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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
188
Figure 5−41 Complete bandage on
the upper extremity.
Figure 5−42 Soft foam padding for
hand and forearm (right) and upper
arm (left).
Figure 5−43 Soft foam padding is
held in place with gauze bandages.
5 Treatment
189
Figure 5−44 Soft foam padding on
the upper extremity.
Figure 5−45 High-density foam
(Komprex) on the palm.
High-density foam must never be applied in
layers. If used circumferentially on parts of the
extremity, it should be applied using the
“sandwich” technique (not in one piece
around the extremity).
Lower Extremity Bandaging
Following is a list of recommended materials
to apply a compression bandage on the lower
extremity during the decongestive phase of
CDT (phase 1). The quantities listed represent
two sets of compression bandages:
쐌
1 bottle of skin lotion
쐌
1 box of stockinette (tubular bandage) in
the appropriate size
쐌
1−2 boxes of gauze bandages (4 cm width)
쐌
2 high-density foam pieces (kidney-
shaped)
쐌
6 synthetic nonwoven padding bandages
(10 cm) or 2−3 Rosidal Soft foam bandages
(10 cm)
Application of Compression Bandages
190
쐌
4−6 synthetic nonwoven padding bandages
(15 cm) or 2−3 Rosidal Soft foam bandages
(15 cm)
쐌
2 short-stretch bandages (6 cm)
쐌
2 short-stretch bandages (8 cm)
쐌
6−8 short-stretch bandages (10 cm)
쐌
8−12 short-stretch bandages (12 cm)
쐌
4 wide-width short-stretch bandages (15 or
20 cm, depending on the patient’s size)
쐌
Tape to secure the bandages
쐌
If necessary: 1 sheet of soft foam 苲3 feet x 6
feet (about 0.5-inch thickness)
쐌
If necessary: 2 sheets of Komprex or 2 rolls
of soft foam rubber
Application
Generally, bandages are applied with an even
pre-stretch of 苲30 to 40% and an overlap of
苲50 to 70 %. To bandage the foot and the lower
leg, the patient should be in the supine posi-
tion and should stand on the floor during the
application of the compression bandages from
the knee up to the groin.
Skin care: Wash and bathe the skin, then
apply the appropriate lotion thoroughly.
Stockinette: The tubular bandage should be
cut to a length that allows for an overlap of 苲 5
inches on the proximal end of the extremity.
This overlap is used to extend over and cover
the complete compression bandage on the
proximal border (Fig. 5−46).
Toe bandages: Start the first gauze bandage
with a loose anchor turn around the dorsum of
the foot (in the metatarsophalangeal joint
area), then proceed to bandage the big toe
(Fig. 5−47). Enter the toe over the dorsum,
apply two or three circular turns, and leave the
toe again over the dorsum; avoid sliding or rol-
ling of the bandages in the web space area. The
tips of the toes remain unbandaged. Proceed to
bandage the remaining toes (except the fifth
toe, which generally is not involved in the
swelling) in the same manner (Fig. 5−48). One
4 cm gauze bandage (usually folded to half
width) is generally sufficient to cover the toes.
Any unused part of the gauze bandage should
be wrapped spirally (not circular) around the
foot. Upon completion, the tips of the toes
should be checked for proper circulation.
Padding materials: Nonwoven synthetic pad-
ding (3 rolls) or soft foam rolls (2 rolls of
Rosidal Soft) are applied on the foot and lower
leg (Figs. 5−49, 5−50). Komprex foam kidneys
are secured between the medial and lateral
malleolus and the Achilles tendon with the
padding bandages (Fig. 5−51). Synthetic pad-
ding bandages may be doubled over the shin
area to provide additional protection.
Short-stretch bandages: Using a 6 or 8 cm
wide bandage (depending on the size of the
foot), do a loose anchor turn around the
metatarsus (Fig. 5−52). The foot is bandaged
down to the web spaces with three or four
circular turns in the metatarsophalangeal joint
area. The bandage should roll from lateral to
medial (toward the big toe) and is applied
without tension on the foot. The same
bandage proceeds to cover the heel, using the
“heel lock” technique, which provides addi-
Figure 5−46 Application of stock-
inette.
5 Treatment
191
Figure 5−47 Gauze bandages start
with a loose anchoring turn around the
dorsum of the foot.
Figure 5−48 Application of gauze
bandages on the toes.
Figure 5−49 Application of padding
materials on the foot.
Application of Compression Bandages
192
Figure 5−50 Application of padding
materials (soft foam roll) on the foot.
Figure 5−51 High-density foam (Kom-
prex) pieces behind the ankles are held
in place by padding bandages.
Figure 5−52 Loose anchor turn
around the metatarsus with the first
short-stretch bandage.
5 Treatment
193
tional support for the ankle and keeps the
bandage from sliding (Figs. 5−53, 5−54).
