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NURSING PR ACTICE & SKILL

Elastic Bandage: Applying

What is an Elastic Bandage?


44 An elastic bandage is a stretchable piece of material that is applied in order to maintain stable pressure to a specific area of a patients body. Elastic bandages are available as long strips that are appropriate for wrapping extremities and, for patients with dependent edema of the extremities, as tubular pull-on stockings. What: Elastic bandages are used for a variety of indications (e.g., compression following mastectomy). The focus of this Nursing Practice & Skill is the application of elastic bandages to the feet and hands How: Application of an elastic bandage is a noninvasive intervention. The role of the nurse includes assessment of the condition of the patients skin in the area of the body to which the bandage will be applied. Evaluation includes examining the area for wounds, drainage, alterations in skin integrity, and any signs and symptoms (e.g., edema, coolness, cyanosis, abnormal pulses) that suggest circulation to the area is compromised evaluating the patient for pain, numbness, and/or tingling in the affected limb applying and monitoring the bandage Elastic bandages applied to an extremity are first wrapped and anchored at the distal part of the affected area of a limb. The bandage strip is stretched slightly and wound around the limb using overlapping turns. Once wrapping is complete, tape or another type of closure is used to secure the end of the strip to the rest of the bandage. Periodic monitoring is performed to evaluate the integrity of the bandage monitoring the condition of the skin under the bandage and the adequacy of circulation to the patients limb distal to the elastic bandage Where: Elastic bandages are used in all healthcare settings and in the home Who: The skills of applying the elastic bandage and monitoring patient status should not be delegated to assistive healthcare staff, because nursing expertise is required to adequately assess the patient and initiate appropriate interventions to reduce risk for adverse patient outcomes. After application of the bandage, however, assistive personnel can monitor and report monitoring findings to the nurse regarding the integrity of the bandage, for changes in temperature or appearance of the bandaged area, and patient reports of pain, numbness, and/or tingling in the area of the dressing. Family members and, in some cases, the patient can apply elastic bandages after appropriate instruction

What is the Desired Outcome of Applying an Elastic Bandage?


44 Elastic bandages exert gentle, firm, and consistent pressure on the soft tissue in a specified area of the body

Why are Elastic Bandages Important?


ICD-9
93.59

Author
Nathalie Smith, RN, MSN, CNP

Reviewers
Darlene A. Strayer, RN, MBA Cinahl Information Systems Glendale, California Nursing Practice Council Glendale Adventist Medical Center Glendale, California

44 The various functions of elastic bandages are to provide tissue compression to reduce the flow of blood and lymphatic fluid to the area in order to reduce pain and swelling of soft tissue at and around an area of traumatic injury (e.g., a joint sprain) hold other bandages in place on wounds in extremities, including amputation stumps stabilize an arm or leg in a splint in order to allow time for tissue swelling to resolve prior to casting promote the return of venous blood in a limb to central circulation in patients with lymphedema or other conditions characterized by diminished venous return maintain cold or hot packs in place on a body part, such as the arm

Facts and Figures


44 Elastic compression bandages have traditionally been used to provide compression to amputation stumps of patients with below-knee amputations. For this indication, compression prevents stump swelling and promotes optimal stump shaping prior to fitting the patient with a leg prosthesis. Several studies have compared the usefulness of rigid, plaster-impregnated dressings with standard elastic compression bandages for this purpose. In an early comparison study involving 15 patients, rigid dressings were significantly more effective than standard elastic compression bandages in shaping the stump. The author concluded that rigid dressings are more effective than elastic compression bandages in providing stump compression in preparation for fitting with a leg prosthesis (Mueller, 1982). Authors of a later literature review comparing findings from 11 controlled clinical trials concluded that rigid dressings outperform elastic bandage compression in promoting optimal stump healing (Nawijn et al., 2005)

