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422 LIFELONG MANAGEMENT
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Off- the- Shelf Hosiery
This type of hosiery is simpler in terms of the amount of measurements required, but it remains vital that correct measurements are
taken to ensure the person receives eective and tolerable maintenance therapy. Again the practitioner must ensure t of the hosiery
and that the patient can don and do the hosiery correctly.
Measurement
Whether using o- the- shelf or made- to- measure garments, once
the type of product has been selected, accurate measurement of the
limb needs to take place and be documented correctly to ensure
that the garment will t properly and provide therapeutic levels of
compression. The practitioner needs to ensure that they have the
correct measurement chart for the garments and manufacturer and
as the points of measurement vary by manufacturer, the practitioner needs to be condent in the measurement of limbs to prescribe the correct garment. The measurement should be entered
into the patient record for reference and another copy be kept with
the order/prescription for the garment. Measurement should ideally
be taken in the morning, immediately after removal of compression
bandaging, or after a period of limb elevation to ensure optimum t
(Wounds UK2021).
Tips for hosiery measurement include the following (Wounds
UK2021):
Take measurements as early in the morning as possible when
oedema is at a minimum.
Take measurements directly against the skin to ensure accuracy
(use a skin marker to ensure reproducibility and accuracy).
Take measurements for both legs, as they may dier.
Take measurements when the patient is sitting down, with their
feet at on the oor.
Use the correct and current measuring guide for the brand of
hosiery to be prescribed, as each manufacturer will dier.
If the patient has skin folds due to oedema, or the limb is particu-
larly misshapen, a specialist at- knit garment and therefore
referral for specialist assessment may be required for limb reduction prior to the application of a compression garment.
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TABLE9.6
Measuring site
Top of thigh Y
Thickest part of the calf Y Y
Narrowest part of the leg above the ankle Y Y
Length from heel base to top of calf Y Y
Foot length from toe to heel (if closed toe) Y Y
Location forleg measurement forleg compression hosiery.
Hosiery type
Below knee Thigh length
If the patient feels uncomfortable or embarrassed when having
their legs measured, try to make them feel at ease by:
Taking the measurements in a private area.
Explaining how you are going to measure their legs before you
start, including how far up the leg you will need to measure for
thigh- length hosiery and answer any questions the
patient may have.
Explain why it is important to get the right size of hosiery so
that it works properly.
Explain to the patient what you are doing at each stage.
Across dierent brands of made-
to- measure and o- the- shelf
garments dierent measurements are needed and thus it may be necessary for practitioners to access products available on their local
wound care formularies. Table9.6 oers a broad overview of some of
the measurements required and Figure 9.1 illustrates the sites for
measurement.
OTHER CONSIDERATIONS WHEN CHOOSING
A COMPRESSION THERAPY SYSTEM
When assessing the patient during the limb assessment, the whole
leg should be examined, not just the lower limb, for oedema in knee
and thigh. Examination of the whole limb is recommended as varicose veins in the thigh will give an indication of the length of hosiery
that will be required.
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424 LIFELONG MANAGEMENT
ence
Fo
ence
Foot length
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Thigh and
panty
length
Thigh circumfer
Knee high
length
ot measurement
and length
Calf circumference
Ankle circumfer
FIGURE 9.1 Sites to measure limb circumference for compression hosiery.
Thigh Length or Knee Length?
Compression therapy is likely to be lifelong so the patient’s tolerance
of the garment is important. The choice of length of hosiery should
be based on patient choice, but also on the clinical presentation
of the limb.
Below- knee compression hosiery is recommended:
To prevent reoccurrence of venous leg ulceration in patients
where leg ulceration healing has been achieved.
When the swelling is limited to the lower leg, or if use of thigh
length is not possible or desirable.
Consider thigh- length hosiery in people with severe varicose
veins above the knee or who have swelling that extends above the
knee (NICE2022).
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Open or Closed Toe?
There are a few other considerations to consider when deciding
whether a patient should have open- or closed- toe garments. The
healthcare practitioner should be able to guide the patient in making
this decision. Assessment of the patient’s gait should also be considered to ensure patients are picking up their feet correctly, as if this is
not being done it can push the hosiery up the foot, which can lead to
tissue damage or oedema in the toes or dorsum of the foot.
People may require open- toed garments for several reasons:
The patient has arthritic or clawed toes.
The patient has a fungal infection or is prone to fungal infections
of the toes and interdigital spaces such as athlete’s foot/tinea pedis.
The patient prefers to wear a sock over the hosiery.
The patient has a long foot compared to the size of the calf (some
garments do have a longer foot option).
The patient requires regular podiatry/chiropodist appointments.
There is no oedema present in the toes and the patient prefers
open- toed hosiery (NICE2021).
Contraindications forStockings, Garments andHosiery
Compression stockings/garments and hosiery should not be oered
to patients who have any of the following red(NICE2022; Wounds UK2021; National Wound Care Strategy2020):
Symptoms of sepsis.
Acute or chronic limb- threatening ischaemia.
