Wound, Ostomy, and Continence Nurses Society™ (WOCN®)
Compression therapy is the cornerstone of treatment for chronic venous insufficiency (CVI) and lymphedema. Compression has been shown to improve healing rates in patients with existing venous leg ulcers (VLU) and reduce the likelihood of VLU recurrence and prevent edema leading to fibrosis in the treatment of lymphedema. In an effort to customize compression therapy for each individual with CVI and/or lymphedema, the Wound, Ostomy, and Continence Nurses Society™ (WOCN®) set out to develop an evidence- and consensus-based algorithm on compression therapy. To learn more about how the original algorithm was developed, view the accompanying article in the Journal of Wound, Ostomy and Continence Nursing (JWOCN). To learn more about most recent updates to the algorithm, view the accompanying article in JWOCN by clicking here.
The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box.
Tap or click the "Back" button to return to the previous page or step.
Tap or click the home icon to return to the beginning.
Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. A hand icon will guide you to the next step in the algorithm. You cannot proceed until the hand disappears.
Tap or click any number to return to that step in the process.
Tap or click the "Full Screen" button to optimize the fit to your device's viewable area.
In many patients, chronic venous insufficiency and lymphedema can be diagnosed by health history and physical examination alone.
location, circumference of lower extremity, pitting versus non-pitting.
Stemmer sign is the inability to pinch the skin proximal to the phalanx of the second or third toe in patients with lymphedema.
Obtain appropriate studies such as Ankle Brachial Index (ABI) to exclude significant arterial disease. Refer to ABI Procedure and Value Table.
Conduct differential diagnosis (Refer to LEVD Appendices B: Differentiation of Edema due to Lower-Extremity Venous Disease (LEVD), Lymphedema, and Lipedema, and C: Characteristics of Venous Eczema/Dermatitis Versus Cellulitis located in WOCN Society Guideline for Lower-Extremity Venous Disease [2019]).
Refer to “Lower-Extremity Wounds due to Venous Disease, Arterial Disease, or Diabetes Mellitus and/or Neuropathic Disease: Clinical Resource Guide” (2021).
* Lower-Extremity Wounds due to Venous Disease, Arterial Disease, or Diabetes Mellitus and/or Neuropathic Disease: Clinical Resource Guide
* Differentiation of Edema and Venous Dermatitis vs Cellulitis
Chronic venous insufficiency including phlebolymphedema
Disease or wound of other etiology (e.g., lipedema, arterial, or neuropathic)
Refer to WOCN Society document: Lower-Extremity Wounds due to Venous Disease, Arterial Disease, or Diabetes Mellitus and/or Neuropathic Disease: Clinical Resource Guide
Lymphedema
Phlebolymphedema is commonly due to the inability of the lymphatic system to adequately drain the interstitial fluid that accumulates in chronic venous insufficiency (CVI)
Refer to CEAP table to determine severity of chronic venous insufficiency
No wound (CEAP 1-4) or healed wound (CEAP 5)
Active wound (CEAP 6)
No visible or palpable signs of venous disease (CEAP 0)
Proceed to the CEAP 1-2 pathway
Proceed to the CEAP 3-4 pathway
Proceed to the CEAP 5 pathway
Manage Signs/Symptoms per Facility Protocol OR Clinical Guideline
Patient should be reassessed at least annually to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Determine need for compression based on symptoms (i.e., burning, itching, heaviness, aching, or pain)
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression stockings Class 1 or 2 have not been shown to impair microcirculation in patients with peripheral arterial disease or diabetes mellitus.
Age is not a barrier to adherence when using adjustable compression wraps for self-management of CVI CEAP 0-3. Obesity, gripping difficulties, and cognitive impairment are barriers to self-management.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.
Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
Compression stockings Class 1 or 2 have not been shown to impair microcirculation in patients with peripheral arterial disease or diabetes mellitus.
If ABI ≥ 0.8 and ≤ 1.3 proceed to compression.
If ABI < 0.5 or > 1.3, do not use compression.
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression garments that do not cover the foot and heel are not inferior to standard compression stockings that include the foot and heel in patients with venous disease CEAP 3-6. They are easier to don and doff unaided and may improve adherence.
Complete decongestive therapy (CDT) may be used as an adjunct to compression in patients with venous disease CEAP 3 and 4.
Adjustable hook and loop compression devices are more effective than multilayer bandages in patients with venous disease CEAP 3.
Intermittent pneumatic compression may be used as an adjunct to 4 layer compression for patients with venous disease, phlebolymphedema and lower extremity lymphedema.
Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Compression stockings Class 1 or 2 have not been shown to impair microcirculation in patients with peripheral arterial disease or diabetes mellitus.
If ABI ≥ 0.5 and ≤ 1.3 proceed to compression.
If ABI < 0.5 or > 1.3, do not use compression.
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Patients using Class 3 compression stockings have a significantly longer time to venous leg ulcer recurrence than Class 2.
Compression garments that do not cover the foot and heel are not inferior to standard compression stockings that include the foot and heel in patients with venous disease CEAP 3-6. They are easier to don and doff unaided and may improve adherence.
Intermittent pneumatic compression may be used as an adjunct to 4 layer compression for patients with venous disease, phlebolymphedema and lower extremity lymphedema.
Manual lymphatic drainage (MLD) may be used as an adjunct to compression therapy in patients with venous disease CEAP 5-6.
Consider use of pentoxifylline (Trental) to enhance microcirculation and prevent recurrence. (Refer to Pharmaceuticals Table)
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Initiate and coordinate topical wound care for patients with lower extremity wounds. Consider principles of wound bed preparation prior to selection of topical therapy
Apply topical dressing that will manage venous leg ulcer exudate.
Apply emollients to intact skin underneath compression to prevent occurrence of dermatitis.
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
If ABI < 0.5 or > 1.3, do not use compression.
If ABI ≥ 0.8, proceed to compression, In patients with mixed venous and arterial disease (ABI 0.5 to 0.8), consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Manual lymphatic drainage (MLD) may be used as an adjunct to compression therapy in patients with venous disease CEAP 5-6.
Simple progressive resistance and aerobic exercises are recommended to supplement compression therapy in the treatment of venous disease CEAP 6.
Compression garments that do not cover the foot and heel are not inferior to standard compression stockings that include the foot and heel in patients with venous disease CEAP 3-6. They are easier to don and doff unaided and may improve adherence.
Intermittent pneumatic compression may be used when other compression options are not available, cannot be used (immobile, extremely large legs, intolerant of stockings or wraps), have failed to aid in VLU healing after prolonged compression therapy, or when higher levels of compression are needed than can be provided by stockings or wraps.
If the wound fails to improve or deteriorates, evaluate for barriers to healing.
If treatment is effective, continue current therapy until healed
Proceed to the CEAP 5 section of the algorithm.
Refer for advanced adjuvant therapies and/or consider referral for evaluation and management of significant arterial disease. Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Evaluate skin of lower extremity for cellulitis* and initiate or refer to provider for antimicrobial treatment.
Initiate and coordinate topical wound care for patients with lower extremity wounds.
Initial and ongoing assessment should include the patient’s social determinants of health, self-care abilities, the presence of a caregiver who is able, willing and available, and adherence to the plan of care.
Comprehensive management of lower extremity lymphedema should be based on the International Society of Lymphology stages of lymphedema (Stages 0-III).
Stage 0—Latency (subclinical lymphedema)
Edema is not evident despite impaired lymph transport
Extremity may feel heavy, full, tight, or achy
This stage may exist for months or years before edema is observable
Stage I—Early-onset edema
Edema is observable and measurable
Edema may pit with pressure
Edema resolves with elevation
Tissue feels soft (no fibrosis)
Clothing and jewelry may feel tight and produce constriction
Stage II (May be divided into early and late stage II)
There will be a combination of pitting and nonpitting edema (late stage II)
Edema does not resolve with elevation
Fibrosis present in the tissue (late stage II)
The patient may begin to experience decreased range of motion,
difficulty fitting into clothing
Stage III
Significant skin changes present (generalized fibrosis and pitting
response is absent)
Hypertrophy of the subcutaneous tissue
Papillomas and warty overgrowths may develop on the skin
Skin folds and lobules begin to develop
Disfigurement of the extremity
Ongoing infections of the tissue likely
References:
Adapted from The International Society of Lymphology. (March 2013).
Consensus document on diagnosis and treatment of peripheral lymphedema.
Lymphology, (1), 1–11.
Lymphedema Stage - 0: Edema is not evident despite impaired lymph transport, Extremity may feel heavy, full, tight, or achy.
Lymphedema Stage - I: Edema is observable, measurable and may pit with pressure, Edema resolves with elevation, Tissue feels soft (no fibrosis)
Lymphedema Stage - II: Combination of pitting and nonpitting edema (late stage II), Edema does not resolve with elevation, Fibrosis present in the tissue (late stage II)
Lymphedema Stage - III: Generalized fibrosis and pitting is absent, Hypertrophy of the subcutaneous tissue, Papillomas and warty overgrowths may develop on the skin, Skin folds and lobules begin to develop, Disfigurement of the extremity
If assessment suggests stage 0 lymphedema (no visible edema) but patient has symptoms of numbness, tingling, heaviness; consider alternative causes (such as chronic venous insufficiency, peripheral neuropathy, spinal pathology, undiagnosed malignancy).
