Wound, Ostomy and Continence Nurses Society™

Compression for Primary Prevention, Treatment and Prevention of Recurrence of

Venous Leg Ulcers

An Evidence- and Consensus-based Algorithm for Care Across the Continuum

Get Started

Funded through an unrestricted educational grant from JOBST/BSN medical:

An Evidence- and Consensus-based Algorithm

Compression therapy is the cornerstone of treatment for CVI. Compression has been shown to improve healing rates in patients with existing venous leg ulcers (VLU) and reduce the likelihood of VLU recurrence. In an effort to customize compression therapy for each individual with CVI, the Wound, Ostomy and Continence Nurses Society™ (WOCN®) set out to develop an evidence- and consensus-based algorithm on Compression for Primary Prevention, Treatment and Prevention of Recurrence of Venous Leg Ulcers. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article.

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.

Clinical Assessment of Lower Extremities

Health History

triggers (e.g., injury to leg, cellulitis, dry skin with itching, etc.)
risk factors (e.g., family history, previous deep vein thrombosis, surgery/trauma to leg, etc.)
comorbid conditions (e.g., obesity, impairment of calf muscle pump, varicose veins, sickle cell disease, etc.)

Physical assessment:

Examination of both lower extremities noting condition of the skin, hemosiderosis, ankle range of motion and calf muscle strength, functional mobility, extent and location of edema, superficial vascular changes, presence of any wounds, capillary refill < 2 seconds and palpation of pulses.

Obtain appropriate studies such as Ankle Brachial Index (ABI)/Ankle Brachial Pressure Index (ABPI) to exclude significant arterial disease. Refer to ABI Procedure and Value Table.

* ABI Procedure and Value Table

Conduct differential diagnosis (Refer to LEVD Appendices C: Differences between Edema, Lymphedema, & Lipedema and D: Venous Eczema and Cellulitis located in WOCN Society Guideline for Lower-Extremity Venous Disease [2011]) Refer to Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide (2017)

* Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide

* WOCN Society Guideline for Lower-Extremity Venous Disease: Appendix C: Differences between Edema, Lymphedema, & Lipedema and Appendix D: Venous Eczema and Cellulitis

What do your findings indicate?

Chronic venous insufficiency

Disease or wound of other etiology (e.g., lymphedema, lipedema, arterial, or neuropathic)

Refer to WOCN Society document: Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide

*2017 WOCN Society document: Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide

Refer to CEAP table to determine severity of chronic venous insufficiency

* Refer to CEAP table

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

Educate patient and family about lifestyle factors that promote leg health including

effects of smoking, advise smoking cessation
following healthy nutrition practices such as weight management
avoiding mechanical trauma to leg
avoiding crossing legs, prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
avoiding wearing high heels.

Manage Signs/Symptoms per Facility Protocol OR Clinical Guideline

Here is your result

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).

Test again

Determine need for compression based on symptoms (i.e., burning, itching, heaviness, aching, or pain)

Compression is needed

Compression is not needed

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 Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Evidence of prior deep vein thrombosis

No evidence of prior deep vein thrombosis

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
extremity elevation
prevention of trauma
appropriate footwear (e.g., avoid high heels)
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis

Here is your result

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).

Test again

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.

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
extremity elevation
prevention of trauma
appropriate footwear (e.g., avoid high heels)
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of compression stockings/devices

Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.

Refer to ABI/ABPI

If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.

In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.

If ABI/ABPI < 0.5 or > 1.3, do not use compression.

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding leg elevation
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
appropriate footwear
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

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).

Test again

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 Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Evidence of prior deep vein thrombosis

No evidence of prior deep vein thrombosis

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.

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
extremity elevation
prevention of trauma
appropriate footwear (e.g. avoid high heels)
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of compression stockings/devices
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.

Here is your result

Test again

Refer to ABI/ABPI

If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.

In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.

If ABI/ABPI < 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:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Consider use of pentoxifylline (Trental) to enhance microcirculation and prevent recurrence. (Refer to Pharmaceuticals Table)

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
extremity elevation
appropriate footwear (e.g. avoid high heels)
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of lifelong compression stockings/devices
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.

Here is your result

Test again

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
extremity elevation
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
appropriate footwear
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

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).

Test again

Consider principles of wound bed preparation prior to selection of topical therapy.

Apply emollients to intact skin underneath compression to prevent occurrence of dermatitis.

Refer to ABI/ABPI

If ABI/ABPI < 0.5 or > 1.3, do not use 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.