Suspected or proven peripheral arterial disease.
Peripheral arterial bypass grafting.
Peripheral neuropathy or other causes of sensory impairment.
Any local conditions in which compression stockings may cause
damage (for example fragile skin, dermatitis, gangrene or recent
skin graft).
Known allergy to the material of the stockings/hosiery.
Severe leg oedema.
Major limb deformity or unusual leg size or shape preventing
correct t.
Acute infection of the leg or foot (increasing unilateral redness,
swelling, pain, pus, heat).
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ag symptoms
426 LIFELONG MANAGEMENT
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Suspected acute deep vein thrombosis.
Suspected skin cancer.
Onward referral to the vascular team, dermatology or a tissue
viability nurse should be considered for these patients.
Fitting andCare ofHosiery
Once the measurements have been taken and the hosiery garment
ordered, the healthcare professional should ensure that the garment
is well tting on the rst application. The patient should have a further appointment for an application and tting check. This may take
time and the patient should be given the opportunity to practise this
new skill until they are condent in donning and dong the hosiery.
Patients should not be given a prescription under the assumption
that they can check and ensure correct tting of the garment unless
they have had the same hosiery previously and the healthcare professional is condent in the patient’s application technique.
Table9.7 is a guide to good t, which could be given to patients
as an aide mémoire.
Patients need to understand how to care for their hosiery to
ensure that it has the maximum life expectancy for the garment and
should be given hints and tips and shown how to apply the hosiery
correctly. The healthcare professional should support the patient
TABLE 9.7
Hosiery should t well and not feel too loose.
Hosiery should not be twisted, rolled, creased or folded down.
Hosiery should sit two ngers’ width below the knee crease, or four ngers’
width below the gluteal fold in thighThe fabric should be evenly distributed over the length of the garment.
Hosiery should not pinch the skin or cause pain.
If numbness or pain occurs while wearing medical compression, the hosiery
should be removed and reported to the clinician who prescribed it for review.
The patient should be given the information to remove the hosiery and seek
advice from there healthcare professional.
Hosiery should not cause shortness of breath. If this occurs, remove the
compression and seek medical review of the patient.
Source: Adapted from Wounds UK (2021).
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Quick guide forgood medical compression hosiery t.
length garments.
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until they are condent in the application and removal of their
hosiery garment independently. Information should also be provided
in written form so that the patient can refer to it if needed (see
Table9.8 for a suggested check list).
The healthcare practitioner should prescribe at least two pairs of
hosiery (one for wearing and one for washing) and ideally provision
TABLE 9.8
Do Don’t
Take care when donning and
removing hosiery over areas of hard
skin that can damage the garment
or while wearing jewellery. Ensure
that the hosiery is smooth and free
of creases. Wearing gloves can help.
Hosiery should be tted well and
not loose. Hosiery should sit two
ngers below the back of the knee
or four ngers below the thigh
(gluteal fold). Hosiery should be
evenly distributed along the limb
with no gathered areas.
Ensure legs are dry before putting on
hosiery, to protect the skin and
garment integrity. If the skin is
fully intact and in good condition,
consider patting the legs dry to
absorb excess moisture prior to
application of the hosiery.
Speak to the GP, nurse or a pharma-
cist or other relevant specialist if
compression hosiery is not tting
well, has laddered or has holes in it.
Follow the manufacturer’s instruc-
tions for washing and care of
hosiery. Note: some garments can
go in a normal machine wash cycle
at lower temperatures, although
the label may say hand wash.
Dos anddon’ts ofcompression hosiery.
Do not roll, twist or fold down
compression stockings during
wear, it hampers circulation and
increases the risk of a blood clot
and cause damage to the skin.
Avoid applying emollients (e.g.
lotions or creams) just before
application of hosiery, as it could
make the garment harder to put
on, allow the emollient to be
absorbed prior to application.
Do not cut holes into the elastic or
holdhosiery, these can cause them not
to work as eciently.
Do not cut the feet o the hosiery–
discuss options with the GP, nurse
or pharmacist or other relevant
specialist.
up bands of the compression
(Continued)
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428 LIFELONG MANAGEMENT
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TABLE9.8 (Continued)
Do Don’t
Air- dry hosiery to maintain elasticity
unless stated otherwise. Check
manufactures guidelines.
If applying or removing compression
hosiery is too dicult, speak to the
GP, nurse, pharmacist or health-
care professional about being
prescribed a new application aid.
See table 9.10. Patient many also
benet from a further tting
appointment to gain tips of
application with or without an aid.
If there is new numbness to the toes,
remove the hosiery and inform the
GP or practitioner who tted the
hosiery as soon as possible.
Hosiery should not cause short-
ness of breath if it does removed
immediately and seek imme-
diate help.
Important: See the GP immediately if
the leg suddenly swells, there is
redness or warmth of the skin,
new numbness or tingling in the
toes, fatigue in the leg or pain that
increases when standing or
walking. These are potential signs
of life-
threatening blood clots or
localised cellulitis infection,
removal of the hosiery is necessary
and seek urgent medical help.