Regular follow-up with a healthcare provider is needed, with frequency based on individual and clinical circumstances, to evaluate response to treatment and ensure effectiveness of compression garments or devices, and treatments.
If assessment suggests stage I lymphedema (reversible edema) consider additional etiologies (for example, venous disease CEAP C3 is characterized by pitting edema plus reticular veins, telangiectasias, etc.).
Recommend compression, such as knee high stockings, hook and loop garments, or short stretch wraps/bandages at a level of 20-30 mmHg, during waking hours and during 2 hours or more of air or vehicle travel to control edema. In addition, recommend frequent calf muscle exercises and elevation of lower extremity above the level of the heart.
Regular follow-up with a healthcare provider is needed, with frequency based on individual and clinical circumstances, to evaluate response to treatment and ensure effectiveness of compression garments or devices, and treatments.
If assessment indicates stage II lymphedema (irreversible edema), obtain a history of prior treatment and response including complete decongestive therapy (CDT), which comprises manual lymphatic drainage (MLD), compression therapy, skin and nail care, and exercise
Phase 1: acute intensive (reductive) outpatient visits for manual lymph drainage (MLD), multilayer compression bandaging, and compression garments 3 to 5 days weekly for 1 to 4 weeks. Additional interventions include skin care, therapeutic exercises, patient education, weight control and diet. Phase 2: patient-directed maintenance and home care. Therapy will include a limited number of encounters with CLT. Patient is discharged to home with compression bandages, devices or garment.
Manual lymphatic drainage uses very light and strategically directed touch to improve lymphatic flow; it should not be confused with massage, which uses high-pressure touch and is totally contraindicated in the management of lymphedema.
Refer patient to certified lymphedema therapist (CLT) as indicated for complete decongestive therapy (CDT) which includes manual lymphatic drainage (MLD), compression therapy, skin and nail care and exercise.
Educate colleagues regarding the potential adverse effects of the use of diuretics for lower extremity edema associated with chronic venous insufficiency and/or lymphedema, due to the risk of worsening fibrosis, volume depletion, renal insufficiency, and hypotension.
Initiate and coordinate topical wound care for patients with lower extremity wounds.
Regular follow-up with a healthcare provider is needed, with frequency based on individual and clinical circumstances, to evaluate response to treatment and ensure effectiveness of compression garments or devices, and treatments.
If assessment indicates Stage III lymphedema (elephantiasis), obtain a history of prior treatment and response including complete decongestive therapy (CDT), which comprises manual lymphatic drainage (MLD), compression therapy, skin and nail care, and exercise
Refer patient to certified lymphedema therapist (CLT) for complete decongestive therapy (CDT), manual lymphatic drainage (MLD), compression therapy, skin and nail care and exercise as indicated.
Evaluate skin of affected lower extremity for lymphorrhea and consider absorbent products with application of multicomponent compression wraps/bandages.
Refer to Tables:
Leaking of lymph fluid from the surface of skin
Superabsorbent products, ABD pads, incontinent products, etc.
Initiate and coordinate topical wound care for patients with lower extremity wounds.
In patients with persistent or refractory stage III lymphedema despite previous complete decongestive therapy (CDT), consider referral to surgeon for lymphatic system reconstruction or lower extremity reduction procedures.
Regular follow-up with a healthcare provider is needed, with frequency based on individual and clinical circumstances, to evaluate response to treatment and ensure effectiveness of compression garments or devices, and treatments.
