compression therapy - wound care resource · 2018. 5. 31. · 'wound care: a broad look from a...

Compression Therapy

KimKaim,RNBNursing(Dtn)[email protected]

www.woundcareresource.com

Whatiscompressiontherapy? 2Whyusecompressiontherapy? 3Pathophysiology 4Scienceofcompression 5

Ulcertypesandcompression 7Venouslegulcer 7Arterialulcer 7Diabeticfootulcer 8Lymphoedema(trophicskinchanges) 8

WhenwouldINOTusecompressiontherapy? 9NotCompetent 9ArterialDisease 10Usewithcaution… 10HeartDisease 10TheDiabeticLimb 10

Guidelines 11References 12

CreatedfortheWoundsAustralia(Qld)EducationSeminar:

'WoundCare:ABroadLookfromaRegionalPerspective'

March2017

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ProducedforWoundsAustralia(Qld)byKimKaim,2017

Whatiscompressiontherapy?Compressiontherapyistheapplicationofaproductthatappliesanexternalforcetoabodyareawiththeaimofsupportingvenousandlymphaticreturn.Thissupportresultsinreductionofoedema(4),healingofvenouslegulcers(5),reductionintrophicskinchangesrelatedtochronicvenoushypertension(6),andreductioninimmune-complexdepositioninpatientswithvasculitis(7).Theforcecanbeaccomplishedinanumberofwaysincluding:Tubularbandages Astraight,elastic,tubularbandagethat

isappliedinthreelayersofseparatelengthscreatingapressuregradientthatisgreatestatthefootandankle.

UnnaBoot Generalnamegiventoagauzebandage

impregnatedwithzincpasteunderacohesiveinelasticbandage.(5)

Short-stretchbandages

Bandageswithminimalornoelastomers.Lowextensibilityandhighstiffness..Lowrestingpressureandhighworkingpressure.(5)

Long-stretchbandages

Highlyextensible(elastic)bandagesthatexpandorcontracttoaccommodatechangesinleggeometryduringwalkingresultinginonlysmallpressurechanges.Insteadthebandagesustainsappliedpressuresforextendedperiods,evenwhenthepatientisatrest.(8)

Mutliplelayerbandaging

Acompressionsystemthatusesoneormorelayerandmayconsistofacombinationofshortandlongstretchbandages.

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Compressiongarments

Speciallymanufacturedgarmentsthatneedtobeindividuallymeasuredandfitted.

Pneumaticcompression

Pressureisappliedviaaninflatablegarment,continuously,intermittentlyorinsequentialcycles.(5)

Theimagesintheabovetableareonlyoneexampleineacharea.Therearemanyotheroptionsandtheonesshownabovearegivennoparticularendorsement.

“Ingeneral,bandagesaremostcommonlyusedforthetreatmentofactiveVLUs;compressionstockingsaregenerallyusedtopreventrecurrenceoncetheulcerhashealed.“–“Principlesofcompression…”pg1(3)

“CompressionTherapy”isatherapyandtheuseandapplicationofsuchneedstobedonebyhealthprofessionalswhounderstandtheunderlyingprinciplesandtheirimportance.Thepractitionershouldseektoearncompetencyintheapplicationofdifferentformsofcompressiontherapy.Youmustalsoworkwiththepatientforamutualunderstandingofwhythetherapyisrequiredandtoalsoexplorethebestformofthetherapyforthatpatienttoensureoptimumcompliance.Thisbookletwillfocusonlowerlegcompressiontherapy,butthereadershouldbeawarethatcompressiontherapyisnotrestrictedtothelowerlimb.

Whyusecompressiontherapy?Chronic,impairedvenousreturnleadstoleakageofproteinsintotheextra-cellularspaces,inflammation,andultimately,localskinchanges.Thesechangesincludeankleflair,hyperpigmentation,lipodermatosclerosis,atropheblanchéandvenouseczema.