Do not wear compression stockings
while sleeping unless specically
advised otherwise by a healthcare
professional. Hosiery should be
re-applied when walking or
straight after a shower.
Do not wear larger- sized compres-
sion hosiery without speaking to
the GP, nurse, pharmacist or other
relevant specialist about alternate options.
Do not buy extra pairs of compres-
sion hosiery o prescription
unless you have been advised to
do so by the relevant practitioner.
Do not double-
hosiery unless specically advised
to by a healthcare professional.
Do not wear compression hosiery
that has been prescribed for
someone else.
Do not keep old hosiery after new
pairs have been prescribed, to
avoid wearing over- stretched or
ill- tting garments.
layer compression
Source: Adapted from Wounds UK (2015).
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of a third pair is advocated every three to six months with a reassessment prior to the next prescription. This will ensure the eectiveness
of the garment (NICE2022).
Application Aids
The patient’s physical ability and dexterity need to be assessed when
treatment planning for patients, as the correct application of hosiery
is key to the success of the garment. There is also a risk of trauma
caused by poor application technique. Healthcare professionals need
to ensure that the patient is condent and safe in the application of
the garment and that no further trauma is caused to the limb.
There is a vast number of aids that patients can have to help with
application of compression therapy (Table 9.9). They are generally
either fabric or rigid. A fabric aid is normally made of material that is
slippery and therefore aids in the application of the hosiery over the
heel and then guides the hosiery up the leg; with this type of application aid the patient still needs to be able to bend to reach their feet.
The rigid aids typically provide a frame that the patient applies the
hosiery garment to and then steps into. This enables the patient to
put the garment on without having to bend (Dilks and Green2005).
However, there is a potential risk of trauma to the limb from a rigid
device if care is not taken.
Other options available include roll- on membranes and non- slip
mats. Patients can also wear rubber gloves with a soft interior lining,
which can help in the application of compression hosiery
(Wounds UK2021).
Patient Education andPromoting Self- care
Patients need to have enough information and education to ensure
that they understand the reasons for the treatment prescribed and
the benets to them, as well as support and tools to facilitate self- care
on going. Patients can also reduce their risk of recurrent leg ulcers by
adhering to the following recommendations (Venables 2015;
Wounds UK2021):
Understanding why they have been prescribed the hosiery and
understanding the underlying condition.
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TABLE 9.9 Main examples ofhosiery application aids – (BPS-Compression Hosiery: A patient - centric approach,
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2021). Health care professionals who prescribe hosiery should be know which aids are available on prescription to help
their patients with donning and dong hosiery.
Fabric applicators Rigid applicators Miscellaneous
Fabric applicators work similarly
to slide sheets. They are made
of slippery material to assist
with the application of hosiery
therefore helping the hosiery
over the heel. They can be
used for open- toe and
toe hosiery, and are
closedcompactable and
transportable.
Source: Adapted from Wounds UK (2021).
Rigid applicators often consist of a
frame with a semiassist with the opening of
compression stockings to allow
easier application. These types of
frames typically have long handle
options and may assist those who
have diculty bending forward to
reach their foot. Measurement of
the ankle is required to ensure the
limb ts in the frame correctly.
circular tube to
Anti- slip mats can aid in the application and
removal of hosiery.
Rubber gloves with soft interior linings help
during the application and removal of all types
of compression stockings.
Roll- on adhesives helps the hosiery ‘stick’ to the
limb and can be washed o with water.
Rolling compression aids can be used: the hosiery
is folded down over the exible, doughnutshaped aid, which is then slid up or down the
leg to apply or remove hosiery.
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Ensuring the hosiery garment is well tted and they know how to
apply and remove it correctly and that the patient understands how
to care for the hosiery in line with the manufactures instructions.
Keeping active.
Elevating legs when sitting.
Avoiding trauma.
Skin care regimen - Using emollients daily.
Wearing compression hosiery daily.
Having information on ‘red ags’ and what to look out for and
when to contact a healthcare professional, personalised to their
particular history.
Emergency contact details of the healthcare professional/service.
Having regular check- ups every 6–12 months with a healthcare
professional.
Knowing when and how to reorder new hosiery.
Patients may also benet from keeping a self- care journal and
being provided with access or signposting as to where to nd online
materials and support groups/organisations.
Hosiery Care
As part of the information given to patients to promote self- care, they
should be given information about care of their hosiery, so that they
get the maximum wear time out of the garment and keep the hosiery
in good condition. This needs to be in accordance with the manufacturer’s instructions for care. Patients also need to know that they
should obtain a new garment from their healthcare professional
should it get any damage, holes or ladders. This information should
be provided in written form for the patient so that they can refer to it
later if needed.
Maintaining Skin Integrity: Use ofEmollients
A skincare regimen should form part of the patient’s daily care plan
and the healthcare professional should stress the importance of
washing, cleansing and moisturising the skin. This will help with
maintaining overall skin integrity (Wounds UK2022).
The skin is the largest organ in the human body and is very complex. It provides a protection barrier between the body and the
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