During the application of compression band-
ages on the heel, the ankle is in 苲70 to 90
degrees of dorsiflexion. The bandage is guide d
from the plantar surface toward the Achilles
tendon, covering the area between the heel
and the lateral malleolus, from here around
the ankle to the area between the medial mal-
leolus and the heel, and again down to the
plantar surface of the foot (Fig. 5−55). Proceed
with a circular turn without tension around
the foot, and repeat the heel lock technique
until the bandage is used up; secure with tape.
The next bandage (8 or 10 cm) starts above the
ankle with a loose anchor in the opposite
direction of the previous bandage (applying
compression bandages in the opposite direc-
tion to each other prevents bandaging the foot
in eversion or inversion; i.e., it provides for a
functional bandage and adds durability). The
goal is to cover the heel and the foot with the
second bandage in a circular technique (Figs.
5−56, 5−57). The lower leg is bandaged with 10
or 12 cm wide bandages (typically 2−4 rolls).
To provide a smooth gradient from distal to
proximal, the individual bandages are started
in areas of soft pressure (Fig. 5−58). The ther-
apist continues to check the gradient of the
compression bandage during the entire
process of application. Feedback from the
patient is necessary and helpful. Secure the
last bandage on the lower leg with tape
(Fig. 5−59).
Figure 5−53 “Heel lock” technique
around the lateral ankle.
Figure 5−54 “Heel lock” technique
around the medial ankle.
Application of Compression Bandages
194
Figure 5−55 Complete application of
the first short-stretch bandage on the
foot.
Figure 5−56 Start of the second
short-stretch bandage with a loose an-
chor around the ankle.
Figure 5−57 The heel and foot are
covered with the second short-stretch
bandage.
5 Treatment
195
The remaining compression bandage is ap-
plied with the patient in standing. The patient
should shift the body weight to the extremity
being bandaged, with the knee slightly bent.
Padding materials using nonwoven synthetic
padding or soft foam rolls are applied on the
knee and thigh. When using synthetic padding
bandages, the layers may be doubled in the po-
pliteal fossa to provide additional protection.
The knee and thigh should be bandaged using
12 cm wide short-stretch bandages (typically
4−6 rolls). The first bandage starts with a loose
anchor turn below the knee, proceeding to
cover the knee using the figure-eight tech-
nique (Figs. 5−60, 5−61). The remaining thigh
is bandaged in a circular manner up to the
groin area; the last bandage (or each individual
bandage) is secured with tape (Fig. 5−62). An
additional 15 or 20 cm wide medium-stretch
bandage may be applied on the thigh to add
stability.
Hip attachments: If the lower truncal quad-
rants are involved in the swelling, or to pre-
vent the compression bandages on the leg
from sliding, the hip may be bandaged using
one or two rolls (depending on the size of the
patient) of 20 cm wide short stretch bandages.
(Note: Hip attachments are applied directly on
the skin; the patient wears the underwear on
top of the bandages.) Start the first bandage
with a loose turn around the proximal thigh to
secure (Fig. 5−63), then proceed to cover the
trunk, guiding the bandage from the lateral
thigh to the opposite iliac crest (to prevent
sliding, at least one third of the width of the
bandage should be cranial to the iliac crest).
From here, apply a complete circular turn
around the trunk, and proceed with the ban-
dage over the buttocks back down to the thigh
(Fig. 5−64). Proceed with the same technique
until the lower trunk is thoroughly covered.
Circular turns on the proximal thigh should be
Figure 5−58 Bandaging of the lower
leg.
Figure 5−59 Finished bandage on the
lower leg and foot.
Application of Compression Bandages
196
Figure 5−60 Application of short-stretch bandages
on the knee using the figure eight technique.
Figure 5−61 Application of short-stretch bandages
on the thigh starting with a loose anchor turn.
컅 Figure 5−62 Finished bandage on the
lower extremity.
왕
Figure 5−63 Hip attachment using wide short-
stretch bandages (15−20 cm).
5 Treatment
197
Figure 5−64 Hip attachment, posterior view.
Figure 5−65 Special padding on the foot using soft
foam.
Figure 5−66 Special padding on the
foot and lower leg using soft foam.
avoided to prevent tourniquet effects. Upon
completion, the bandage is checked again for
correct pressure gradient. If two rolls of band-
ages are needed for the hip attachment, the
ends may be sewn together to simplify the ap-
plication.
Special padding: If additional padding is re-
quired, or to prevent the compression bandage
from sliding, soft foam sheets may be cut to fit
the patient’s foot, lower leg, and thigh (Fig. 5−
65). Soft foam may be used in combination
with nonwoven synthetic padding bandages
(especially in areas where foam pieces overlap,
e.g., joints). Foam pieces are held in place with
gauze bandages (Figs. 5−66, 5−67). In appro-
priate cases, pieces of custom-cut high-density
foam or chip bags (Fig. 5−68) may be used to
soften areas of lymphostatic fibrosis.
Note: High-density foam must never be ap-
plied in layers. If used circumferentially on
parts of the extremity, it should be applied
Application of Compression Bandages