The prevention of venous leg ulcer recurrence following ... which comprises about one-third of total body water ... the lower extremities leading to blood pooling.
Clinical practice Clinical innovation: the HOSIERY system for compression assessment
Author: Massimo Rivolo
Correct assessment or reassessment of patients to determine their suitability for compression therapy, and the accurate measurement and selection of garments are essential if compression is to have the desired effect. The HOSIERY system is an acronym that has been developed to aid healthcare professionals and carers choose and apply compression garments or wraps. HOSIERY stands for Holistic assessment, Oedema evaluation, vaScular evaluation, lImb measurement, sElection, Reevaluation, and Yourself. A traffic light system is used within the acronym guidance to act as an alert code, whereby red signifies where hosiery is not indicated, amber signifies where reassessment and monitoring of the patient are required, and green signifies where hosiery is indicated.
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egistered and non-registered healthcare professionals and carers need clear, concise guidance on how to appropriately assess for, choose and apply compression hosiery[1]. For this reason, the author has developed a new aide-memoire using HOSIERY as an acronym in an attempt to make it easier and safer to assess patients, and to choose the right compression garments.
Reasons for compression
Massimo Rivolo is Independent Tissue Viability Nurse Consultant, Eastbourne, UK
Compression garments are widely recognised as an important measure in preventing the recurrence of venous leg ulcers[2]. Compression is also recognised as the cornerstone of longterm management of chronic oedema and is considered a lifelong regimen[3]. The correct choice of compression is a challenge for nurses and they often have difficulty getting patients to comply with long-term use as it requires considerable commitment on behalf of the patient[4]. Poor compliance with compression could be due to inappropriate fabric choice, poor stocking fit, lack of patient understanding, inability to apply hosiery or poor manual dexterity[4]. Compression garments are worn for a number of reasons, including[5]: ■■ The healing of venous leg ulcers ■■ The prevention of venous leg ulcer recurrence following initial healing of the wound ■■ Primary prevention of leg ulcers where varicose veins are present ■■ The prevention of deep vein thrombosis (DVT) ■■ The prevention of complications following DVT
■■ Maintenance of reduction of lymphoedema in the lower leg. Compression is widely recognised as an important aspect of venous eczema and lipodermatosclerosis management. It is also used to manage swelling in the legs associated with pregnancy[1].
The HOSIERY system The HOSIERY system offers a new approach [Figure 1] that provides an aide-memoire to help clinicians assess patients and select appropriate hosiery and other compression systems, such as wraps. It uses the traffic light system (green, amber and red), shown in Table 1, to alert clinicians. Depending on the colour of the item, it is possible to identify whether the patient is suitable for compression, requires reassessment or monitoring, or should not receive compression stockings or devices, as they are not indicated, are unsafe or inappropriate.
Holistic assessment Holistic assessment aims to define whether the patient is suitable for a compression regimen and which underlying condition(s) he/she has. There can be confusion as to which assessment should be carried out before compression stockings are prescribed. Arterial insufficiency needs to be excluded and the condition of the skin checked[6]. It should be considered whether the patient is able to manage compression stockings[6] and whether the nurse understands the causes of oedema[7]. To fully understand the suitability of the patient, past medical and surgical history should be
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Clinicalpractice Practice Clinical
Figure 1. The components of the HOSIERY system. obtained, and limb trauma, skin infection, family history of venous disease or limb swelling, and ankle mobility should be assessed[8]. Wellbeing, quality of life and activities of daily living need to be assessed and addressed[9,10]. Some medications have oedematigeneous effects that can trigger lower-limb oedema. Calcium-channel blockers, such as amlodipine[11], dopamine agonists, such as pramiprexole[12], antidiabetics, such as glitazones[13] and corticosteroids[14] are the most likely medications to be responsible for oedema. Compression is not usually contraindicated when patients take these medications. Neuropathy is a potential contraindication and should be ruled out before the compression garment is applied[2]. Compression therapy with stockings is not advisable while the limb is severely oedematous[15]. Phlegmasia alba and cerulea dolens are two contraindications for compression hosiery as stated in most of the manufacturing companies’ explanations and compression should be avoided. Both are very uncommon consequences of deep venous thrombosis that can cause amputation, which is due to severe oedema resulting in arterial compromise, therefore, compression therapy is not indicated, at least in the first instance.
Oedema evaluation Oedema that has been present for longer than 3 months and is not resolved by elevation, bed rest or diuretics is known as chronic oedema[7]. Total body water is divided between the intracellular and extracellular spaces. The extracellular space, which comprises about one-third of total body water, is composed of the intravascular plasma volume (25%) and the extravascular interstitial space (75%)[16]. Many forces are present in normal
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fluid homeostasis. Those involved in maintaining the intra- and extracellular water balance are the hydrostatic pressures between the intra- and extravascular spaces (also called the pressure gradient), the hydraulic permeability of blood a vessel walls, and the difference in oncotic pressures within the interstitial space and the plasma[17,18]. Oedema can develop as a result of a number of conditions: ■■ Chronic venous insufficiency ■■ Cirrhosis ■■ Cardiac failure ■■ Hypoproteinaemia ■■ Idiopathic or inflammatory processes ■■ Lymphatic impairment (lymphoedema) ■■ Nephrotic syndrome. The term ‘chronic venous insufficiency’ describes a condition that affects the venous system of the lower extremities leading to blood pooling (stasis). It can lead to venous hypertension and cause various pathologies, including pain, swelling, oedema, skin changes and ulceration. Eberhardt and Raffetto (2005)[19] stated: “Although the term chronic venous insufficiency is often used to exclude uncomplicated varicose veins, varicose veins have incompetent valves with increased venous pressure leading to progressive dilation and tortuosity.” Advanced cirrhosis causes salt and water retention. Most of the fluid retention can be found in the peritoneal cavity, known as ascites, but peripheral oedema may appear in the later stages, particularly if severe hypoalbuminaemia is present[20]. One of the central causes of peripheral oedema is congestive cardiac failure. This can trigger a series of humoral and neurohumoral mechanisms causing sodium and water reabsorption by the kidneys with an extracellular fluid expansion[21]. In cardiac failure, an elevation in venous pressure caused by ventricular systolic or diastolic dysfunction increases hydrostatic pressure in the capillaries[20]. Hypoproteinaemia reduces the effective colloid osmotic pressure gradient, which results in increases in the transcapillary fluid flux[22]. Idiopathic or inflammatory oedema is due to fluid retention. It causes swelling of the face, hands, trunk and limbs. It is known to occur in premenopausal women in the absence of cardiac, hepatic or renal disease[23]. Lymphoedema is a chronic, progressive and often debilitating condition caused by organic or functional deficiency of the lymphatic system[24]. Földi and Földi describe lymphoedema as a “chronic inflammatory lymphostatic disease caused by mechanical failure of the lymphatic system,” which
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Clinical practice
Table 1. The HOSIERY system.
Component
Related information/questions
Holistic assessment
■■ No risk factors present ■■ Medical history shows one or more risk factors ■■ No social support ■■ Oedematigeneous medications ■■ Poor mobility/poor hand dexterity ■■ Peripheral neuropathy ■■ Phlegmasia alba and cerulea dolens
Oedema evaluation
Type of oedema (if known): ■■ Inflammatory ■■ Lymphoedema ■■ Venous insufficiency/ dependency ■■ Cardiac ■■ Cirrhosis ■■ Hypoprotinaemic
Plus: ■■ Non-pitting ■■ Pitting ■■ Acute unilateral oedema 0.5–3.5 g/24 hours), hypoalbuminaemia (