AnkleflairHyperpigmentation Venouseczemaand

LipodermatosclerosisPhotoscourtesyofDermNetNZ.orgTheuseofcompressiontherapysupportsvenousreturnandreducestheimpactontheskin.Thecompressionofthetissuesreducesoedemabyopposingleakageoffluidfromcapillaries

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intotissuesandbyencouraginglymphaticdrainage.Itisalsobelievedtoincreasethespeedofvenousbloodflow,whichmayreducelocalinflammatoryeffects.(9)

PathophysiologyThreethingsimpactuponthenormalreturnofbloodflowtotheheartfromthelegs(3):

• Thefunctionalstructureoftheveins• Theefficacyofthecalf-musclepump• Gravity

Tablemodifiedfrom“Anatomy&Physiology”(1)Veinsarethebloodvesselsthatreturntheflowofbloodtotheheart.Thevenoussystemisalowpressuresystemthatutilizesvalvestostopretrogradeflow.Beinguprightduringthedayencouragesbloodtopool,especiallyinthelowerlimbs,duetothepullofgravity.Thispoolingincreasespressurewithinthatvein,which,inturn,putsback-pressureonthesmallerveins,venules,andcapillariesthatfeedintoit.Overtimethethinwallsoftheseveinscanbecomedistortedcausingtheirvalvestonolongerbeabletofunction,increasingtheincompetenceofthesystemandfurtherincreasingthepressures.(1,3)Theincreasedpressuresfromtheincompetentvenoussystemleadstoleakageoffluidsoutofthecapillariesandintothesurroundingtissues.Thisisknownasoedema.Therearemanyothercausesofoedemaincludinghypertensionandheartfailure,severeproteindeficiency,andrenalfailure.Itisimportantduringyourassessmenttodeterminetheunderlyingcausetobeabletocreatethebestmanagementplan.(1,3)Togetthebloodmovingwheninanuprightposition,bloodinthelowerlimbissqueezedupwardsbythecontractionofthesurroundingthigh,calfandfootmuscles.ThisisreferredtoastheCalfMusclePump.About90%ofvenousreturnfromthelegsisthroughthisaction.Thisismosteffectiveduringwalkingandanklemovement.Asaresultanyimpairmenttonormalcalfmuscleactivitysuchasreducedanklemobility,anabnormalgaitorneurologicaldeficit,decreasestheeffectivenessofthispump.Agealsoplaysitspartwithcalfmusclefunctionasaresultofreducedmusclebulk.(3)

ImagecourtesyofAnatomy&Physiology(1)

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Copiedfrom“Principlesofcompression…”(3)

ScienceofcompressionTherearetwoprinciplesthatwecanapplytocompressionsystems:Pascal’sLawandLaplace’sLaw.Pascal’sLawrelatestorigidcompressionsystemssuchasthoseprovidedbyshort-stretchbandagingsystemsandmulti-layersystemsthatincorporateashort-stretchcomponent.Pascal’sLawstatesthatpressureappliedtoanenclosedsystemofanincompressiblefluidisdistributedevenly.Seetheimageontherightwherepressureisappliedtooneareaofthetubeoftoothpastebutthetoothpasteitselfisextrudedfromalloftheholesatthesamerate,nomatterhowfarawaytheyarefromtheappliedpressure(3).(Feelfreetotrythisathome!)Theshort-stretchbandagingactsliketherigidcontainer.Whenthemusclesinthelegcontracttheyincreaseincircumferencebutaretrappedwithinarigidbandage.Thismusclemovementcreatesapressurewavethatisdistributedevenlyunderthebandagingthroughoutthelowerlimb.Thishasacompressiveeffect,reducingthediameteroftheveinswithinthelowerlegandforcingthevenousbloodtoreturntotheheart,producingamorenormalvenouspressureprofileintheleg.(3)Thisisparticularlyusefulintheambulantpatientwherethereisamorepronouncedeffect(highpeakpressures)duringexercise.Inthepurelyshort-stretchsystem,withnoelasticto

Imagecopiedfrom“Principlesofcompression…”(3)

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constantly‘squeeze’,italsomeansthatwhenthemusclesarenotbeingusedtherestingpressuresarelower,whichmayimprovecomfort.Therigidsystemhasbeenshowntoquicklyreduceoedema,butagain,withouttheelastic’sabilitytoconform,astheoedemareducesthebandagequicklybecomeslooseandcanchangeitspositionontheleg.Thiscanresultinanunwanteddistributionofpressure,possiblyevendangerouslyincreasingpressureinspecificareasliketheankle.Laplace’slawcanhelptoexplainwhathappenstopressureswhenthebandagingslipsandbunchesupattheankle.Laplace’sLawrelatestohowwecanunderstandwhatkindsofpressuresarebeingexertedunderthebandage(10).Fromtheequationitselfwecangetanideaofthebasictenets.Withmathematicalequations,thevalueontheleftisdirectlyaffectedbythevalueontherightorinverselyaffectedifthevalueontherightisinverted.