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems

December 7, 2012

Published by Cinahl Information Systems. Copyright2012, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

become dumbbell-shaped 44 Removal of saphenous veins during coronary artery bypass graft (CABG) surgery may cause significant lower leg edema and is associated with increased pain, numbness, and delayed healing of the vein removal site. In a study of 255 patients randomized to treatment with compression stockings or elastic bandages after CABG surgery, compression stockings were reported to be significantly more effective in reducing foot edema in the leg from which the vessel was obtained. These findings suggest that compression stockings are more effective than elastic bandages in promoting venous return after CABG, an advantage that may lessen pain and promote healing following CABG (Zohreh et al., 2009) 44 A number of recent controlled clinical trials have compared the use of soft immobilizer splints to traditional casting methods in children with upper extremity fractures. Prior to application of the soft immobilizer splint, the affected extremity was often wrapped in an elastic bandage for compression and support of injured tissue. Authors of a review of literature comparing outcomes of the use of such immobilizer splinting versus casting on resolution of distal tibial fractures found that soft immobilizer splints are equally as effective as plaster casts. The splints were preferred by children and parents because of the ability to remove them prior to bathing (Boutis et al., 2010; Firmin et al., 2009) In addition, children with soft immobilizer splints showed greater improvement in physical functioning and lower pain scores after initial injury compared with children who had casts plaster casts often required more frequent medical visits because of problems such as pain or the need for reapplication of the cast because it got wet. This had economic implications because more money was spent in terms of time and resource management Radiographs taken at 4 weeks of all subjects (both the cast and splint groups) confirmed that all fractures healed comparably well Overall, existing studies suggest that the use of soft immobilizer casts, which often include the use of an underlying elastic bandage, are as effective as the use of plaster casts in supporting the distal tibia and wrist in children during healing, and may offer more cost-effective care

Patients and caretakers involved in the study reported in 1982 identified the following problems with use of elastic bandages (Mueller, 1982): Elastic bandages are less likely to remain secure than plaster-impregnated dressings, especially when patients are in bed Elastic bandages may also provide poor control of edema compared with rigid dressings, cause skin breakdown, and cause the limb stump to

What You Need to Know Before Applying an Elastic Bandage


44 Elastic bandages are also known as ACE bandages, elastic wrap bandages, compression bandages, and roller bandages. They are described as being long stretch or short stretch. When fully stretched, the long-stretch elastic bandages may be up to 36 in (270 cm) long. A shorter elastic bandage (e.g., 18 in [135 cm]) is also available. Elastic bandages are available in various widths, and are secured in place with metal clips, tape, or Velcro fasteners Elastic bandages are frequently applied to reduce the flow of blood and lymphatic fluid to restrict swelling at the site of tissue injury. For this reason, elastic bandages are commonly used to treat muscle sprains and strains Elastic bandages are useful in the treatment and prevention of dependent edema, such as that which occurs in patients with chronic venous insufficiency. In addition to the above effects, elastic bandages can also provide the following therapeutic advantages: Reduction of venous hypertension Stimulation of fibrinolysis Increased local tissue oxygenation 44 By varying the ratio of cotton, polyester, and elastic yarns within a bandage, manufacturers are able to offer various grades of stretchability, compression, and durability in elastic bandages 44 Elastic bandages have historically contained latex for stretchability, but currently other materials are more commonly used because of the increasing incidence of latex allergies among healthcare providers and the general public. Allergic reactions to latex range from mild cutaneous reactions to life-threatening anaphylaxis Some elastic bandages still contain latex; nonlatex-containing elastic bandages use a variety of elastic materials, including woven and knitted cotton and polyester and latex-free elastic yarns. Elastic bandages made of these alternative materials have been shown to provide adequate compression without the use of natural rubber or latex 44 Elastic bandages can be used to provide support to soft tissue and bone during treatment of bone fractures. For this indication, padding is initially applied to the fractured limb to cushion soft tissues and bony prominences, and then a temporary splint is applied. The elastic bandage is applied over the padding and splint to hold the splint in place and protect it Temporary splints are usually removed after swelling of soft tissue decreases. A fiberglass or plaster cast is then applied to the limb to support the bone during healing Rates of healing for uncomplicated long bone fractures are typically 610 weeks for adults and 46 weeks for children. Bone fractures in children heal faster than in adults because normal bone growth in children involves significantly greater osteoblastic activity 44 Preliminary steps that should be performed before applying an elastic bandage include the following: Review facility/unit specific protocol for applying elastic bandages, if one is available Review the treating clinicians order for application of an elastic bandage, noting the indication for the elastic bandage the type, width, and length of elastic bandage prescribed the area of the body ordered to be bandaged Review the patients history/medical record for any allergies (e.g., to latex, medications, or other substances); use alternative materials, as appropriate 44 Gather supplies Nonsterile gloves; additional personal protective equipment (PPE; e.g., eye protection, gown, and mask) may be needed if exposure to body fluids is anticipated A type of elastic bandage that is appropriate to the therapeutic needs of the patient and to the size and shape of the body part to be bandaged

