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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
198
Figure 5−67 Soft foam padding is
held in place by gauze bandages.
Figure 5−68 Chip bags.
using the “sandwich” technique (not in one
piece around the extremity).
Genital Bandaging
Female patients: Soft foam pieces or pieces of
high-density foam rubber are custom cut in
the shape of sanitary pads. These pads are
placed directly on the skin, which makes it
necessary to place the pads in several layers of
stockinette, which should be renewed daily. To
maximize the therapeutic benefit, compres-
sion pantyhose should be worn. Compressive
garments for the lower trunk with thigh at-
tachments (biker-shorts style) may be used if
the lower extremities are uninvolved.
Male patients: The soft tissues of the penis
and scrotum are usually involved in the swel-
ling. The bandages on the scrotum may be-
come loose during the day, and renewal may
be necessary. Therefore, patients should be
taught early in the treatment phase how to
apply compression bandages on the genital tis-
sues. During the decongestive phase, the
scrotal compression bandages may be held in
place by wearing biker shorts, athletic support
(jockstraps), or briefs (instead of shorts). In the
self-management phase, slipping of the ban-
dages is usually prevented by compression
pantyhose if genital lymphedema is combined
with lower extremity swelling. Compressive
garments for the lower trunk with thigh at-
tachments (biker-shorts style) may be used if
the lower extremities are uninvolved. In most
cases, genital bandaging has to be applied
lifelong to avoid reaccumulation of fluid.
Recommended materials to apply a com-
pression bandage on the penis and scrotum:
1 pair of surgical gloves
1 bottle of skin lotion
Stockinette (tubular bandage) in the appro-
priate size to cover the scrotum
Gauze bandages (4 or 6 cm width) for the ap-
plication on penis and scrotum
Fastening options for the bandage on the
scrotum: Because slippage is a common prob-
lem, the bandages can be held in place by using
cohesive gauze bandages (4 or 6 cm width) or
special foam materials (Velfoam). Velfoam is
covered with a hook-sensitive material on one
side (Fig. 5−69).
If lymphatic cysts and/or fistulas are present
(Fig. 5−23), appropriate skin cleansing pro-
ducts (as prescribed by the physician) and
sterile gauze should be incorporated.
Application
Proper hygiene is of utmost importance. Ap-
propriate products, as prescribed by the physi-
cian, should be used.
5 Treatment
199
Figure 5−69 Fastening system to hold
scrotum bandage in place.
Figure 5−70 Application of gauze
bandage on the penis starting behind
the glans penis.
Figure 5−71 The finished gauze ban-
dage on the penis is affixed with tape.
Application on the penis: The penis is ban-
daged with circular turns using one or two
rolls of gauze bandages (Figs. 5−70, 5−71). In
uncircumcised patients, the bandages should
be applied with the foreskin pulled back and
the first bandage starting proximal to the glans
penis. If the foreskin cannot be pulled back, a
separate bandage should be used to bandage
the foreskin. This bandage is renewed every
time the patient urinates. Soft foam pieces
(wrapped in stockinette) may be used if un-
padded gauze bandages cause discomfort.
Application of Compression Bandages
200
Figure 5−72 Application of stock-
inette on the scrotum.
Figure 5−73 Application of the
fastening system around the base of
the scrotum.
Figure 5−74 Application of the
fastening system around the circumfer-
ence of the scrotum.
Scrotal bandage: A stockinette of appropriate
size and length is used to cover the scrotum
(Fig. 5−72). To provide a secure base for the
gauze bandages to adhere to, a Velfoam piece
(2 inches wide) is cut to the appropriate length
and placed around the base of the scrotum
(Fig. 5−73). Velcro is used to secure the foam
and on several areas on the foam to provide a
hook system for the gauze bandages. An addi-
tional Velfoam piece is then applied to the cir-
cumference of the scrotum and secured with
Velcro to the foam on the base of the scrotum
(Fig. 5−74). These foam pieces provide a suffi-
cient base for the gauze bandages; upon de-
5 Treatment
201
Figure 5−75 Velcro pieces attached
to the fastening system prevents slid-
ing of gauze bandages.
Figure 5−76 Application of gauze
bandages on the scrotum.
Figure 5−77 Velcro pieces prevent
slippage of the gauze bandages.
congestion of the scrotum, the foam pieces are
shortened as necessary. Velcro spots affixed to
the foam pieces prevent the gauze bandages
from sliding (Fig. 5−75). The scrotum is then
wrapped with gauze bandages, which are se-
cured with tape (Figs. 5−76, 5−77, 5−78). In-
stead of foam pieces, cohesive gauze bandages
may be used to prevent sliding.
