Chapter 27: Living with and beyond cancer
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Compression bandaging
Definition
Short‐stretch, inelastic bandages are used during the intensive or reduction phase of treatment for lymphoedema.
Related theory
The bandages used in compression therapy are termed ‘short‐stretch bandages’. They have a high resistance to stretch. When applied to a limb, they provide it with a firm external encasement. During joint movement and muscular contraction of the limb, pressure against the firm external encasement leads to a temporary increase in pressure within the tissues (working pressure), providing a massaging effect on the lymphatics as well as the venous system to stimulate lymph drainage (Partsch and Mortimer [220], Williams [288]). Conversely, when the muscle is inactive during rest, short‐stretch bandages support the tissues and provide a relatively low resting pressure. This ensures that the patient remains comfortable and encourages compliance with the planned course of treatment (Williams [288]).
Long‐stretch bandages with a high degree of elasticity are unsuitable for the management of lymphoedema. These bandages exert a high working and high resting pressure on the tissues of the limb and can be uncomfortable when left in place for long periods of time.
The pressure exerted by the short‐stretch bandage on the limb is influenced by a number of factors:
- The circumference of the limb: the highest pressure is achieved where the limb is narrowest (Partsch [221]). When a bandage is applied to a limb of normal proportions, therefore, the highest pressure will be achieved at the ankle or wrist, with graduated, reducing pressure along the length of the limb as the circumference increases (Quéré and Sneddon [231]). Limbs that are thin and areas where there are bony prominences will need careful protection to avoid high pressure on these exposed areas which can lead to skin or tissue damage (Linnitt [146]).
- The number of layers: every bandage is applied with a degree of overlap. Several layers applied over each other increase the stiffness and pressure applied to the limb (Partsch and Mortimer [220]).
- The components of the bandage system: the use of padding and foam beneath the bandages increases the sub‐bandage pressure and stiffness of the assembled bandage (Partsch and Mortimer [220]).
Evidence‐based approaches
Rationale
Indications
- Large limbs. Elastic compression garments used on large swollen limbs may be ineffective due to the difficulties of applying sufficient tension to compress the limb (Linnitt [146]).
- Mis‐shapen limbs. Elastic compression garments cannot accommodate extreme shape distortion (Linnitt [146]). Elastic compression garments can tourniquet in skin folds if the limb is awkwardly shaped, and can cause discomfort or skin damage (Todd [272]). Foam or soft padding placed under short‐stretch bandages will smooth out the folds and restore normal shape to the limb. (See Figures 27.16 and 27.17 for examples of a misshapen limb before and after bandaging.)
- Severe lymphoedema. Large limbs with long‐standing oedema require high pressures to break down tissue fibrosis. Short‐stretch bandages provide a low resting and high working pressure which promotes a softening of hardened tissues (Partsch and Moffatt [219]).
- Lymphorrhoea. The leakage of lymph fluid from the skin responds readily to external pressure provided by short‐stretch bandages (Board and Anderson [18]).
- Damaged or fragile skin. Elastic compression garments can cause damage to fragile skin. Short‐stretch bandages should be used until the skin condition improves (Linnitt [146]).
Figure 27.16 Example of a misshapen limb before bandaging. Source: Dougherty and Lister ([90]).
Figure 27.17 Example of a misshapen limb after bandaging. Source: Dougherty and Lister ([90]).
Contraindications
Short‐stretch bandages should not be used if (Todd [272]):
- there is arterial disease; tissue ischaemia can occur
- there is infection in the swollen limb; pain may occur
- there is uncontrolled cardiac failure; fluid overload can occur
- there is deep vein thrombosis; anticoagulation therapy should be commenced prior to the use of bandages
- the patient lacks manual dexterity and would be unable to remove bandages if they became uncomfortable.
Principles to be followed in multilayer bandaging
This discussion of multilayer bandaging will focus on the use of short‐stretch, inelastic bandages using a standard approach to application. The application of alternative bandaging systems available (usually comprising two layers: a foam padding layer for comfort and a self‐adhesive compression layer) will not be discussed in this section. Short‐stretch bandages are available in a range of widths and provide a low resting pressure to the swollen limb when the muscle is inactive and a high working pressure during activity when the muscle is pumping against the resistance created by the bandage (Partsch and Mortimer [220]).
