For which of the following patients is the use of an adhesive bandage contraindicated

Bandages

Low-stretch arm or finger bandages are used as a treatment adjunct to maintain edema reduction between treatment sessions. Elastic gauze bandaging, such as Elastomull (BSN Medical, Charlotte, NC) is wrapped on the patient’s hand after lymphatic therapy to decrease colloid pressure in the interstitial space, thus pushing the proteins and the fluid back into the lymphatic system. These bandages are anchored at the wrist and wrapped using a technique that leaves the palm of the hand free for functional use (Fig. 57.10). When properly applied, these wraps allow for full active finger flexion to the distal palmar crease to encourage active muscle pumping. Bandages should not restrict ROM.

Park and coworkers54 evaluated the effect of a modified hand compression bandage in patients with hand edema after burn injury and concluded that it was effective with this population, improving MCP joint ROM, hand circumference, and skin thickness, and that it will be clinically useful for the treatment of patients with edema after burn injury.

Leduc and associates55,56 found that the combination of multilayered bandages on the forearm combined with exercise increased protein absorption by lymphatic capillaries.Figure 57.6 presents a case example that demonstrates the effects of multilayer edema wrapping after MLD in addition to a home program consisting of active exercise in the affected limb.

Kurz57 demonstrated that the flow of lymph within the vessel is best between 22° and 41°C but sharply slows down or stops below and above these temperatures. Bandaging can influence protein absorption by providing light compression and perhaps by providing a buildup of body heat that is within the midrange of ideal temperature to mobilize lymph. Gustafsson58 investigated the effectiveness of compression bandaging from finger to axilla in reducing poststroke edema in the upper extremity using a single-case study (n = 5). The study concluded that the bandaging appears to be effective in reducing edema in the hand and forearm, but return of edema upon removal suggests that further study is warranted.5,58 Also investigated was the difference between the use of low- and high-stretch bandaging of the hand. It was found that both types were effective in reducing poststroke edema, but the edema shifted to the forearm and returned to the hand upon removal of bandages.58 The efficacy of compression gloves in maintaining benefits gained from compression bandaging in the stroke-affected upper limb (n = 4) was also explored. It was found that compression gloves had mixed benefits in managing reductions in edema.59

Inelastic and Short-Stretch Bandages

Bandages with an extensibility close to zero, such as zinc paste (Unna boot) and rigid Velcro-bands like CircAid (CircAid Medical Products, San Diego, CA) or Hydro Boot, (Incappe Inc, Brandon, MS) are examples of completely nonelastic material. Nonelastic bandages must be applied with skill and some knowledge. If light compression is indicated they should be applied without extension of the fabric by molding the material to the leg without tension. When strong compression is indicated completely rigid zinc paste bandages need to be applied with full extension of the material and adjusted to the configuration of the leg. Figure 6.16 shows a bandage applied with zinc paste on the lower leg wrapped over with a short-stretch bandage, and with adhesive bandages over the knee and thigh of a patient with a proximal deep vein thrombosis (DVT).

Short-stretch bandages can be extended 30% to 100% and should be applied with a pressure of more than 50 mmHg on the distal leg if strong compression pressure is indicated. As a result of the immediate removal of edema, this pressure will fall to values that are also well tolerated in the supine position. After a few hours there will be a low to slight resting pressure, but still a high and very effective working pressure. Short-stretch bandages exert little pressure when the calf muscles are relaxed, but prevent expansion in calf diameter when the muscles are contracting during standing and walking (‘high working pressure’). Therefore they are comfortable when patients are recumbent and they act to decrease venous pressure with ambulation.40 The main disadvantage is that they may become loose after a few hours of wear, especially when applied too loosely. In immobile patients, correctly applied short-stretch and inelastic bandages are even more effective than long-stretch material. Even minimal toe movement or passive ankle mobilization performed by physiotherapists will produce a much higher massaging effect compared with elastic material.

Nonelastic bandages made of cotton may be washed and reused. Another category of short-stretch material is the cohesive or adhesive bandage. A cohesive bandage sticks only to itself, and not to skin or hair, whereas an adhesive bandage also sticks to the skin. These bandages cannot be reused after removal.

Stiff bandage material is not easy to handle. Most untrained persons apply inelastic bandages with too low a pressure. To obtain a resting pressure on the distal leg of about 40 mmHg, the initial pressure after application should reach about 60 mmHg. As can be seen from the example in Figure 6.17, the resting pressure in the supine position drops from 70 mmHg to 50 mmHg after 2 hours. This pressure exerted by an inelastic bandage is also well tolerated during nighttime. However, there is less pressure loss in the standing position, so an effective range of pressure values is still maintained after 24 hours (see Fig. 6.17). In the first days after bandage application, the reduction of swelling may be so pronounced that the bandages will get loose and have to be renewed. When edema reduction is stabilized, inelastic bandages may stay on the leg for several days.