Application of Compression Bandages
202
Measurements for Compression
Garments
To ensure preservation and improvement of
the therapeutic success achieved in phase 1 of
the treatment, it is imperative that a compres-
sion garment is chosen that meets the patient’s
individual needs. To select the correct style
(ready-made or custom-made), compression
level, length, and, if necessary, fastening sys-
tems, the patient’s age, physical abilities (and
limitations), lifestyle, type of lymphedema,
and any other conditions must be taken into
consideration.
Most manufacturers provide compression
garments in a variety of sizes. Custom gar-
ments should be ordered if the extremity is
either too large or too small for standard size
garments or if a single compression garment
with a compression level of more than
50 mmHg is necessary. The length of a com-
pression garment is indicated by a system of
letters used by the manufacturers. These let-
ters represent the measuring points on both
ends of the garment; an arm sleeve that covers
the extremity from the wrist (measuring point
C) to the axilla (measuring point G), for ex-
ample, is called a C-G sleeve. An open-toe
stocking covering the lower extremity from
the foot (point A) to the groin (point G) would
be referred to as an A-G stocking.
Only trained individuals with a thorough un-
derstanding of lymphedema and its implica-
tions should take measurements. Ill-fitted and
Figure 5−78 Finished bandage on
penis and scrotum.
ineffective compression garments not only
produce poor results but also can be dangerous
to the patient.
To increase effectiveness, it would be benefi-
cial to have an assistant present at the time of
measurements to complete the data on the
measuring forms.
Measurements should be taken at the end of
the intensive phase of CDT (phase 1), when the
extremity is at its most reduced state. Ideally,
the measurements should be taken early in
the morning, at the end of a treatment, or after
the compression bandages have been re-
moved.
Materials needed to take measurements in-
clude a measuring board obtained from the
manufacturers. These boards simplify the
measuring process and increase accuracy.
Other materials needed are a metric system
measuring tape (measurements should be
taken in centimeters), a nontoxic skin marker,
a pen, and a measuring form (order form).
Measuring for Stockings and
Pantyhose
Circumferential as well as length measure-
ments are required. The skin of the patient
should be marked with a nontoxic, nonper-
manent marker on each circumferential meas-
uring point (these markings also determine
the length measurements). The length mea-
surements are taken on the inside of the leg
from each circumferential point to the sole of
the foot (Fig. 5−79).
5 Treatment
203
Figure 5−79 Measurement form for compression stockings and pantyhose (with permission from JUZO, Inc.).
If the lymphedematous leg is unusually
shaped, the positions of the circumferential
measurement points, as well as the length
measurements, should be taken first on the
nonaffected extremity. This technique helps
to identify the position of the measuring
points on the affected extremity.
Required Measurements for Custom-
Made Knee-High Stockings (A-D)
Circumferential measuring points (indicate the
position of all measuring points with nontoxic,
nonpermanent marker):
쐌
Point cA: around the metatarsal heads,
horizontally around the base of the fifth
metatarsal base
쐌
Point cY: around the instep and the heel at a
45-degree angle, taken with the ankle in
maximum dorsiflexion
쐌
Point cB: around the smallest circumfer-
ence above the malleoli
쐌
Point cB1: around the lower leg at the tran-
sition between the Achilles tendon and the
calf musculature (plantar flexion in the
ankle helps to find this measuring point)
쐌
Point cC: around the largest circumference
of the calf
쐌
Point cD: smallest circumference of the
knee, in the area of the fibular head.
Length measurements:
For open-toe stockings, take the length
measurement from point cA to the heel (l-A); if
a closed toe stocking is required, the length
measurement from the longest toe to the heel
is taken (l-Z). The length measurements from
the sole of the foot (even with the floor or the
measuring board) to the circumferential
measurements points cB to cD are taken with
the ankle in 90 degrees of dorsiflexion.
Required Measurements for Standard-Size
Knee-High Stockings (A-D)
쐌
Circumferential measuring points: points
cB and cC
쐌
Length measurements: from the floor to
circumferential measuring point cD (deter-
mines the length of the stocking)
Measurements for Compression Garments
204
Required Measurements for Custom-
Made Thigh-High Stockings (A-G)
Circumferential measuring points in addition
to the ones taken for A-D stockings (indicate
the position of all measuring points with non-
toxic, nonpermanent marker):
쐌
Point cE: around the popliteal fossa and the
patella with the leg slightly bent
쐌
Point cF: around the middle of the thigh
쐌
Point cG: horizontally around the proximal
end of the thigh with the patient standing.