For bandaging to be effective, the following principles must be considered:
- An even pressure should be provided around the circumference of the limb. Where the limb shape is irregular or distorted by swelling, an even profile can be achieved with the use of padding or foam to add bulk to an area where shape requires correcting (Schuren [252]).
- The pressure from the bandages must be graduated along the length of the limb to ensure that the greatest pressure is achieved distally and the least proximally. Graduated pressure will be achieved naturally in a regularly shaped limb where the circumference of the wrist or ankle is smaller than the circumference of the root of the limb. Graduated pressure can also be achieved by selecting the correct bandage width for the size of the limb and controlling the amount of bandage tension and overlap used (Hegarty‐Craver et al. [123]). Moderate tension only should be used and the bandages should never be stretched to their maximum length.
- The pressure applied to the limb should be adequate to counter the limb circumference. Greater pressure is required when the circumference of the limb is large. This can be achieved by using more than one layer of bandages and selecting the correct width of bandage for the circumference of the limb (Hegarty‐Craver et al. [123]).
- The bandages should be left in place day and night and removed once every 24 hours. This enables skin hygiene to be attended to and the condition of the skin to be checked. Reapplication of the bandages then ensures that effective compression is maintained on the changing limb shape (Quéré and Sneddon [231]).
- The bandages should be comfortable for the patient and removed at any time if they cause any pain, numbness or discoloration (blueness) in the fingers or toes. This may indicate a variety of causes, including too great a compression on the limb. A satisfactory outcome of treatment should be achieved within 2–3 weeks. More advanced stages of lymphoedema may require up to 4–6 weeks of treatment. The patient may then begin the maintenance phase of treatment in which containment compression garments are fitted.
Palliative care
Compression bandaging can be versatile and extremely useful in the palliative care setting when volume reduction may be unrealistic or not indicated and the emphasis is on optimizing the patient's quality of life.
The burden of treatment should not exceed the benefit to be gained from providing support and comfort to a limb with a low level of pressure using a modified technique of bandaging designed around the patient's needs. The therapist should have expertise to apply the correct degree of pressure to the limb and avoid forcing fluid into adjacent areas (Towers [275]). Many hospices now employ a lymphoedema therapist to support palliative care patients.
Legal and professional issues
Ensure the patient understands the procedure and all it entails and has given consent (NMC [202]). Written information should also be supplied. Compression bandaging should only be carried out by a skilled therapist with the necessary skills and experience to apply bandages to the swollen limb (Quéré and Sneddon [231]), ensuring that pressure is graduated towards the root of the limb and evenly applied. Poor technique can lead to serious consequences with damage to the skin and tissues if the bandages are incorrectly or inappropriately applied (Linnitt [146]). The therapist has a professional responsibility to ensure the safety of the patient and should therefore always ensure that there are no contraindications to the use of low‐stretch compression bandages. Therapists also have a duty to maintain the knowledge and skills they need for safe and effective practice (NMC [202]).
Appropriate courses are available for therapists throughout the UK, however there is no one specific body that accredits therapists.
Pre‐procedural considerations
Specific patient preparations
Arterial blood flow
If there is any concern regarding the patient's arterial blood flow, an ABPI should be measured using a hand‐held Doppler before undertaking any compression therapy. An ABPI reading of 0.8 or below should be referred for medical opinion (Cooper [54]).
Appropriate clothing
The bandaging materials used on a swollen limb can be bulky and patients will therefore require appropriate information and advice concerning suitable loose‐fitting, easily applied clothing and, if the leg is being bandaged, appropriate wide‐opening footwear that will accommodate the bulk of the bandages during treatment.
Timing of appointments
As the bandages are worn for 23 hours a day, the timing of appointments for the bandages to be replaced will need to consider opportunities to attend to personal hygiene, travel arrangements and family and work commitments. The bandages can be removed at home before the appointment to allow for personal hygiene but it is advisable for the patient to wear a suitable compression garment on the journey to the appointment.
