Which of the following are the correct places to measure a client for knee high anti embolism stockings select all that apply?

Guideline for the care of patients wearing anti embolism stockings

• Summary
• Aims
• Background
• Prescribing Anti-embolism Stockings
• Treatment / Management
• Procedure for fitting the stockings
• Appendix 1 Anti-embolism stockings (AES) risk assessment flowchart
• Appendix 2 Care Plan
• Appendix 3 Nursing Care Standard

Summary

Anti-embolism stockings (AES) are an integral part of VTE prevention and harm free care however they are not appropriate for all patients. Prior to applying AES patients should be assessed to ensure they are suitable candidates. If AES are contraindicated because of co-morbidities, this should be clearly documented and suitable alternatives should be considered.

All staff involved in the ‘application of mechanical thromboprophylaxis including AES’ must have received education on VTE and training on fitting/application of AES.

Back to top

Aims

To ensure that anti-embolism stockings (AES) are prescribed and fitted safely and appropriately.

Back to top

Background

AES, which are also known as Thrombo-Embolism Deterrent Stockings (T.E.D.S) are designed for people whose mobility has been reduced.

When correctly applied AES are a safe therapy that works by assisting venous return by increasing venous blood flow velocity and preventing venous dilation. They can be used on their own or as an adjunct to prophylactic anticoagulant therapy in patients who have been clinically assessed as having a thrombotic risk.

The harm of incorrectly fitted AES outweighs the benefits of VTE prevention (NICE 2010). Recognised hazards include increased pressure ulcers on heels and toes, which can result in tissue necrosis, blisters on the skin, which can lead to infection and leg ulcers, restricted arterial blood flow which in turn leads to limb ischemia and possible amputation.

The purpose of this guideline is to ensure the safe use and appropriate care of patients wearing anti-embolism stockings. This guideline will provide the best practice principles in the use of anti-embolism stockings, a mechanical method of thromboprophylaxis for adult patients.

Back to top

Prescribing Anti-embolism Stockings

Anti-embolism stockings may be prescribed by either medical or non-medical prescribers (following and adhering to current local VTE prophylaxis guidelines).

Caution

1. AES must be prescribed on a prescription chart.
2. For the majority of patients, knee length AES are appropriate (NICE 2010). However in some patients, for example cardiovascular surgical patients, it is more appropriate for thigh length stockings to be applied to avoid compression on the wound (LHP VTE prophylaxis, 2010).

Assessment

Prior to applying AES the health care practitioner should refer to the Anti-embolism Risk Assessment Flowchart (Appendix 1) to identify any :-

Contraindications to anti-embolism stockings
The assessing health care practitioner should be aware of the following conditions, as anti-embolism stockings should not be applied if present.

• Suspected or proven peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
• Allergy to the material of manufacture
• Severe leg oedema
• Major limb deformity or unusual leg size or shape preventing correct fit
• Acute stroke

Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds. (NICE 2010, amended 2018)

If any concerns are observed on assessment, do not apply anti-embolism stockings and seek senior/medical advice.

If AES are contra-indicated, this should be clearly documented and other methods of prophylaxis should be considered.

If a patient is identified as having a higher risk of developing complications from wearing anti embolism stockings, they should be applied and evaluated as per “care plan: application & care for anti-embolism stockings” see appendix 2.
For all other patients the anti-embolism stockings should be applied and evaluated as per “Nursing care standard: Anti-embolism stockings” see appendix 3.

Back to top

Treatment / Management

Equipment
Prior to applying the AES the health care practitioner should ensure that they have the following:-
The anti-embolism risk assessment flow chart, to identify any potential problems from the use of AES (see appendix 1).
The prescription for AES, ensuring the appropriate length of stocking has been prescribed.
Single patient-use tape measure, to measure the patient’s leg as per manufacturers’ guidelines. Single patient-use tape measures can prevent cross infection (Walker & Lamont, 2007).
An Apron, to aid prevention of cross-infection (Doughty and Lister, 2008).
The LTHT “Preventing blood clots (Deep Vein Thrombosis and pulmonary embolism)” patient information leaflet. NICE (2010, updated 2018) recommends that before starting VTE prophylaxis patients and/or their families or carers should be given information on:

• the risks and possible consequences of VTE
• the importance of VTE prophylaxis and its possible side effects
• the correct use of VTE prophylaxis (e.g. anti-embolism stockings)

The health care practitioner should verbally explain the types of viable alternative prophylaxis and also the risks associated with no VTE prophylaxis.

Back to top

Procedure for fitting the stockings

Explaining to the patient
Provide patients with the LTHT “Preventing blood clots (Deep Vein Thrombosis and pulmonary embolism)” patient information leaflet. In addition verbally explain the risk of developing a DVT and that wearing AES may prevent this. This should assist in obtaining patients’ informed consent and promote compliance with the treatment (Dougherty & Lister 2008).

If the patient refuses to wear AES this should be clearly documented in their health records.

