Bandaging: a vital skill

Proficient bandaging is an essential component of dressing retention for patients with friable and/or sensitive skin, as well as a method of supporting injured limbs (Macleod et al, 1993). Skilful bandaging is also crucial for patients with venous leg ulcers (Fletcher et al, 1997). Poorly applied bandages are at best ineffective and expensive. At worst, they can cause discomfort and pain or result in further injury (Griffiths and Williams, 1997).

While numerous articles have been written on compression bandaging, few discuss retention and supportive bandages. This article describes the different types of bandage available and provides examples of their practical application.

Class 1: retention bandages

These are lightweight cotton, conforming bandages with little elasticity. Their main function is to hold dressings in place. Although many modern primary or secondary dressings are self-adhesive, a retention bandage may be necessary for awkward areas, such as on heels or elbows. They are also of benefit to patients who have friable or sensitive skin, when adhesive tapes or dressings should be avoided.

Though they are conformable, retention bandages should not be used to apply pressure (Welsh Centre for the Quality and Control of Surgical Dressings, 2001). Care should be taken when applying them as poor technique can result in a tourniquet effect (Fig 1).

They should not be used on oedematous limbs as they do not provide support and will not shift fluid. Ideally, a retention bandage should be applied from joint to joint to prevent tightness and discomfort.

Retention bandages have largely been superseded by tubular retention products. These are quick and easy to apply and tend to be comfortable to wear and neat in appearance (Fig 2). They are particularly useful in patients with vascular disease or diabetes, when adhesive products may be contraindicated and dressings need to be kept in place with little or no pressure on the underlying tissues.

Dressing awkward areas

Hippocrates appreciated that bandages could be tricky to apply: ‘One ought to be well aware that every bandage has a tendency to fall off towards the part that declines or becomes smaller as, for example, upwards in the case of the head and downwards in the case of the leg.’

The heels, elbows, ears, head, chin, breast/chest and sacral areas are notoriously difficult to apply dressings to and skilled application is crucial if a bandage is to stay in place for any length of time. However, the introduction of shaped bandages and tapeless dressing retention products has made the task much easier in many cases.

With a few strategic cuts, different sizes of tubular bandages can be used to secure head, ear or chin dressings (Fig 3). Larger sizes with slits cut for the arms can be used as a vest to secure chest, back or complex breast dressings.

Tapeless secondary dressings are ready-made, anatomically shaped garments used to dress awkward areas. They are made of conforming, hypoallergenic, non-latex, stretchy material that can be secured with adhesive-backed tapes.

‘Windows’ are built into the garments to allow easy viewing of the primary dressing without disturbing it. Tapeless secondary dressings are available in a range of shapes, such as those made to fit around the ankle and heel (Fig 4), and adhesive-backed shorts are available to hold sacral dressings in position. Although they are relatively expensive, they can be washed and re-used on the same patient and have been shown to reduce dressing application times and improve patient comfort (McGregor and Baxter, 1999).

Class 2: light-pressure bandages

These include the traditional cr[ep3]pe bandages used to support sprains and strains and are capable of supplying a low level of pressure, up to about 15mmHg. Although they can be used to ease and support injured limbs by helping to prevent some swelling, they do not provide enough pressure to move existing oedema or reverse venous hypertension in venous leg ulcers (Cameron et al, 1996).

Cr[ep3]pe bandages used on sprains or strains or for general support should always be applied from the toe to the knee, or from the base of the fingers to the elbow in lower arm/wrist injuries. Joint-to-joint bandaging prevents a tourniquet effect, and ensures drainage to the larger veins and lymphatic junction. For example, fluid from the foot and lower limbs can be removed at the popliteal fossa by the popliteal vein and lymph nodes (Tortora and Anagnostakos, 1990). Cr[ep3]pe bandages can be applied either in a spiral formation or in a figure-of-eight formation. The bandage should be applied with firm pressure (about 50% stretch) and with 50% overlap to ensure even pressure and adequate support.

Cr[ep3]pe bandages can also be used to retain dressings in patients where the limb may swell or require support. In most cases an injured lower limb that requires a dressing will also need some degree of support, so a light support bandage may be more appropriate for dressing retention than a class 1 retention bandage. The bandage should be applied from joint to joint.

Tubular elastic bandages are often used for soft-tissue injuries. These are easy to apply and provide better support to the limb than a cr[ep3]pe bandage as they do not become loose or slip around the heel. Tubular elastic bandages are usually applied as a double layer, but can also be used as a single layer if very light support is required.