A study of elastic minimal-stretch and nonelastic orthoses (CircAid) demonstrated that 4 hours after application, elastic bandages had 94% of their initial pressure, compared with 70% for minimal-stretch and 63% for the nonelastic orthose.91 In the supine position, the decrease at 4 hours was 72% for elastic, 59% for minimal-stretch and 44% for nonelastic compression. One of the advantages of this particular orthosis is the fact that it can be readapted by the patient when it becomes loose (Figs 6.18 and 6.19). Smaller but significant decreases in pressure under short-stretch bandages were also found in studies on changes in pressure with exercising.92,93 Measurement of compression after walking for 3 hours and then again 7 days later showed a decrease in pressure from 80.5 mmHg to 43.6 mmHg after 3 hours and to 26.3 mmHg after 7 days. In this study, Comprilan (Beiersdorf, Germany) with an extensibility of 70% was used.92 In the second study, elastic bandages did not demonstrate a similar degree of compression loss after tip-toe exercise.93 Although the authors speculate that the loss in pressure during exercise may be related to application technique of the short-stretch bandage with a maximum tension of 45% (Compridur; Beiersdorf, Germany), this could also be explained by an immediate volume reduction of the leg as shown in healthy volunteers and in lymphedema patients (Rosidal sys and Rosidal Lymphset; Lohmann & Rauscher, Germany).94

When the bandage becomes loose it should be renewed to prevent refilling of the extremity with edema and to avoid tourniquet effects from the down-gliding compression material. In patients with lymphedema, who are best treated with short-stretch bandages in the initial phase, renewal may be necessary once a day.95

Main indications for inelastic and short-stretch bandages are venous and mixed arteriovenous leg ulcers, DVT, superficial phlebitis, compression after surgery, sclerotherapy or endovenous therapy of varicose veins and lymphedema.

Ankle Wraps and Bandages

There are no data supporting the routine use of ankle wraps for simple sprains, but some pain relief may be afforded by a proper wrap. Some type of temporary immobilization is commonly used in the ED and usually requested and expected by patients. For minor ankle injuries, a simple elastic (Ace) bandage can be applied in a figure-of-eight configuration. Apply the wrap to give only lateral support with minimal compression. It should not be tight enough to impair venous drainage, a common problem when patients apply their own elastic wraps (seeFig. 50.4).

An Unna boot placed over Webril is an alternative to a simple elastic bandage (seeFig. 50.25C). The Unna boot is constructed from a semisolid paste roll that hardens as it dries. Apply an Unna boot in a figure-of-eight configuration, similar to a simple elastic bandage. Once in place, wrap the ankle with roller gauze or an elastic bandage. The entire dressing can be cut off by the patient at home.

INTRODUCTION

Bandage fabrics, which are mostly used outside the human body, are designed to perform a very wide variety of specific functions depending upon the medical requirement. In the simplest form, they may be used to hold the dressing in place over the wound, but most modern bandages and stockings are designed for the treatment and management of specific wounds or diseases, such as post burns hypertrophic scarring, varicose veins, deep vein thrombosis (DVT), venous leg ulcers and many other surgical requirements. The history of bandages can be traced back to the ancient Egyptians who used simple woven fabrics, often coated with adhesives, resins and other medicaments as dressings to aid wound healing. Hippocrates is the first known medical source who described the relationship between venous disorders and leg ulcers (1).

Bandage Contact Lenses for Treatment of Corneal Abrasions

Acute corneal abrasions can cause significant pain, limit function, and result in lost days of work. Several studies have shown that bandage contact lenses are very effective in reducing pain without a requirement for narcotic analgesia, in decreasing time away from work, and in returning to baseline functioning when used for uncomplicated acute corneal abrasions.89–91 Yet bandage contact lenses are seldom used in the ED. An immediate benefit can be gained when the emergency practitioner selectively uses this treatment modality.