Clips, Velcro, or adhesive tape to secure the bandage. The type of closure chosen depends upon the needs of the patient, manufacturers Facility-approved pain assessment tool
44 44 44 44 instructions, and/or facility protocols; many commercially available elastic bandages include a closure device

3-inch-wide elastic bandages are appropriate for bandaging an adults leg 2-inch-wide elastic bandages are routinely used for an adults wrist

How to Apply an Elastic Bandage


Perform hand hygiene and don nonsterile gloves; don additional PPE if exposure to body fluids is anticipated Identify the patient according to facility protocol Establish privacy by closing the door to the patients room and/or drawing the curtain surrounding the patients bed Introduce yourself to the patient and family member(s), if present; explain your clinical role; assess the coping ability of the patient and family and for knowledge deficits and anxiety regarding the procedure Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs if they are present Use professional certified medical interpreters, either in person or via phone, when language barriers exist Explain the procedure for application of an elastic bandage and its purpose; answer any questions and provide emotional support as needed As appropriate, ask family members and other visitors to leave the patients room in order to promote privacy Assess the patients general health status, including his/her pain level using a facility-approved pain assessment tool Position the patient for privacy, comfort, and accessibility, with the limb to be bandaged in normal functioning position Prior to application of the bandage, observe for the presence of wounds or other breaks in skin integrity, and evaluate the adequacy of circulation to the affected limb Abnormal circulation may be indicated by pallor, cyanosis, excessive redness, and/or coolness of the skin on the affected limb. (For related interventions, see Red Flags, below) If no breaks in skin integrity are assessed, proceed with applying the elastic bandage Apply the elastic bandage appropriately, depending on the indication and intended purpose. The following steps are appropriate for applying an elastic bandage for compression and support to a foot, another proximal area of a limb (e.g., hand, wrist, elbow, knee, calf, or thigh), or an amputation stump (the foot is used as the site in the following example): To prepare for bandaging an extremity with a rolled elastic bandage, place the outer surface of the rolled bandage against the patients skin. Anchoring the loose end of the bandage with one hand, apply the bandage by rolling it around the foot. Use even tension to slightly stretch the bandage during its application Secure the end of the elastic bandage in place by wrapping it twice around the foot Overlap the elastic bandage by one-half to one-third of its width each time you circle the extremity to which the bandage is being applied Leave the heel uncovered After the distal site of the extremity has been wrapped twice, stabilize the secure end of the bandage with your hand and begin wrapping toward the proximal site of the extremity (e.g., toward the ankle) Wrap the bandage in a spiral, making a figure 8 Cross the bandage over the foot, move upward, and pass it behind the ankle Move the bandage down and cross it over the top of the foot Wrap the bandage under the foot to complete the figure 8, and repeat this step one more time to provide compression and support of ankle tissues Pass the bandage around the calf and wrap in circles toward the knee Do not to wrap the bandage too tightly Apply the bandage only to just below the knee To avoid diminishing blood flow to the lower leg, do not wrap the bandage over the calf again Trim the bandage so that the proximal end is aligned just below the knee Fasten the end of the elastic bandage using tape, metal clips, and/or Velcro according to manufacturers instructions and/or facility protocol To avoid damage to the patients skin or soft tissues, do not fasten metal clips on a bandage over a skin fold or skin crease (e.g., under the knee) Assess the patient for pain and other discomfort Dispose of used materials in proper receptacles and perform hand hygiene Update the patients plan of care, if appropriate, and document application of the elastic bandage in the patients medical record, including the following information: Date and time the bandage was applied Description of the procedure Patient assessment findings, such as level of pain skin integrity Patients response to the procedure, including pain/discomfort during and immediately following the application of the bandage Any unexpected patient events or outcomes, interventions performed, and whether or not the treating clinician was notified Patient/family member education, including topics presented, response to education provided/discussed, plan for follow-up education, and details regarding any barriers to communication and/or techniques that promoted successful communication