It is important to apply the correct size of tubular elastic bandage: if it is too large it will not provide adequate support, conversely if it is too small it will be overstretched and may create high-pressure zones in the larger part of the limb.

Because tubular elastic bandages are able to provide low-level pressure they are not suitable for use on patients with ischaemic limbs and should not be substituted for, or confused with, tubular retention bandages.

Tubular elastic bandages do not provide the correct pressure gradient or level of compression needed to treat venous hypertension or to shift lymphoedema. But if they are used, for example, to treat a sprained ankle, a better pressure gradient can be obtained with shaped products that will overcome the difference in width between the ankle and the calf.

Minimal-stretch bandages

More commonly known as short-stretch bandages, these fall into the support group but have also been used to treat venous ulcers (Charles, 1996) and lymphoedema (Badger, 1996).

Short-stretch bandages reach maximum elasticity at relatively low extension, which allows them to be applied at full stretch. Used in this way with 50% overlap they provide enough support to move existing oedema and reverse venous hypertension in some patients.

Ideally, the patient should be mobile as the short-stretch bandage has a low resting pressure and a high working pressure. In other words, the bandage system works by providing ‘pulsed’ pressure when the calf muscle works against the relatively inflexible wall of the short-stretch bandage (Hofman et al, 1998).

Although short-stretch bandages are advocated for use in mobile patients, they have also been shown to reduce oedema and aid the healing of venous ulcers in immobile patients whose legs are largely dependent (Hofman et al, 1998).

Short-stretch bandaging is fairly straightforward to apply and is, perhaps, an easier technique to master than multilayer bandaging.

The simplest method is to use a spiral technique with 50% overlap. Wool padding should be used as the first layer to protect bony prominences and aid comfort, and can absorb perspiration or low levels of exudate. The short-stretch bandage is then applied from the base of the toes to the tibial tuberosity (just below the knee). The anchor turns of the bandage around the foot and the heel are applied with no pressure, then the bandage is applied at full stretch from the ankle to the knee (Fig 5).

As the bandage has little elasticity, once the oedema in the leg has been shifted there is a tendency for the bandage to loosen and fall down. For this reason it is often necessary to reapply the bandage daily in patients with oedematous limbs.

Short-stretch bandages may also be used with caution in patients presenting with ‘mixed’ ulcers, where the ankle-brachial pressure index is less than 0.8 but greater than 0.6 and the ulcer appears to be typically venous.

As the resting pressures are so low, with only temporary high-working pressures, they are less likely to have a detrimental effect on arterial inflow (Thomas and Nelson, 1998). However, full assessment and constant reassessment should be maintained during treatment of such ulcers.

As with all types of compression bandaging, short-stretch bandages should be used with caution in patients with heart or renal failure.

Class 3: moderate to high-compression bandages

These highly elastic bandages are used for the treatment of venous ulcers, lymphoedema and gross varices. Effective compression therapy aims to achieve graduated pressure that is highest at the ankle, reducing as it moves up towards the knee. Stemmer (1969) reported that a pressure of 35-40mmHg at the ankle, reducing to about 17mmHg below the knee, is required to reduce the effects of venous hypertension and therefore aid healing (Collier, 1999).

The natural shape of the leg is usually enough to achieve this pressure gradient but in patients with abnormal leg shapes as a result of chronic oedema, for example, inverted ‘champagne bottle’ or atrophied calf muscles, orthopaedic wool padding is needed to approximate a normal shape and achieve graduated compression.

The British Standard classifies compression bandages according to their compressive abilities and the pressures they are expected to achieve (Thomas and Nelson, 1998), giving all compression bandages an arbitrary class, from 3a (least compressive) to 3d (highly compressive). For clinical purposes it is often easier to classify compression bandages by type. Compression bandages can broadly be classified into three types: short-stretch or inelastic bandages (see previous page), long-stretch and multilayer.

Long-stretch bandages

These are highly elastic bandages that conform well to the contours of the leg and have high resting pressures. Long-stretch bandages can be used alone or with orthopaedic wool padding beneath. As with short-stretch bandages, they are applied in a spiral formation with no pressure around the foot and the heel. They are usually applied from the ankle up to the tibial tuberosity with a 50% stretch (see Fig 6, previous page). Some long-stretch bandages now have rectangles printed at intervals on the bandage which stretch into squares to denote when the correct extension is achieved.

