting hose, for example, can cause pressure ulcers and arterial occlusion, as well as gangrene. To keep patients safe, nurses need to know when and why support stockings are used and how to properly apply, manage, and remove them. An ounce of prevention Compression stockings are most often used in the hospital setting to prevent deep vein thrombosis. Those at high risk for DVT include the critically ill, trauma patients, and postop patients, particularly those who have undergone orthopedic procedures.

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RNweb - Compression stockings

While medical patients are less likely to be evaluated for DVT, they, too, should have an individualized assessment of risk. Complications like Ms. Peterson's are most likely to occur in patients with diabetes, peripheral vascular disease, neuropathy, connective tissue disease, or a leg infection such as cellulitis. That's because the hose compress the superficial vessels in subcutaneous tissue, a serious hazard for a limb that's already ischemic. Compression stockings are contraindicated in patients with severe vascular disease or massive leg edema. Before applying compression hose When you have an order for compression stockings, the first thing to do is clarify the strength of compression and the length ordered. Stockings are available in light, moderate, and firm compression. Hose used for bedbound patients typically exert moderate pressureabout 18 mm Hg. (See the box to learn more about compression therapy.) Stockings also come in two basic lengths: knee-high and thigh-high. The jury is still out regarding which length is more effective. That's because most studies have been done on thigh-high hosiery, and there's not enough evidence on the efficacy of knee-highs to recommend one over the other. Knee-high stockings generally are easier to fit and to adjust, as needed, so patient compliance may be a little better. And for very heavy patientsthose with a thigh circumference greater than 25 inches (63.5 cm) at the gluteal foldthigh-high stockings are out. Next, do a head-to-toe assessment. Zero in on the popliteal, posterior tibial, and dorsalis pedis pulses, as well as the skin on both legs. Look for potential pressure points, fragility, open wounds, rashes, and areas that could be vulnerable to skin breakdown such as healed ulcers. Check the material the stockings are made from and review the patient's chart for allergies. Although the incidence of allergic reaction to compression stockings is low, some brands contain latex and other potential allergens. Compression stockings are available in 27 different sizes, ranging from extra small to extra large. If your hospital carries only small and large, request that other sizes be made available to enhance patient safety. Proper fit is essential to maintaining the pressure gradient; determining it is a nursing responsibility. Normally, the size of both legs differs slightly; in some patients, though, particularly those with neuromuscular diseases, there's a wide variation. So always measure both legs (do not try to guess) according to your hospital's protocol, to determine whether two different sizes are necessary. Follow the manufacturer's directions for measuring the legs. This is generally done by applying the tape measure so that it's snug but not tight. Mark the legs, if necessary, to provide reference points. And document the measurements as a baseline for future assessments.
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RNweb - Compression stockings

For knee-high stockings, measure the circumference in two places: at the narrowest part of the ankle about 2.5 cm above the medial malleolus (ankle bone)and around the widest part of the calf. Then measure from the base of the heel to just below the knee. For thigh-high stockings, follow the same procedure, but also measure the circumference of the widest part of the thigh and the distance between the base of the heel and the gluteal fold. If the patient's condition or leg size changes, you'll need to measure again to ensure that the hose still fit correctly. For example, a patient who has edema may need to have his legs measured at least once a day to see if a larger stocking is needed. Remember, an increase in leg circumference of 5 cm doubles the amount of pressure the stockings apply. Now comes the hard part When you're ready to put the hose on, the patient's legs should be dry. It helps to sprinkle on talc or cornstarch, provided she's not allergic. If possible, apply the hose first thing in the morning or right after surgery, while the patient is still supine and her feet and ankles are less swollen. Open the package and turn the stockings inside out, leaving your hand deep within the stocking and grasping the toe hole. Then gently hold the patient's toes so you can guide the stocking over the foot, pulling it on from the bottom up. Once you're over the toes, release them. Next, hold both sides of the stocking and pull it from the toes and over the heel in one motion. Most medical-grade stockings have a hole in the toe end to allow for circulation checks. In some stockings, the hole is on the top of the foot; in others, it's on the bottom. As long as the heel is centered, the hole will be in the correct place. Continue pulling up the stocking, using your thumbs to guide it over the ankle and up the leg. Make sure you smooth out all wrinkles and that the hosiery is on straight. Avoid folding the hosiery over at the top or the toes. And never allow the stockings to come in contact with lotions, ointments, or oils containing lanolin or petroleum, any of which will cause the stockings to deteriorate. Patient care during therapy Once the stockings are on, document the hosiery length and size, date and time of application, and the condition of the patient's legs before treatment. Monitor circulation in the toes every four hours, or as ordered. If edema is present, more frequent monitoring may be needed. Watch for bunching or twisting of the hose, which could create a tourniquet effect. Apply padding to areas that bunch up, if needed, or to bony prominences or deformities for support. However, padding will alter the pressure gradient and can increase the risk of tissue damage. Use it only as a last resort, and monitor the padded areas closely for signs of complications.
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RNweb - Compression stockings

On a flow sheet, document the color, sensation, swelling, and temperature of the legs, as well as the patient's ability to move them. Describe any abnormalities you find, along with patient compliance and treatment tolerance. Unless the physician has ordered otherwise, teach patients that they will need to wear the stockings continuously, except when bathing and during circulation checks. Remove the stockings at least once a day for skin care. Simply begin at the top and roll the stocking down in a slow, steady motion. Once the postop patient is strong enough to stay out of bed for at least four hours a day, the stockings can usually be removed for good.

How compression prevents DVT

It's easy to take simple therapies like compression stockings for granted, but important to realize that their use may involve hidden dangers. Patients on compression therapy need knowledgeable nurses, providing ongoing monitoring and careful assessment, to prevent serious, possibly even deadly, complications. SOURCES 1. Evans J. (2004). DVT prophylaxis often overlooked, experts say: Only 29% receive prophylaxis. Fam Prac News, 34(5), 15. 2. Hayes, J. M., Lehman, C. A., & Castonguay, P. (2002). Graduated compression stockings: Updating practice, improving compliance. Medsurg Nurs, 11(4), 163. 3. Stephen-Haynes, J. (2006). An overview of compression therapy in leg ulceration. Nursing Standard, 20(32), 68.

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