Length measurements: taken on the inside of
the leg between the floor and each circumfer-
ential measuring point
Required Measurements for Standard-Size
Thigh-High Stockings (A-G)
Circumferential measuring points: points cB,
cC, and cG
Length measurements: from the floor to cir-
cumferential measuring point cG, on the inside
of the leg
Required Measurements for Custom-
Made Pantyhose (A-T)
Circumferential measuring points in addition
to the ones taken for A-G stockings (indicate
the position of all measuring points with non-
toxic, nonpermanent marker):
All measurements are taken with the patient
standing.
쐌
Point cK: taken at the same height as meas-
uring point cG, but includes the circumfer-
ence of both thighs and buttocks
쐌
Point cH: around the greatest circumfer-
ence of the hips
쐌
Point cT: around the waist, just above the
iliac crest
Depending on the condition, the abdominal
part of the compression pantyhose may be
ordered with full, partial, or neutral compres-
sion. Adjustable and highly elastic abdominal
parts are available (pregnancy, postsurgical
conditions). Front openings may be ordered for
male patients.
Length measurements between the floor
and up to circumferential point cG are taken on
the inside of the leg. Length measurements be-
tween the floor to points cH and cT are taken
on the outside.
Required Measurements for Standard Size
Pantyhose (A-T)
쐌
Circumferential measuring points: points
cB, cC, cG, and cH
쐌
Length measurements: from the floor to
circumferential measuring point cG
Depending on the condition, the abdominal
part of the compression pantyhose may be
ordered with full, partial, or neutral compres-
sion. Adjustable and highly elastic abdominal
parts are available (pregnancy, postsurgical
conditions). Front openings may be ordered for
male patients.
Measuring for Arm Sleeves
Circumferential as well as length measure-
ments are required. The skin of the patient
should be marked with a nontoxic, nonper-
manent marker on each circumferential meas-
uring point. The length measurements are
taken on the anterior arm from the wrist (point
c) to each circumferential measuring point
(Fig. 5−80).
Required Measurements for Custom-
Made Arm Sleeves (C-G)
Circumferential measuring points (indicate the
position of all measuring points with nontoxic,
nonpermanent marker):
쐌
Point c: around the smallest circumference
of the wrist, on the transition from the hand
to the forearm
쐌
Point c1: this measurement is necessary for
arm sleeves worn in combination with com-
pression gauntlets. The measurement is
taken around the forearm, 6 cm (may vary;
see Measuring for Hand and Finger Com-
pression Garments later in this chapter) pro-
ximal to circumferential measuring point c.
쐌
Point d: around the forearm, at the mid-
point between point c and the elbow
쐌
Point e: around the elbow, in the cubital
fossa, with the arm slightly bent
5 Treatment
205
쐌
Point f: around the middle of the upper arm
쐌
Point g: around the proximal end of the
upper arm, in the axillary fold
If a shoulder cover and strap is required:
쐌
Point h: vertically around the axilla and the
shoulder
쐌
Point h−i: this measurement is necessary to
require the length of the shoulder strap. It is
taken circumferentially from measuring
point h across the thorax to the opposite ax-
illa.
Length measurements are taken from the cir-
cumferential measuring point c along the
anterior arm (the arm is in supination) to each
circumferential measuring point.
For arm sleeves with a shoulder cover and
strap, an additional length measurement is re-
quired:
쐌
g−h: this length is taken on the outside of
the shoulder between circumferential
measuring points g and h.
Figure 5−80 Measurement form for compression arm sleeves (with permission from JUZO, Inc.).
Required Measurements for Standard-Size
Arm Sleeves (C-G)
쐌
Circumferential measuring points: points c,
e, and g
쐌
Length measurements: from circumferen-
tial measuring point c to circumferential
measuring point g along the anterior arm
(forearm in supination)
Measuring for Hand and Finger
Compression Garments
See Figure 5−81 for example of measurement
form for hand and finger compression gar-
ments.