Measuring for anti-embolism stockings
It is essential that this guidance is followed accurately to ensure that the patient receives the right size stockings. Bariatric stockings are available for patients whose ankle circumference is greater than 33cm.

As the position of the patient and the time of day may have an effect on the shape and size of the leg, where possible the measurement should be taken early in the morning and the patients should preferably be standing, or lying down. Gravity and muscular action deform the legs natural resting shape when the patient is in a sitting position and so could potentially provide incorrect measurement information. Furthermore it is easier to apply the stockings whilst the patient is lying down (Walker & Lamont, 2007).

Perform hand hygiene and put on apron prior to the procedure, to aid prevention of cross-infection (Doughty and Lister, 2008).

Expose the patients’ legs by removing all socks, stockings and pyjama bottoms (the latter is only necessary if applying thigh-length stockings). Measurements obtained over clothing could lead to the patient receiving the wrong size stockings (Walker & Lamont, 2007). Maintain the patient’s dignity throughout.

Using the single patient-use tape measure:

• Measure both of the patients’ legs according to the manufacturer’s guidelines. Each manufacturer may require that measurements are taken from different parts of the limb. (Walker & Lamont, 2007).
• The size of the patients’ legs may vary and the patient may need two different sizes of stocking to be fitted to ensure the correct fit on each leg.
• Optimum therapeutic value is dependent upon well fitting stockings. Incorrect sizing causes swelling and bruising to ankles and can constrict blood supply leading to long term complications (Doughty and Lister, 2008).
• Record in the patients’ health records; patient’s leg measurements, type and size of stocking and date stockings applied. This provides a comparison benchmark for reassessing staff. (A change in patient’s leg size can indicate that there may be some underlying physical or medical problem (Walker & Lamont, 2007)).
• If a patient complains that the stockings are too tight and causing pain, the stockings must be removed immediately, leg resized and skin checks performed for signs of limb ischemia.

Applying the anti-embolism stockings

After selecting the correct size stockings, show the patient how to put them on.

3. Place foot into the opening you made. Make sure that the heel is correctly fitted	4. Ease the stocking over the rest of the leg

• Insert hand into the stocking as far as the heel pocket.
• Grasp centre of heel pocket and turn the stocking inside out to heel area.
• Position the stocking over the foot and heel ensuring the patient’s heel is located in the heel pocket.
• Begin pulling body of stocking up around the ankle and calf.
• Pull the stocking up the rest of the leg.
• Smooth out any excess material.
• Pull toe section forward to smooth the ankle and instep area and allow for patient toe comfort.
• For knee length stockings ensure the top of stocking is about two finger’s width below the crease of the knee.
• For thigh length stockings ensure the gusset is over the inner thigh.

To make application easier ensure the patients’ feet and legs are dry. If the legs are sticky, putting a little talcum powder on the palms and dusting the legs helps the stockings slide on (Kahn, 2009). Remember to check with patient prior to use for any allergy/sensitivity to talcum powder.

Patients should be advised

1. How to apply and remove the AES and ensure they understand they will reduce the risk of VTE.
2. To smooth out any wrinkles otherwise they will dig into the skin underneath and cause tissue damage.
3. Not to turn/roll down the top of the stockings, as this will create a tourniquet effect.
4. To inform nursing staff if they experience tingling, numbness, coldness, pain or swelling as this indicates the stockings are too tight
5. Stockings should be worn for twenty four hours a day unless otherwise instructed.

Help the patient to redress and put on their slippers, if required. Stockings are slippery if worn without footwear. To prevent falls, advise the patient to wear slippers or foot wear whenever they are mobile.

After the first application of AES the limbs should be checked after 30 minutes. This check should consist of a nail bed capillary refill test to check circulation. If any redness is present a blanch test should be performed. If the nail bed does not return to pink after 5 seconds, if blanching does not occur in less than 2 seconds, and/or if the patient complains of pain/cramps, the stockings should be removed, leg measurements and stockings size rechecked and medical staff informed. 

Daily care of patient wearing anti-embolism stockings

Stockings should be removed daily for hygiene purposes and to inspect skin condition. In people with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin 2 or 3 times a day particularly over the heels and bony prominences (NICE 2010). Document inspections in the patients’ health records. Discontinue the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences or if the patient experiences pain or discomfort. If suitable, offer intermittent pneumatic compression as an alternative (NICE 2010, amended 2018)

Ensure that people who develop oedema or post-operative swelling have their legs re-measured and anti-embolism stockings refitted (NICE 2010). An increase in leg diameter of 5cm can double the pressure applied by the stocking and create a tourniquet effect. If the size in the leg decreases in circumference the stocking will become too loose and will be ineffective (Walker & Lamont, 2007).

Check that the stockings fit smoothly, i.e. not wrinkled or rolled down, and there is no pain or discomfort. This is to ensure the stockings are not causing damage underneath. To provide evidence of care, document that you have checked the AES in the patients’ notes.