| Clinical Observations | Proposed Pathophysiology | Clinical Actions | Effect of Actions | Clinical Outcome |
|---|---|---|---|---|
| Tissue nonviable or deficient | Defective matrix and cell debris | Debridement (episodic or continuous): Autolytic, enzymatic/chemical/surfactant, biosurgical/larval, mechanical, sharp |
Restoration of wound base and functional extracellular matrix proteins | Viable wound base |
| Infection or inflammation | High bacterial counts or prolonged inflammation ↑Inflammatory cytokines ↑Protease activity ↓Growth factor activity |
Remove infected foci Topical/systemic: Antimicrobials Anti-inflammatories Protease inhibition |
Low bacterial counts or controlled inflammation: ↓Inflammatory cytokines ↓Protease activity ↑Growth factor activity |
Bacterial balance and reduced inflammation |
| Moisture imbalance | Desiccation slows epithelial cell migration | Apply moisture-balancing dressings | Restored epithelial cell migration, desiccation avoided | Moisture balance |
| Excessive fluid causes maceration of wound margin | Compression, negative pressure or other methods of removing fluid | Edema, excessive fluid controlled, maceration avoided | ||
| Edge of wound—nonadvancing or undermining | Nonmigration of keratinocytes Nonresponsive wound cells and abnormalities in extracellular matrix or abnormal protease activity | Reassess cause or consider corrective therapies: Debridement Skin grafts Biological agents Adjunctive therapies |
Migration of keratinocytes and responsive wound cells. Restoration of appropriate protease profile | Advancing edge of wound |
Adapted from Ermer-Seltun, J. & Rolstad, B. S. (2022). General principles of topical therapy. In L.L. McNichol, C. R. Ratliff & S.S. Yates (eds.). WOCN Core Curriculum - Wound Management (2nd ed.), Philadelphia: Wolters Kluwer.
| Uses | Dose | Reference | |
|---|---|---|---|
| Phlebotonics (natural flavonoids extracted from plants or synthetic flavonoid-like products) Examples: rutoside, French maritime pine bark extract (pycnogenol), grape seed extract, calcium dobesilate, naSazone, etc. | Venoactive drugs whose mechanism of action is not scientifically well established that are associated with effects on edema, QOL, and other subjective symptoms of CVI | Varies by product | Martinez-Zapata MJ, Vernooij RW, Simancas-Racines D, et al. Phlebotonics for venous insufficiency. Cochrane Database of Syst Reviews 2020, 11(11):CD003229. Published 2020 Nov 3. doi:10.1002/14651858.CD003229.pub4 |
| Horse chestnut seed extract | Reduce symptoms of CVI such as leg pain, fatigue/tiredness, leg swelling | 300 mg of horse chestnut seed extract containing 50 mg of the active ingredient, aescin, twice daily. | Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD003230. DOI: 10.1002/14651858.CD003230.pub4 |
| Pentoxifylline (Trental) | Hemorheologic agent enhances microcirculatory blood flow and may be used in CVI patients in conjunction with compression therapy | 400 mg ORALLY 3 times per day with food | Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD001733. DOI: 10.1002/14651858.CD001733.pub3. |
| ABI | Perfusion Status |
|---|---|
| > 1.3 | Elevated, incompressible vessels |
| > 1.0 | Normal |
| ≤ 0.9 | LEAD |
| ≤ 0.6 to 0.8 | Borderline |
| ≤ 0.5 | Severe ischemia |
| ≤ 0.4 | Critical ischemia, limb threatened |
J Wound Ostomy Continence Nurs. 2012;39(2S):S21-S29.
| Type of Compression | Examples | Performance Characteristics and mmHg Pressure |
|---|---|---|
| Light Support | Crepe, rolled gauze | Holds dressings in place No significant compression |
| Light Compression, support (elastic) | Elastocrepe (BSN medical), Tubigrip (Mölnlycke), Medigrip (Medline) | Low pressure, light support 14-17 mmHg |
| Cohesive bandage | Coban (3M), Co-flex (Andover), Medi-Rip (Hartmann), Sensi-wrap (Dynarex) | Self-adherent, compression well sustained |
| High elastic compression | Tensopress (BSN Medical), Setopress (Mölnlycke), SurePress (Medline) | Sustained compression, wash and reuse 25-40 mmHg |
| Multilayer high compression 3 or 4 layer | Profore (Smith & Nephew), Comprifore (BSN medical), Dynaflex (Systagenix), FourPress (Hartmann), Fourflex (Medline) | To maintain 35-40 mmHg at the ankle |
Table compiled from information in:
O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265.
For lymphedema, select class based on recommendations of certified lymphedema specialist.
| U.S. Class | Descriptor | Ankle Pressure | Indication |
|---|---|---|---|
| Class 1 | Light support | 20-30 mmHg | Treatment of varicose veins |
| Class 2 | Medium support | 30-40 mmHg | Treatment of more severe varicosities and prevention of leg ulcers |
| Class 3 | Strong support | 40-50 mmHg | Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent leg ulcers |
| Class 4 | Very Strong support | 50-60 mmHg | Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent leg ulcers |
| U.K. Class | Descriptor | Ankle Pressure | Indication |
|---|---|---|---|
| Class 1 | Light support | 14–17 mmHg | Treatment of varicose veins |
| Class 2 | Medium support | 18-24 mmHg | Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent venous leg ulcers in patients with thin legs |
| Class 3 | Strong support | 25-35 mmHg | Used to treat more severe varicosities and to prevent venous leg ulcers |
Adapted from: WOCN (2019). Lower Extremity Venous Disease guideline; Kelichi, Brunette & Burgess (2022). Lower extremity venous disease, venous leg ulcers and lymphedema in McNichol, Ratliff & Yates, WOCN Core Curriculum – Wound Care, Philadelphia: Wolters Kluwer.