Sotoputitsimply:

• PressureincreasesifTensionincreases• Pressureincreasesifn(numberofbandagelayers)increases• PressuredecreasesifRadiusofthelegincreases• PressuredecreasesifBandagewidthincreases

Thefirstpointrelatestohowmuchtensionisinthebandage.Forelasticbandagingthiswillvarygreatlydependingonhowfarthebandageisstretchedbeforeapplication.Ifwedon’tstretchitenoughthepressurewillbelower,ifwestretchittoomuchthepressurewillbehigher.Thesecondpointtakesintoaccountthemethodweusetoapplythebandage.Aspiralapplicationwith50%overlapwillresultineffectivelyapplying2layersofthebandage,doublingthepressure.Ifwedida66%overlapwewouldbeapplying3layers,triplethepressure!Forthisreasoncareshouldbetakenwhenapplyinghighlyelasticbandagestonotexcessivelyoverlaptheedges.(10)Thethirdpointsaysthatwheretheradiusofthelegissmaller(ie-ankle)thepressureappliedbythedressingwillbegreater.Inaperfectlyshapedleg(calf:ankle=2:1)thiswillresultinagraduatedcompressionfromhigherattheankletoloweratthecalf.Butthisalsoappliestosub-shapeswithintheleg.Thelawappliestoacylinder,butthelegisnotaperfectcylinder;thetibiaormalleolusmayprotrude.Thesebecomesub-shapesofadifferent(smaller)circumferencethanthemainshapeoftheleg.Pressureontheseareaswillbehigher.Thisiswhypaddingofthelimbissoimportant.

Imagecopiedfrom“Principlesofcompression…”(3)

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Finally,thebandagewidthitselfwillhaveanimpactonthepressuresapplied.Thereisamathematicalformulathatexplainstherelationshipbetweenpressure,forceandarea,howeverIthinkananalogythatmostofusarefamiliarwithwillmakemoresense.Imagineyouhavetwobagsofgroceries.Theybothhaveexactlythesameweightofgroceriesinthem.Oneisaplasticbagwiththosethinhandlesthatseemtostretchandgetthinnerasyoucarrythebaghome(youknowtheones!).Theotherbaghasawiderhandletocarryitby.Thebagwiththethinnerhandlewilltendto‘cutin’toyourhand(orarm)sothatbythetimeyougettowhereyoucanputthemdownyouhaveredstripeswheretheydugin.Thebagwiththewiderhandledoesnotdigin.Thisisbecausetheforceisdistributedoverawiderarea,effectivelyreducingthepressureonyourhand.Wherebandagekitsareavailableindifferentwidths,itisveryimportanttoapplyitasdirected.

Ulcertypesandcompression

VenouslegulcerVLUsarethemostcommontypeofchroniclowerlimbwound(40-85%)andareduetodiseaseordisruptedfunctionoftheveinsleadingtoachronicvenousinsufficiency.Therecanalsobesomearterialinsufficiencyaddingtothewound’sinabilitytohealandthisisconsideredamixedaetiologylegulcer(10-20%)(9).Bothofthesetypesofulcerationsrespondwelltocompressiontherapywherecompressionisnotcontra-indicatedduringyourassessment.

Type Location History UlcerCharacteristics OtherfindingsVenouslegulcer

Gaiterregionoftheleg;mostcommonlyaroundthemedialmalleolus

VaricoseveinsDVTOthervenousdiseaseTraumaSurgery

IrregularslopingmarginsUsuallyshallowFibrinous,granulatingbaseVariablesize:fromsmalltoencirclingthelegHighexudatelevelsMaybepainful;painrelievedbyelevationofthelimb

Periwound/lowerlimboedemaAnkleflareVaricoseveinsVaricoseeczemaLipodermatosclerosisHyperpigmentationAtrophieblanche

Tablecopiedfrom“SimplifyingVenousLegUlcerManagement”(9)andphotofromDermNetNZ.org

ArterialulcerArterialulcersaccountfor5-30%oflegulcersandareduetoadisruptionofthefunctionofthearteries.Thepointatwhichmicrocirculationandnutrientbloodflowtotissuesareseverelydisturbedisknownascriticallimbischaemia(11).Thesetypesofwoundscontra-indicatetheuseofcompression.Revascularisation,risk-factormodificationandadministrationofantiplatelettherapyarethecornerstonesoftreatmentforthesepatients.Riskreductionincludessmokingcessationandtreatmentofhyperlipidaemiawhilearterialhypertensionanddiabetesmellitusshouldbeadequatelytreated.(12)