Required Measurements for Compression
Gauntlets with Finger Stubs or Closed
Fingers
Circumferential measuring points (indicate the
position of all measuring points with nontoxic,
nonpermanent marker) (the fingers should be
slightly spread for points a and b):
쐌
Point a: around the metacarpus (bases of
the second and fifth metacarpal bones)
Measurements for Compression Garments
206
쐌
Point b: around the metacarpus, at the web
space between the thumb and the index
finger (parallel to point a)
쐌
Point c: around the smallest circumference
of the wrist, on the transition from the hand
to the forearm
쐌
Point c1: around the forearm, 6 cm (see also
length measurement c−c1) proximal to cir-
cumferential measuring point c
쐌
Point w: around the distal end of each fin-
ger and the thumb, at the point where the
end of the finger portion is desired (finger
stubs should not end in the joint/crease
area of the finger)
쐌
Point x: around the proximal end of each
finger and the thumb. Point x can be easily
identified using the crease on the palmar
surface of the finger bases
Length measurements:
a−b: distance between circumferential
measuring points a and b. Take measurement
with open palm.
c−c1: distance between circumferential
measurements c and c1. This measurement de-
termines the length of the wrist extension. If
an extension shorter than 6 cm is desired, cir-
Figure 5−81
Measurement form for
hand and finger com-
pression garments
(with permission from
JUZO, Inc.).
cumferential measurement c1 should be taken
at the appropriate point.
w−x: the length of each finger is measured
between the circumferential measuring points
w and x.
For a gauntlet with closed fingers, the length
of the fingers between circumferential meas-
uring points x and the fingertips are taken.
Required Measurements for Compression
Gauntlets with Thumb Stub (no Finger
Swelling)
Circumferential measuring points (indicate the
position of all measuring points with nontoxic,
nonpermanent marker):
쐌
Point a: around the metacarpus (bases of
the second and fifth metacarpal bones). The
fingers should be slightly spread for this
measurement.
쐌
Point c: around the smallest circumference
of the wrist, on the transition from the hand
to the forearm
No length measurements are necessary for
standard-size compression gauntlets.
5 Treatment
207
Compression Neck and Chin Straps
and Face Masks
Pressure garments for the face are available as
neck and chin straps and as partial or full-face
masks. Full-face masks may be ordered with or
without openings for the eyes, nose, or mouth.
Depending on the severity and chronicity of
the swelling, compression garments for the
face may be ordered in knitted materials or
other synthetic fabric.
Custom-made face masks in knitted materi-
als generally provide firmer and more durable
compression, but they often have a long turn-
around time and are costly to produce. Face
masks made of other materials (often used in
burn care and post−facial surgery)are manufac-
tured in the more cost-effective “cut and sewn”
technique. These garments are available in
standard sizes, but they tend to be less durable.
See Figure 5−82 for example of measure-
ment form for neck and chin compression gar-
ments.
Compression Garments for the
Upper Thorax and Breast
Compression bras (Fig. 5−83): these garments
typically are used if swelling in the mammary
gland is an issue.
Advantages: Velcro closure in the back al-
lows for adjustments; fashionable; available in
a variety of standard sizes; only one circumfer-
ential measurement on the chest (below the
breast) required; relatively inexpensive.
Disadvantages: Closure in the back may be
difficult to reach; does not provide sufficient
support in truncal swelling; the low cut in the
axillary area may allow fluid to accumulate.
Compression vests (Fig. 5−84): These custom-
made garments are available in different com-
pression levels (20−30 and 30−40 mmHg) and
are appropriate for patients with a tendency to
swell in the upper quadrant(s). Compression
vests may be ordered as slip-ons or with op-
tional closure systems (Velcro, zipper), which
may be located in the front or back. Vests can
be ordered with attached compression arm
sleeves.
Required Measurements for Compression
Vests
Circumferential measuring points (indicate the
position of all measuring points with nontoxic,
nonpermanent marker):
쐌
Point h: vertically around the axilla and the
shoulder. The arm should not be elevated
during this measurement.
쐌
Point m: around the waist (just below the
last rib)
쐌
Point n: around the chest, under the axilla
Length measurements:
쐌
s−s: this measurement determines the neck
opening. It is taken on the front of the neck
between the desired points of the neck
opening on the shoulder height (point s
represents the height of the shoulders).
쐌
qu−r: this measurement determines the
lower portion of the neck opening and is
taken between the desired points of the
opening.
쐌
r−s: determines the height of the opening
between the shoulder height (point s) and
the lower portion of the neck opening
(point r)
쐌
m−s: determines the length between the
waist measurement (point m) and the
shoulder height (point s)
쐌
m−n: the distance between the circumfer-
ential measurements on the waist (point m)
and the chest (point n)
Figure 5−83 Compression bra (with permission
from JUZO, Inc.).
Measurements for Compression Garments