| Type Compression | Examples of Compressiona | Compression Level at the Ankleb | Characteristics of Compression |
|---|---|---|---|
|
Elastic/Long-Stretch Bandages/Wraps |
Setopress (Molnycke) |
30-40 mmHg |
|
|
Surepress (Convatec) |
40 mmHg |
||
|
Inelastic/Short-Stretch Bandages/Wraps |
Comprilan (BSN Medical) Rosidal K (L&R USA Inc.) |
30-40 mmHg |
|
|
Multicomponent Compression Systems |
Elastic Profore (Smith & Nephew) FourPress (Hartmann USA Inc.) Coban 2-layer (3M Health Care) UrgoK2 (Urgo Medical) |
40 mmHg |
|
|
Inelastic: Zinc oxide impregnated bandage. Econopaste (Hartmann USA Inc.) Viscopaste (Smith & Nephew) |
30 mmHg |
|
|
|
Inelastic Garment/Orthotic |
mediUSA Juxtalite (mediUSA Medical Products) |
Adjustable compression: 20-30 mmHg; 30-40 mmHg; 40-50 mmHg |
|
|
Jobst FarrowWrap (essity) |
30-40 mmHg |
||
|
Tubular Elasticated Bandage |
Tubigrip (Molnlycke Health Care US) |
10-15 mmHg with a double layer. |
|
|
Intermittent Pneumatic Compression |
Hydroven 3 (ArjoHuntleigh) Model SC-2004-OC (Bio Compression Systems, Inc.) Flexitouch Plus (Tactile Medical) |
Can deliver a wide range of compression pressures. |
|
Note . mmHg = millimeters of mercury-a unit of pressure measurement.
a Product names are examples only and are not inclusive or intended as an endorsement.
b Levels of compression (mmHg) can vary in the clinical setting. It is important to follow the manufacturer's directions regarding the use and application technique for specific products in order to achieve the desired level of compression.
| Category | Type | Examples * |
|---|---|---|
| Wraps | Multilayer Long stretch Short stretch Paste** |
Profore (Smith & Nephew), Comprifore (BSN Medical), Dyna-Flex (Systagenix) ACE bandage (3M) Comprilan (BSN Medical), Setopress (Mölnlycke) Gelocast (BSN Medical), Viscopaste (Smith & Nephew), Primer (Derma Sciences) |
| Intermittent Pneumatic Compression Pumps | Tactile Systems Technology Lympha Press Bio Compression Systems, Inc. |
**Use with cohesive bandage
*Not all inclusive
Adapted with permission from Carmel, J. E. (2012). Venous ulcers. In R. A. Bryant & D. P. Nix (Eds.) Acute & chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Elsevier.
| Class | Clinical Signs | |
|---|---|---|
| 0 | No visible or palpable signs of venous disease |  |
| 1 | Telangiectasias or reticular veins |  |
| 2 | Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more or recurrent varicose veins |  |
| 3 | Edema without skin changes |  |
| 4 | Changes in skin and subcutaneous tissue secondary to CVD 4a – Hyperpigmentation or eczema 4b – Lipodermatosclerosis or atrophie blanche 4c – Corona phlebectatica (a fan-shaped pattern of small veins on the medial or lateral aspects of the ankle and foot) |
 |
| 5 | Healed venous ulcer | 
 |
| 6 | Active venous ulcer or recurrent venous ulceration | 
 |
| Special Considerations | |
|---|---|
| Patient with functional limitations |
|
| Patient with atypical shape/size leg |
|
| Patient with limited financial resources |
|
| Non-ambulatory or bedbound patients |
|
| Patients unable to tolerate 30-40 mmHg compression |
|
While it may be true that a patient has a Braden score of less than 18 and a pressure ulcer on the trunk or pelvis, it may not be necessary for them to have a different level of support surface. There are some factors that cannot be reflected on an algorithm and while few, they exist. At those moments, a skilled clinical assessment with critical thinking/decision making is required.
For example, a patient may have a Braden score of 17 and a Stage I or II on their sacrum or trunk but are able to turn side to side so would be able to stay on their current surface. However, if they have a medical condition that prohibits turning to one side (e.g., SOB, cardiac rhythm changes, device in place, etc.), they would need to be moved to a higher-level support surface because they have only one available turning surface.