Driving
It is not recommended that patients drive themselves in a car to or from appointments. The bandages will mean that the affected limb will be bulkier than usual, making reaction times slower. Safety can therefore be compromised. If the patient chooses to drive, they must be advised to check with their motor insurance company before doing so.
Activities of daily living
Activities of daily living may have to be adapted because of the bulk of the bandages. The therapist should discuss and outline with the patient an appropriate exercise regimen to be followed during treatment, to ensure that maximum effectiveness is gained from the course of bandaging.
Information
Verbal information given should be supported by written information and include details of what the patient should do if problems develop with the bandages and whom to contact (Fu et al. [108]).
Procedure guideline 27.12
Compression bandaging (multilayer short‐stretch): bandaging an arm and the fingers
Procedure guideline 27.13
Compression bandaging (multilayer short‐stretch): bandaging a leg and the toes
| Problem | Cause | Prevention | Action |
| Patient becomes breathless. | An unknown cardiac pathology may lead to fluid overload as the lymphatic fluid moves from the swollen limb. | Initiate immediate first aid and seek medical attention if the patient becomes breathless during compression bandaging. Compression bandaging should be stopped until the patient's condition is stabilized. | |
| Pain, discomfort, numbness and/or tingling of digits when bandages are in place. | Incorrect pressure gradient. | Ensure patient gives feedback throughout the procedure.
Observe the skin each day for signs of inflammation where excess pressure may have been applied. | Check the pressure gradient after each bandage application. Ensure overlap of bandages is even along the length of the limb. Feel the pressure of the bandages regularly to ensure the consistency of the gradient. |
| Pain and tenderness over bony prominences noted when the bandages are removed, for example wrist and ankle. | Inadequate padding over bony prominences. | Careful assessment of the limb shape prior to application of bandages. | Use foam and padding to protect bony prominences and even out the shape of the limb. |
| Skin irritation developing in sensitive areas, for example elbow crease and popliteal crease, during the course of bandaging. | Areas of excess movement resulting in friction from the bandages. | Ensure there are no skin allergies to the materials being used. | Use appropriate moisturizer for the patient. Protect the limb with stockinette. Use extra padding in areas of sensitivity. |
| Poor compliance with bandaging causing premature removal of bandages each day. | Lack of information given to patient.
Lifestyle commitments. | Ensure the patient is given appropriate information verbally and in writing prior to commencement of treatment. | Explore the problems the patient is experiencing.
Explain the procedure thoroughly and its intended benefits. |
| Congestion developing at the root of the limb during bandaging. | Too much pressure throughout the limb causing an overload of fluid at the root of the limb. | Reduce the pressure of the bandage throughout the limb. Teach simple lymphatic drainage (SLD). Carry out manual lymphatic drainage (MLD). |
Figure 27.18 Bandaging an arm and the fingers.
Figure 27.19 Bandaging a leg and the toes.
Post‐procedural considerations
Immediate care
Evaluation of each stage of the bandaging procedure is essential to ensure that the bandage and padding have been used appropriately and correctly. This ensures that the best results are being achieved and that resources are being used to the maximum.
The process of evaluation must be thorough and should include the following.
- Continuous attention to the colour of the digits. Too much pressure will result in compromised circulation.
- Continuous attention to the sensations experienced in the bandaged limb. The bandages should not cause pain, numbness or tingling.
- The shape of the limb. A cylindrical contour should be achieved with the use of soft foam and padding.
- The overlap of the bandages. This should be even and consistent with no gaps in the bandages.
- The pressure achieved. This should feel even to the patient and there should be no creases in the bandages. Layers should be used appropriately (Quéré and Sneddon [231]). The therapist should feel the bandages regularly during the procedure to ensure the consistency of the gradient.
Ongoing care
The patient should feel comfortable and be able to move their limb. Information should be given concerning when and how to remove the bandages if necessary. The patient should be made aware that if the bandages do have to be removed, a compression garment must be worn until their next appointment. It is vital that the patient reports any concerns to the therapist at each visit.