Long-stretch bandages are highly successful in treating venous leg ulcers and gross oedema (Callam et al, 1992). But application requires skill, as any areas of overstretch or understretch will increase or decrease the sub-bandage pressures and may cause injury or discomfort.

It can be difficult to maintain equal pressures throughout the bandage application, so once the bandage has been applied, the nurse should run his or her hands up, down and around the bandage to check for bulges or indents. Bulges indicate areas of reduced pressure and indents may mean areas of overstretch or higher pressure.

The bandage can be retained in place over the heel and toes using adhesive tape (Figs 7 and 8).

Multilayer bandages

Multilayer bandages comprise both the four-layer (Charing Cross) system and three-layer bandages. The four-layer system is perhaps the best known of the multilayer bandages, and comprises:

1. An orthopaedic wool layer;

2. A cr[ep3]pe layer;

3. A class 3a elastic bandage;

4. A class 3a elastic cohesive bandage.

The four-layer system promotes effective compression and reduces the risk of areas of excess or reduced sub-bandage pressure because the layers of the bandage absorb and distribute any unequal pressure. Four-layer bandaging is extremely effective in healing venous ulcers and reducing oedema. It also has a high wear time (lasting one week) and can cope with high levels of exudate, which are absorbed into the layers of the bandage.

At any one point there should be eight layers of bandage because of the 50% overlap. Surprisingly, this is generally a comfortable bandage system, although some patients find it unacceptable as it is difficult to find appropriate footwear to accommodate the bandage and it can be uncomfortably hot in warm weather.

The bandages are applied from the toe to the tibial tuberosity in the following formation:

1. Orthopaedic wool padding - applied in a spiral to pad bony prominences and reshape the leg if necessary (Fig 9);

2. Cr[ep3]pe - applied in a spiral at 50% stretch and 50% overlap (Fig 10);

3. Elastic compression layer - this gives the greatest degree of sustained pressure if applied in a figure-of-eight formation at 50% stretch and 50% overlap. It can be applied as a spiral, but this may not secure the desired levels of compression over a long period. No pressure is exerted on the anchor turns over the foot and the heel (Fig 11);

4. Elastic cohesive layer - applied in a spiral with 50% stretch and 50% overlap. No pressure is exerted over the anchor turns at the foot and heel (Fig 12).

Three-layer bandages

The four-layer system can be adapted for a number of reasons. If reduced compression is required, for example in diabetic patients or those who cannot tolerate four layers, the third layer (class 3a elastic compression) can be omitted. A reduced level of compression is derived from the elastic cohesive layer.

For patients with grossly oedematous limbs, that is with an ankle circumference greater than 25cm, the traditional four-layer system is not likely to achieve enough sub-bandage pressure to be effective.

In the three-layer bandaging system, the layers are made up of:

1. Orthopaedic wool padding;

2. Long-stretch bandage;

3. Cohesive elastic bandage.

This achieves more consistent pressures for larger limbs and should be maintained until the ankle circumference has reduced. Multilayer bandages are now available on The Drug Tariff as individual kits.

Multilayers can also be made up of: paste bandage, long-stretch and graduated tubular elastic bandages.

Choosing a compression bandage system

All methods of compression bandaging discussed have been shown to be effective in treating oedema and venous ulceration (Charles, 1996; Badger, 1996; Hofman et al, 1998; Thomas and Nelson, 1998; Collier, 1999). When deciding which method of bandaging to use on a particular patient, the following should be taken into account:

- Patient mobility;

- Patient comfort and the ability to wear shoes;

- The experience and skill of the person doing the bandaging;

- Frequency of application/nurse visits.

For example, ambulatory patients may benefit more from short-stretch bandaging because it is easier to find footwear that will fit than when using a bulky multilayer bandage.

Conversely, patients who are able to visit the clinic only once a week could benefit more from a multilayer system that is likely to stay in place and absorb exudate for longer. Two or three different systems may need to be tried and tested before the best bandaging regime for an individual can be found.

Conclusion

Bandaging, whether to heal venous ulcers or keep a dressing in place, is a vital nursing skill. Many different products are available on the market or on The Drug Tariff and can improve application, patient comfort and aesthetics, as well a greatly reducing the time nurses spend changing dressings.

The skilled application of bandages or bandage products can improve patient comfort and the potential for healing, while reducing the possibility of further injury or discomfort and enhancing quality of life.