44 44 44

44

44 44

Other Tests, Treatments, or Procedures That May Be Necessary Before or After Applying an Elastic Bandage
44 After the bandage has been applied, the patients condition and the integrity of the bandage are evaluated at regular intervals according to facility protocols to promote patient safety and comfort and to assess the adequacy of blood flow to the affected limb During initial monitoring, the bandage should be removed at least twice for a few minutes to evaluate the condition of the skin under the bandage At regular intervals, assess skin color and temperature and the adequacy of pulses in the bandaged limb distal to the bandage, and assess for pain

What to Expect After Applying an Elastic Bandage


44 The elastic bandage will apply even, stable pressure to the affected area 44 Signs and symptoms of excessive tissue pressure (for details, see Red Flags, below) will not develop in the area under or distal to the elastic bandage. If signs and symptoms of excessive tissue pressure develop, prompt recognition will lead to rapid and appropriate treatment to resolve the pressure

Red Flags
44 If wounds or other breaks in skin integrity are noted at the site to be bandaged or manifestations of inadequate limb circulation are present, the elastic bandage should not be applied 44 Signs and symptoms indicating that excessive tissue pressure is being exerted on the site by the elastic bandage include patient reports of pain, numbness, and/or tingling under or distal to the elastic bandage blueness, paleness, and/or coolness in the area of the patients limb that is distal to the area where the elastic bandage is wrapped 44 If signs and symptoms of excessive tissue pressure develop, initiate the following: Remove the dressing because the bandage is probably too tight and is compressing muscles and nerves Gently massage the area under and distal to the bandage to relieve the muscle and/or nerve compression and to promote blood circulation Reassess the patient within 5 minutes and replace the dressing if the signs and symptoms have resolved, applying it more loosely to the affected area If the signs and symptoms are unresolved, notify the treating clinician, who will evaluate the patient and initiate appropriate interventions (e.g., discontinuing use of the elastic bandage)

What Do I Need to Tell the Patient/Patients Family?


44 Educate the patient/family about what to expect during and after application of an elastic bandage 44 If the patient is cared for at home or will be discharged to home after the procedure, explain how the family can contact the treating clinician if questions or problems arise 44 Instruct the patient/family about clinical signs and symptoms that may indicate the development of a problem after application of the bandage, and that should be reported immediately to the treating clinician. These signs and symptoms include pain or cramping in the wrapped extremity tingling or numbness that does not resolve after removing the bandage blue, pale, and cold skin around the elastic bandage redness in or distal to the area of the bandage 44 Explain the importance of keeping follow-up medical appointments to allow continued medical surveillance of the patients condition, if appropriate

Note
44 Recent review of the literature has found no updated research evidence on this topic since previous publication on April 29, 2011

References
Boutis, K., Willan, A., Babyn, P., Goeree, R., & Howard, A. (2010). Cast versus splint in children with minimally angulated fractures of the distal radius: A randomized controlled trial. CMAJ, 182(14), 1507-1512. Elastic bandage application. (2012). Lippincotts nursing procedures and skills. Retrieved from http://procedures.lww.com/lnp/view.do?pId=792162&s=p Firmin, F., & Crouch, R. (2009). Splinting versus casting of torus fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): A literature review. Int Emerg Nurs, 17(3), 173-178. Mueller, M. J. (1982). Comparison of removable rigid dressings and elastic bandages in preprosthetic management of patients with below-knee amputations. Physical Therapy, 62(10) 1438-1441. Nawijn, S. E., van der Linde, H., Emmelot, C. H., & Hofstad, C. J. (2005). Stump management after trans-tibial amputation: A systematic review. Prosthetics and Orthotics International, 29(1), 13-26. Zohreh, K., Farah, A. E., Mehrab, M., Abbas, S. O., Alireza, H., Soraya, M., & Soheil, S. (2009). Comparison of compression stocking with elastic bandage in reducing postoperative edema in coronary artery bypass graft patient. Journal of Vascular Nursing, 27(4), 103-106.