2.4.5 Current problems and novel bandages

During the past few years there have been increasing concerns relating to the performance of bandages especially pressure distribution properties for the treatment of venous leg ulcers. This is because the compression therapy is a complex system and requires two or multilayer bandages, and the performance properties of each layer differ from other layers. The widely accepted sustained graduated compression mainly depends on the uniform pressure distribution of different layers of bandages in which textile fibres and bandage structure play a major role. The padding bandages commercially available are nonwovens that are mainly used to distribute the pressure, exerted by the short stretch or compression bandages, evenly around the leg, otherwise higher pressure at any one point not only damages the venous system but also promotes arterial disease. Therefore there is a need to distribute the pressure equally and uniformly at all points of the lower limb and this can be achieved by applying an effective padding layer around the leg beneath the compression bandage. In addition, the padding bandages should have the capability to absorb high pressure created at the tibia and fibula regions. Wadding also helps to protect the vulnerable areas of the leg from generating extremely high pressure levels as compared to those required along the rest of the leg. The research carried out at the University of Bolton involving the ten most commonly used commercial padding bandages produced by major medical companies showed that there are significant variations in properties of commercial padding bandages,73,74 more importantly the commercial bandages do not distribute the pressure evenly at the ankle as well as the calf region (Fig. 2.5).

The integrity of the nonwoven bandages is also of great concern. When pressure is applied using compression bandages, the structure of the nonwoven bandages may collapse and the bandage would not impart cushioning effect to the limb. The comfort and cushioning effect are considered to be essential properties for padding bandages because they stay on the limb for several days.

Twelve padding bandages which consisted of single component fibres, binary blends and tertiary blends incorporating polyester, bicomponent fibres and natural fibres such as cotton and viscose have been designed and developed at the University of Bolton (Table 2.5). The salient properties of the developed bandages are:

Table 2.5. Novel padding bandages

All the developed padding bandages possess suitable bulkiness

None of the bandages has lower tensile strength or breaking extension that hinders the performance characteristics of an ideal padding bandage

The tear resistance of bandages, except 100% hollow viscose (NPB5), is high and this means that the bandage cannot be easily torn by hand after wrapping around the leg. However, making perforations at regular intervals across the bandage facilitates easy tearing

The absorption of solution containing Na+ and Ca2 + ions (artificial blood) is significantly high, irrespective of fibre type and structure

The rate of absorption of all the developed bandages is also high

The pressure distribution of all the novel bandages is good up to 60 mmHg (Fig. 2.6).

In the UK, multilayer compression systems are recommended for the treatment of venous leg ulcers.75 Although multilayer compression bandages are more effective than single-layer bandages in healing venous leg ulcers,76 it is generally agreed by the clinicians that multilayer bandages are too bulky for patients and the cost involved is high. A wide range of compression bandages is available for the treatment of leg ulcers but each of them have different structure and properties and this influences the variation in performance properties of bandages. In addition long stretch compression bandages tend to expand when the calf muscle pump is exercised, and the beneficial effect of the calf muscle pump is dissipated. It is a well established practice that elastic compression bandages that have the extension of up to 200% are applied at 50% extension and at 50% overlap to achieve the desired pressure on the limb. It has always been a problem for nurses to exactly stretch the bandages at 50% and apply without losing the stretch from ankle to calf, although there are indicators for the desired stretch (rectangles become squares) in the bandages. The elastic compression bandages are classified (Table 2.3) according to their ability to produce predetermined levels of compression and this has always been a problem to select the right compression bandage for the treatment. The inelastic short stretch bandage (Type 2) system, which has started to appear on the UK market, has the advantage of applying at full stretch (up to 90% extension) around the limb. The short stretch bandages do not expand when the calf muscle pump is exercised and the force of the muscle is directed back into the leg which promotes venous return. The limitations of short stretch bandages are that a small increase in the volume of the leg will result in a large increase in compression and this means the bandage provides high compression in the upright position and little or no compression in the recumbent position when it is not required. During walking and other exercises the sub-bandage pressure rises steeply and while at rest the pressure comparatively drops. Therefore patients must be mobile to achieve effective compression and exercise is a vital part of this form of compression. Moreover the compression is not intact with skin when reduction in limb swelling because the short stretch bandage is inelastic, and it has already been stretched to its full.

In order to address the above problems, a novel nonwoven vari-stretch compression bandage (NVCB) has been designed and developed at the University of Bolton. The principal features of the NVCB are:74

Novel nonwoven technology was used to develop the variable compression bandages. It should be mentioned that no nonwoven compression bandages are listed in the Drug Tariff. In the UK, the availability of wound dressings and bandages for use in patients’ homes is dictated by the Drug Tariff.

The performance and properties of the novel bandages are superior to existing multiplayer commercial compression bandages. This fulfils the requirement of ideal variable pressure from ankle to below knee positions of the limb for the treatment of venous leg ulcers.