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Type Location History UlcerCharacteristics OtherfindingsArterialUlcer

Toes,feetorlateralorpretibialaspectsofthelowerleg

Intermittentclaudication/restpainCardiacorcerebrovasculardisease

Punchedout,sharplydemarcatededgesPainfulSmallanddeepNecroticwoundbaseDry/lowexudatelevelsGangrenemaybepresent

SurroundingskinisoftendryandshinywithlossofhairWeakorabsentfootpulses

Tablecopiedfrom“SimplifyingVenousLegUlcerManagement”(9)andphotofromthePrimaryCareDermatologySociety(http://www.pcds.org.uk)

DiabeticfootulcerThemanagementofdiabeticfootulcers(DFUs)focusesonthetwomainreasonsforulceration:neuropathyandischaemia.Assuch,amulti-disciplinaryteamisveryimportant,Podiatristand/orOrthotistcanlookatoff-loadingoftheDFUandtheVascularSurgeoncandetermine/ensureadequatebloodsupply.Regulardebridingofwoundandsurroundingcallousisalsoimportantaswellasappropriatemanagementforthewounditself.(13)However,thepersonwhohasdiabetesisnotautomagicallyprotectedfromvenousinsufficiency.Wherethereisoedemaorvenousstasisthatrequiresmanagement:

“Compressionmaybeusedsafelyinpatientswithcontrolleddiabetes.Thoroughassessmentofperipheralperfusionandneuropathyisessentialindeterminingthelevelofriskandinselectinganappropriatecompressionsystem”-WUWHS,p10(14)

Type Location History UlcerCharacteristics OtherfindingsDiabeticFootUlcer

Pressurebearingareasofthesoleofthefoot(neuropathic)Marginsofthefoot,e.g.overfirstorfifthmetatarsophalangealjoints(neuroischaemic)

Diabetes

SensorylosswhenneuropathyispresentVariabledepth:maybedeep+/-sinuses,andmayinvolvetendonsandbones

Neuropathic:footmaybewarm;ulceroftensurroundedbycallusNeuroischaemic:footmaybecoolandfootpulsesmaybeabsent

Tablecopiedfrom“SimplifyingVenousLegUlcerManagement”(9)andphotofromDermNetNZ.org

Lymphoedema(trophicskinchanges)Oedemathatdevelopsasaresultofafailureinthelymphaticsystemisreferredtoaslymphoedema.Chronicoedemaisoedemathathasbeenpresentformorethanthreemonths.Chronicoedemamaybearesultofafailureinthelymphsystemoritmayhaveamorecomplexunderlyingaetiology(15).Impairmentofthelymphflowcanberelatedtopressure(capillarypressure,negativeinterstitialpressure,interstitialfluidcolloidosmoticpressure,andplasmacolloidosmoticpressure),effectsontheextrinsicorintrinsicpropulsionmechanisms(fibrosisimpedingmusclemovement)ordamageto/removaloflymphaticstructures(radiationordissectionofnodes)(16).Primarylymphoedemaisconsideredtobegeneticandcanbecongenitallymphoedema(presentfrombirth),lymphoedemapraecox(swellingdevelopingaroundpuberty)orlymphoedematarda(whereitdevelopslaterinlife–althoughitthenbecomesunclearifthis

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istrulyprimaryorasecondarylymphoedema).Secondarylymphoedemascanbecausedbycancerandcancer-relatedtreatments,andnon-cancer-relatedconditionslikechronicvenousdisease,trauma,heartfailure,inflammation,infection,pulmonaryhypertensionandconditionssuchasarthritis.A2005articlebyWiliamsattemptingtodeterminetheextentoftheconditioncitedanoverallprevalenceof1.3to1.4per1000(15).Compressionisamajorcomponentintreatmentandmanagementoflymphoedema,alongwithskincare,manuallymphaticdrainageandphysiotherapy(4).

Type Location(15) History(15,16) Characteristics(16) Otherfindings(17)Trophicskinchanges

Limb/s,hands/feet,upperbody(breast/chest,shoulder,back),lowerbody(buttocks,abdomen),genital(scrotum,penis,vulva),head,neckorface

PrimaryorSecondary.Riskfactorsincludecancer/cancertreatment,infection,elevatedBMI,PVD,CHF,PulmonaryHypertension,serumproteindeficiency

GradeI:thelimbwillswellandpitwithpressure.Elevationmayrelievetheswelling.GradeII:thelimbwillbecomefirmer,notpit,andskinchangesmaybenotedGradeIII:elephantiasisresultsinverythickskinandlargeskinfolds.