If ABI ≥ 0.8 or greater, proceed to 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:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding leg elevation
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
appropriate footwear
wound care management
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

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).

Test again

Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.

Educate patient and family about:

effects of smoking, advise smoking cessation
avoiding mechanical trauma to leg
avoiding prolonged sitting or standing
exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
extremity elevation
appropriate footwear (e.g. avoid high heels)
nutrition, weight management
use of non-sensitizing emollients to prevent dermatitis
use of lifelong compression stockings/devices
wound care and compression management
use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

If the wound fails to improve or deteriorates, evaluate for barriers to healing.

If treatment is effective, continue current therapy until healed

Here is your result

Proceed to the CEAP 5 section of the algorithm.

Test again

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.

Here is your result

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).

Test again

Pharmaceuticals Table

Pharmaceuticals	Uses	Dose	Reference
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 Syst Rev. 2012 Nov 14
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 Table

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.

Compression Therapies

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

Inelastic Compression

Short-stretch - Comprilan (BSN medical), Coban 2 (3M), Rosidal K (Lohmann & Rauscher), Farrow Wrap (Farrow Medical)

Unna’s boot paste- Gelocast (BSN medical),
Primer (DermaSciences)
Duke boot

CircAid legging (mediUSA)

23-40 mmHg

20-30 mmHg light;
30-40 mmHg regular
Zinc oxide impregnated bandage often with calamine (plus cohesive bandage)

Static compression device

Inelastic Compression

Short-stretch - Comprilan (BSN medical), Coban 2 (3M), Rosidal K (Lohmann & Rauscher), Farrow Wrap (Farrow Medical)	23-40 mmHg
Unna’s boot paste- Gelocast (BSN medical), Primer (DermaSciences) Duke boot	20-30 mmHg light; 30-40 mmHg regular Zinc oxide impregnated bandage often with calamine (plus cohesive bandage)
CircAid legging (mediUSA)	Static compression device

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.

Compression Stocking Classifications

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

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: O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265; Partsch, H., Clark, M., Mosti, G., et al. (2008). Classification of compression bandages: Practical aspects. Dermatologic Surgery, 34(5), 600-609.

Formulary of Compression Therapy Products

Clinical Classification of CVI Using
The CEAP Classification
(Clinical, Etiology, Anatomy, Pathophysiology)

Class	Clinical Signs
0	No visible or palpable signs of venous disease
1	Teleangiectases, reticular veins, malleolar flare
2	Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more
3	Edema without skin changes
4	Skin changes ascribed to venous disease 4a – hyperpigmentation 4c – lipodermatosclerosis 4b – venous eczema 4d – atrophie blanche
5	Skin changes (as defined above) in conjunction with healed ulceration
6	Skin changes (as defined above) in conjunction with active ulceration

Special Considerations Table

Special Considerations
All Patients	Use standardized methods when measuring for compression stockings Apply compression wraps from metatarsal head to tibial tubercle, including the heel Assess and monitor pain and circulatory status while using compression
Patient/Caregiver with functional limitations	Use donning/doffing devices Use alternative compression device (not a stocking) Use compression wraps ongoing Refer to rehabilitation services to address limitations
Patient with atypical shape/size leg	Use modified compression Refer to a qualified fitter for custom stockings or garment Use intermittent pneumatic compression device
Patient with limited financial resources	Use reusable wrap products Use reusable garments Use intermittent pneumatic compression device
Non-ambulatory or bedbound patients	Use elastic bandages
Patients unable to tolerate 30-40 mmHg compression	Use lower level of compression to enhance adherence

Critical thinking point:

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.

Compression for Primary Prevention, Treatment and Prevention of Recurrence of

Venous Leg Ulcers

An Evidence- and Consensus-based Algorithm for Care Across the Continuum

Funded through an unrestricted educational grant from JOBST/BSN medical:

An Evidence- and Consensus-based Algorithm

Clinical Assessment of Lower Extremities

Health History

Physical assessment:

Educate patient and family about lifestyle factors that promote leg health including

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family/caregiver about:

Educate patient and family about:

Pharmaceuticals Table

ABI Table

Compression Therapies

Compression Stocking Classifications

Formulary of Compression Therapy Products

Clinical Classification of CVI Using The CEAP Classification (Clinical, Etiology, Anatomy, Pathophysiology)

Special Considerations Table

Critical thinking point:

Clinical Classification of CVI Using
The CEAP Classification
(Clinical, Etiology, Anatomy, Pathophysiology)