Vari-stretch nonwoven bandages also meet the standards and the tolerances stipulated by BS 7505.77

The application of a multilayer bandage system requires expertise and knowledge. Nurses must undergo significant practise-based training in order to develop appropriate bandage application skills needed for multilayer compression system. Successful bandaging relies upon adopting a good technique in both stretching the bandage to the correct tension and ensuring proper overlap between layers. In addition, nurses need to have knowledge of the different performance properties of each bandage within the multilayer system, and how each bandage combines to achieve safe and adequate compression. The ability of multilayer bandage systems to maintain adequate compression levels for up to one week has reduced the necessity for frequent dressing changes and has therefore, decreased treatment costs. However, the cost of multilayer compression system is still relatively high due to the requirement for a specific bandage for each layer. Tolerance to multilayer compression system is generally good but non-compliance in some patients often results in prolonged or ineffective treatment. Some patients are unable to wear footwear due to the bulkiness of multilayer compression regime. These patients often refuse treatment since the requirement to remain house bound is totally unacceptable. At night patients find compression bandages too uncomfortable and often remove them in order to sleep. Since the application of multilayer compression systems is complex most patients are unable to re-apply the bandages themselves.

CONCLUSIONS

Elastic properties of all bandages decreased as the load applied increased. The most elasticity was obtained by using 1 kgf load. But increasing the load applied, elastic properties of the bandages decreased.

Using 45° yarn directions in stead of + 45° and -45° directions improve the tensile strength of the bandages. Bamboo containing bandages have shown beter tensile strength than other samples.

Fibre types apart from elastomeric yarn do not affect the elastic properties of the bandages.

However, bandages can be produced by using different yarn directions (40°, 60° etc). Different yarn direction might improve the elastic properties of bandages.

Low-Stretch Bandaging

Low-stretch bandages are cotton, nonelastic bandages that have a 20% stretch because of the weave of the bandage. These bandages are rolled on rather than stretched on. Because of the low stretch factor, Dr. Judith Casley-Smith and Dr. John Casley-Smith8 call the bandages “high working, low resting bandages.” When a muscle contracts, it bulks up under the bandages. Because they stretch only 20%, they provide a light counterforce, which is not enough to collapse the initial lymphatics. When the muscle relaxes, the bandages only collapse 20%, again not enough to collapse the initial lymphatics. Thus variation in tissue pressure facilitates lymphatic uptake and prevents refilling of stretched tissue. Research has shown that use of a combination of low-stretch and foam bandages on the forearm, along with exercise, increases protein uptake.26

Low-stretch finger wraps also soften lymph and facilitate lymphatic absorption. (see Fig. 3-6, B, on CD) These are often used when a client's hand is so edematous that it does not fit into an elastic glove. Low-stretch finger wraps are not used to squeeze the edema out, because that would collapse the delicate lymphatic structures. The distal-to-proximal spiral pattern in which the wraps are applied, the neutral warmth maintained by the finger bandages, and the effect of finger movement all soften the indurated tissue, improving lymphatic flow and edema reduction.

Low-Stretch Bandaging

Low-stretch bandages are cotton, nonelastic bandages that have a 20% stretch because of the weave of the bandage. These bandages are rolled on rather than stretched on. When a muscle contracts, it bulks up under the bandages. Because the bandages stretch only 20%, they provide a light counterforce, which is not enough to collapse the initial lymphatics. When the muscle relaxes, the bandages only collapse 20%, again not enough to collapse the initial lymphatics. Thus variation in tissue pressure facilitates lymphatic uptake and prevents refilling of stretched tissue. Research has shown that use of a combination of low-stretch and foam bandages on the forearm, along with exercise, increases protein uptake.36 (See the Evolve website for more information on low-stretch bandaging.)

Low-stretch finger wraps also soften lymph and facilitate lymphatic absorption (see the Evolve website). These are often used when a client’s hand is so edematous that it does not fit into an elastic glove. Low-stretch finger wraps are not used to squeeze the edema out, because that would collapse the delicate lymphatic structures. The distal-to-proximal spiral pattern in which the wraps are applied, the neutral warmth maintained by the finger bandages, and the effect of finger movement all soften the indurated tissue, improving lymphatic flow and edema reduction.

Figure-of-Eight Compression Dressing.

An elasticized bandage is wrapped over a pad placed in the axillary fold and around the shoulder joint in a figure-of-eight fashion to extend and abduct the shoulder. The dressing must be worn continuously, and it is removed only for cleansing. Continuous wearing of the dressing for a period of 3–6 months is necessary to obtain release. The mobility of the joint increases as the scar tissues across the axilla soften. The extent of release may be limited if the scar is thick and unyielding to pressure (Fig. 53.8).