ApositiveStemmersignPresenceofhyperkeratosisEnhancedskinfoldsdevelopingintodeepfissuresespeciallyaroundtheanklePapillomatosis,papulesornodulesthatprotrudefromtheskingivingacobble-stoneappearanceLymphangiomasLymphorrea

Photocopiedfromhttp://jamanetwork.com/journals/jamasurgery/fullarticle/394351

WhenwouldINOTusecompressiontherapy?Giventhatcompressiontherapyhassuchimmensebenefitstothemajorityoflowerlegulcers,whywouldInotuseit???

NotCompetentTheapplicationofcompressionandtheuseofcompressiontherapyiscomplex.Asyoucanseebythesciencebehindthebandaging,smallchangesinapplicationcanresultlargeunder-bandagepressurechanges,potentiallycausingharm.Also,yourassessmentneedstobethoroughtoensureyoudonotmisssubtlesignsthatindicatethepatientwillnotbeabletotoleratethecompression(18).

Pressuredamageovertheanteriortibiaona

thinleg

Ruptureofthedistalanteriortibialtendonduetopressuredamage

PhotoscopiedfromBeldon,2008(18)

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ArterialDiseaseWherearterialsupplyisalreadycompromised,addinginadditionalpressure(beitcompressiontherapyoranti-thromboembalismstockings)weareexacerbatingtheproblem.Butwithoutthoroughassessmentwemaynotbeawareoftheproblem.Also,wecannotalwaysrelyonthepatienttotellusifthereisaproblemwiththebandaging,suchas:

• wherethepersonisneuropathic,• onstrongpainmedication,• alreadyinsomuchpainfromtheirulcerthey

maynotnoticeapressureinjuryforming,• ornotwillingtospeakupduetothe“power

difference”orperceptionthat“Doctorknowsbest”

Perrin’sarticleinPhlebolymphology(2008)(2),whileitiscitingsomewhatolderdata,isvalidinit’sconcernsthatthoroughassessmentisrequiredpriortoapplicationandthatapplicationofanycompressionbecloselymonitored.

Usewithcaution…

HeartDiseaseWithcompressionthefluidfromthetissuesisreturnedtothevenoussystemandbackintocirculation.Inthepatientwithheartfailurethiscanleadtoariskofexcessivepre-loadingoftheheart.Itisimportanttointroducecompressioninastagedfashion,lowerpressures(short-stretch)andunilaterally.WorkwiththeCardiologistandprimaryPhysiciantocloselymonitorandmanagetheheartfailure.Iftheheartfailureiswellcontrolled,slowlyincreasecompressiontherapytooptimum,again,inconjunctionwithclosemonitoringbytheirmedicalteam(14).

TheDiabeticLimbInthepatientwithdiabetesthereisariskofdamagetothefootfromlackofsensationorlackofbloodsupplytothefootthatcanleadtoulceration,infectionandworse.Thoroughneurovascularassessmentisrequired.Wherethereisischaemia–donotapplycompression.Explorepossiblevascularinvestigations/interventions.Wherethereisneuropathy–considerusingmildtomoderatecompressionwithextrapaddingandintermittentpneumaticcompression.Alwaysensurediabetesiswellcontrolled,involvetheDiabeticsupportteamandPodiatrist(14).Theremaybeotheradvancedtherapies(negativepressurewoundtherapy,biologicaldressings,bioengineeredskinequivalents,hyperbaricoxygentherapy,plateletrichplasmaandgrowthfactors)thatcanalsobeexploredwheretherearenootheroptionsforimprovingarterialsupplyandwoundsarenotimproving.Howevertheseareexpensivetherapiesandthereisinsufficientevidencetodeterminetheireffectiveness(19).

Photo copied from Perrin(2): High sustained pressure in a patient treated by compression bandages for a lateral leg ulcer with unrecognized occlusive arterial disease. The patient ultimately required a below knee amputation.

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GuidelinesTherearearangeofdocumentstohelpyoutoexplaincompressiontherapyandalsotoguidepracticewiththemostcurrentandbestevidenceavailable.Theguideslistedbelowareaavailablefordownloadonthewebsite.Also,alwaysrefertoyourlocalfacility’spoliciesregardinglegulcermanagement(assessment,investigationsandcompressiontherapy).

