The main indication for a pressure gradient bandage is venous insufficiency, which initially manifests itself in the form oedema and can lead to venous leg ulcers. Causal treatment which, together with the diagnostic work-up for venous leg ulcers falls outside the scope of this booklet, can consist of dietary measures, weight reduction, treatment of cardiac or renal disorders, surgical intervention etc.
Symptomatic/curative therapy aims to improve the muscle pump mechanism in the lower leg and also focuses on wound care.
Muscle pump function can be improved by encouraging the patient to carry out exercises and by applying a pressure gradient bandage. By applying a non-elastic or only slightly elastic roller bandage around the lower leg, the superficial and perforant veins are pressed shut and tissue pressure is increased. This stimulates venous return towards the heart. When the calf muscles are being used (i.e., when walking, moving) the active pressure is high, when lying down the rest pressure is low. For this reason it is notnecessary to remove the bandage at night. For the first two weeks, the compression bandage should be replaced twice a week, and thereafter once a week (at the same time as the ulcer dressing is replaced). The lower leg should be bandaged from the proximal side of the toes up to the knee. The pressure should decrease in a distal to proximal direction (hence the name pressure gradient bandage).
How to Apply a Pressure Gradient Bandage
Material
- Two undyed ideal bandage rolls, 10 cm or 12 cm wide (dyed bandages could, potentially, cause skin irritation).
- Two foam rubber pads (around which a piece of cotton can be wrapped to prevent irritation) or non-absorbent cotton wadding.
- Non-absorbent cotton wadding.
- Tape.
Procedure
Apply this bandage at a time when the oedema is minimal, for example in the morning before the patient gets up. How to care for a venous leg ulcer is described in the section “Contolling bleeding and wound care”.
- Place the foot at a 90° angle.
- Start with two or three circular turns around the forefoot, turning in a lateral to medial direction.
- Fill the retromalleolar spaces with the pads or two plugs of non-absorbent wadding.
- Apply a circular turn around the heel, fixing the foam rubber or non-absorbent cotton wadding [Figure 141].
Figure 141
- Apply a strip of non-absorbent wadding over the tibial crest [Figure 142].
Figure 142
- Make two Figure-of-eight turns distally and proximally to the heel turn [Figure 143].
Figure 143
- Now apply spiral turns towards the knee. Make sure that each turn covers 2/3 of the previous turn and that the pressure decreases in a distal to proximal direction.
- Fix the bandage with strip of leukoplast tape and start with the second bandage, at the point where the previous bandage ended. Continue to apply the bandage in turns going in the opposite direction up to the knee.
- Use up the second bandage by applying circular turns from the knee downwards again, with the pressure increasing in the distal direction [Figure 144].
Figure 144
- Fix the bandages by applying leukoplast along the length of the lower leg and under the sole of the foot to create a ‘stirrup’ [Figure 145].
Figure 145
- Check the colour of the toes: bluish discoloration indicates that the bandage is too tight.
- Encourage the patient to walk.
The pressure gradient bandage has been correctly applied if:
- the heel is fully covered;
- the toes are uncovered and a normal colour;
- there are no wrinkles or creases in the bandage;
- the pressure gradually decreases in the distal to proximal direction and is applied from two different directions (herringbone pattern).
- if the patient experiences a ‘massaging’ pressure when walking.