To prevent constriction of blood supply and swelling, advise patients against crossing their legs or ankles (Doughty and Lister, 2008).

When to change the stockings whilst in hospital
Legs should be re-measured every third day and clean stockings should be applied or earlier if the stockings are soiled.
Launder as per manufacturer’s instructions.
If there is any evidence of swelling or oedema re-measure the legs and report to the medical team.

Discontinuing Anti-embolism stockings
Patients should wear AES day and night until they no longer have significantly reduced mobility (NICE 2010). Immobility has been defined as “patients who are bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair” (LHP VTE prophylaxis, 2010). Document when the stockings are discontinued on the VTE care plan.

Discharge care of patient with anti-embolism stockings
Ensure that patients who are discharged with anti-embolism stockings:

• Understand the benefits of wearing stockings & the importance of wearing them correctly
• Understand the need to remove them daily for hygiene purposes
• Are able to remove and replace them, or have someone available who will do this for them
• Are aware of the signs of skin damage such as skin marking, blistering or discolouration, particularly over the heels and bony prominences and understand that anti-embolism stocking should be discontinued if any of these signs are evident
• Understand that stockings should be worn day and night, while mobility is reduced.
• Understand that stockings should be laundered as per manufacturer’s instructions.
• Know when to stop wearing them
• Are aware of the signs and symptoms of DVT and PE
• Are given a copy of the LTHT “Preventing blood clots (Deep Vein Thrombosis and pulmonary embolism)” patient information leaflet.
• Know who to contact if there is a problem.

Anti-embolism stockings are not available on prescription in the community; therefore the patient must be discharged with enough stockings for the duration of their planned treatment. As a rough guide, Saphena anti-embolism stockings should be replaced after 16 washes, therefore, if the stockings are washed daily, 2 pairs would last for about 1 month.

Inform the patients GP if they have been discharged home with AES. (NICE 2010, updated 2018)

Back to top

Appendix 1

Back to top

Appendix 2

Back to top

Appendix 3

Nursing Care Standard: Anti-embolism stockings (AES)
References: Dougherty L., and Lister S. (2008) “The Royal Marsden Hospital Manual of Clinical Nursing Procedures”
NICE (2010) “Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital”
LTHT Trust Guidelines for the care of patients wearing anti-embolic stockings.

Patients who require anti-embolic stockings
On admission

• Follow the AES flowchart to identify patients who AES may be contra-indicated or more hazardous.
• Inform patient of the need to wear AES and provide information leaflet
• Document if the patient refuses to wear the AES and why. Inform medical staff to assess for alternative thromboprophylaxis
• Ask the patient to lie down, then measure each leg as per manufacturer’s instructions and document on the drug chart
• Select correct size of stockings as per manufacturer’s instructions and document
• Show the patient, and/or, how to put them on
• Check both limbs 30 minutes after initial application for any tissue redness/damage and tissue perfusion

Every shift/8 hours

• Check the stockings are in the correct position (i.e not rolled down, no wrinkles) and there is no pain or discomfort.

Every day

• Assess if the patient is sufficiently mobile to discontinue the AES
• Document when the AES are discontinued
• In order to provide skin hygiene and to observe for skin damage and circulation, stockings should be removed daily, but for no more than 30 minutes
• Sign the AES box on the drug chart to indicate no problems were observed.
• Assess whether patient is able to manage AES stockings independently
• For patients who the nurse is managing the AES
  Pat the legs and feet dry, paying attention to the ankles and between the toes
  If skin is prone to dryness, apply a non-greasy moisturizer, such as Aqueous cream, in a down ward direction
  Assess skin for marks, blisters, skin changes. If any such changes are noted, discontinue with AES, and inform medical staff, commence a pressure ulcer prevention care plan.
• If a change in leg size is observed (AES become looser/tighter) re-measure and change the stockings

Every three days

• New stockings should be applied every three days or sooner if soiled

On discharge

• Complete anti emboli stockings discharge checklist
• Patients should not be discharged with AES unless medically indicated

Provide enough AES for the length of time the patient is expected to wear the stockings for (minimum of 2 pairs).

Dougherty L., and Lister S. (2008) “The Royal Marsden Hospital Manual of Clinical Nursing Procedures” Wiley-Blackwell, Oxford.

Kahn S. R (2009) “How I treat post-thrombotic syndrome” Blood, 19 Nov., Vol.114, No. 21.

Leeds Health Pathways (2010) “Leeds Venous Thromboembolism Resource Page: Reducing the risk in patients admitted to the hospital” http://nww.lhp.leedsth.nhs.uk/VTE/index.aspx

NICE (2010) “Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital”, NICE guidelines CG92, published January 2010

NICE (2018) “Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism “, NICE guideline [NG89] Published March 2018

Walker L. & Lamont S. (2007) “Use and application of graduate compression stockings”, Nursing Standard, June 27, vol. 21, no 42.

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.

Where do you measure for compression stockings?

What does the nurse instruct the patient when applying anti embolism stockings?