• AustralianandNewZealandClinicalPracticeGuidelineforthePreventionandManagementofVenousLegUlcers,AWMA,2011(5)

• CompressioninVenousLegUlcers:aconsensusdocument,WorldUnionofWoundHealingSocieties,2008(14)

• UnderstandingCompressionTherapy,EuropeanWoundManagementAssociation,2003(20)

Otherhelpfuldocumentsincludedinthedownloadare:

• Applicationof3layertubigrip• AssessmentandManagementofVLUsFlowchart,AWMA,2011• AnEconomicEvaluationofCompressionTherapy,KPMGreportproducedforAWMA,

2013(http://www.woundsaustralia.com.au/news/news91.php)• PrinciplesofCompressioninVenousDisease(3)• SimplifyingCompression(9)

Youcanfindthedownloadatwww.woundcareresource.com,clickonEducation,thenSummaries.Thepackagewillbeatthebottomofthepage.

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References1. OpenStax,StructureandFunctionofBloodVessels,inAnatomy&Physiology2013,

OpenStax.2. Perrin,M.,Skinnecrosisasacomplicationofcompressioninthetreatmetnofvenous

diseaseandinpreventionofvenousthromboembolism.Phlebolymphology,2008.15(1):p.27-30.

3. Fletcher,J.,etal.,Principlesofcompressioninvenousdisease:apractitioner’sguidetotreatmentandpreventionofvenouslegulcers.WoundsInternational,2013.

4. EuropeanWoundManagementAssociation,FocusDocument:Lymphoedemabandaginginpractice2005,London:MEPLtd.

5. AustralianWoundManagementAssociationandNewZealandWoundCareSociety,AustralianandNewZealandClinicalPracticeGuidelineforPreventionandManagementofVenousLegUlcers.2011,OsbornePark,WA:CambridgePublishing.

6. Whitaker,J.,Howtomanagelowerlimbcomplications.WoundsMiddleEast,2016.3(1):p.18-22.

7. Sinha,S.N.andP.Luk,Vasculiticlegulcers--areview.PrimaryIntention:TheAustralianJournalofWoundManagement,2002.10(2):p.79-82.

8. Marston,W.andK.Vowden,CompressionTherapy:aguidetosafepractice,inPositionDocument:UnderstandingCompressionTherapy,EuropeanWoundManagementAssociation,Editor2003,MedicalEducationPartnership:London.

9. Harding,K.,etal.,Simplifyingvenouslegulcermanagement.Consensusrecommendations.WoundsInternational,2015.

10. Thomas,S.,TheuseoftheLaplaceequationinthecalculationofsub-bandagepressure.WorldWideWounds,2003.

11. Becker,F.,etal.,ChapterI:Definitions,Epidemiology,ClinicalPresentationandPrognosis.EuropeanJournalofVascularandEndovascularSurgery,2011.42,Supplement2(0):p.S4-S12.

12. Diehm,N.,etal.,ChapterIII:ManagementofCardiovascularRiskFactorsandMedicalTherapy.EuropeanJournalofVascularandEndovascularSurgery,2011.42,Supplement2(0):p.S33-S42.

13. Edmonds,M.,Diabeticfootulcers:practicaltreatmentrecommendations.Drugs,2006.66(7):p.913-929.

14. WorldUnionofWoundHealingSocieties(WUWHS),Principlesofbestpractice:Compressioninvenouslegulcers.Aconsensusdocument.2008,London:MEPLtd.

15. Williams,A.F.,P.J.Franks,andC.J.Moffatt,Lymphoedema:estimatingthesizeoftheproblem.PalliativeMedicine,2005.19(4):p.300-313.

16. Ridner,S.H.,PathophysiologyofLymphedema.SeminarsinOncologyNursing,2013.29(1):p.4-11.

17. Hampton,S.,Caringforresidentswithchronicoedemainthelowerlimb.Nursing&ResidentialCare,2010.12(2):p.70.

18. Beldon,P.,Compressionbandaging:avoidingpressuredamage.BritishJournalofCommunityNursing,2008.13(6):p.S6-S6,S8,S10-2passim.

19. Chadwick,P.,etal.,Internationalbestpracticeguidelines:Woundmanagementindiabeticfootulcers.WoundsInternational,2013.

20. EuropeanWoundManagementAssociation,PositionDocument:UnderstandingCompressionTherapy2003,London:MEPLtd.

compression therapy - wound care resource · 2018. 5. 31. · 'wound care: a broad look from a...

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