Skill 9-10

Applying and Removing Graduated Compression Stockings

Graduated compression stockings are often used for patients at risk for venous stasis, thrombophlebitis, deep vein thrombosis (DVT) as a passive intervention to aid in the prevention of these complications (AACN, 2016; Sachdeva et al., 2018). Manufactured by several companies, graduated compression stockings are made of elastic material and are available in either knee- or thigh-high length. Graduated compression stockings apply pressure to increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart. Pooling of blood is reduced, decreasing the risk of clot formation. Use of graduated compressions stockings is a prescribed intervention.

Be prepared to apply the stockings in the morning before the patient is out of bed and while the patient is supine. If the patient is sitting or has been up and about, have the patient lie down with their legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings.

Delegation Considerations

The application and removal of graduated compression stockings may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Elastic graduated compression stockings in the prescribed length and correct size. See Assessment for appropriate measurement procedure.
Measuring tape
Talcum powder (optional)
Skin cleanser, basin, towel
PPE, as indicated

Assessment

Assess the skin condition and neurovascular status of the legs. Collaborate with the health care team regarding any abnormalities before continuing with the application of the stockings. Assess patient's legs for any redness, swelling, warmth, tenderness, or pain that may indicate DVT. If any of these symptoms are noted, confer with the health care team before applying stockings. Measure the patient's legs to obtain the correct size stocking. For knee-high length: Measure around the widest part of the calf and the leg length from the bottom of the heel to the back of the knee, at the bend. For thigh-high length: Measure around the widest part of the calf and the thigh. Measure the length from the bottom of the heel to the gluteal fold. Follow the manufacturer's specifications to select the correct-sized stockings.

Each leg should have a correctly fitted stocking; if measurements differ, then two different sizes of stocking need to be obtained to ensure correct fitting on each leg

(Muñoz-Figueroa & Ojo, 2015).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Venous thromboembolism risk
Altered skin integrity risk
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when applying and removing graduated compression stockings is that the stockings will be applied and removed with minimal discomfort to the patient. Other outcomes that may be appropriate include the following: edema will decrease in the lower extremities, the patient will understand the rationale for stocking application, and the patient will remain free from DVT.

Implementation

Action	Rationale
1. Review the health record and prescribed interventions to determine the need for graduated compression stockings.	Reviewing the health record and prescribed interventions validates the correct patient and correct procedure.
2. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain what you are going to do and the rationale for use of graduated compression stockings.	Patient identification validates the correct patient and correct procedure. Discussion and explanation allay anxiety and prepare the patient for what to expect.
4. Close the curtains around the bed and close the door to the room, if possible.	This ensures the patient's privacy.
5. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
6. Assist patient to supine position. If patient has been sitting or walking, have them lie down with legs and feet well elevated for at least 15 minutes before applying stockings.	Dependent positioning of the legs encourages blood to pool in the veins, reducing the effectiveness of the stockings if they are applied to congested blood vessels.
7. Expose legs one at a time. Wash and dry legs, if necessary. Powder the leg lightly unless patient has a respiratory problem, dry skin, or sensitivity to the powder. If the skin is dry, a moisturizing lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.	Helps maintain patient's privacy. Powder and lotion reduce friction and make application of stockings easier.
8. Stand at the foot of the bed. Place your hand inside the stocking and grasp the heel area securely. Turn the stocking inside-out to the heel area, leaving the foot inside the stocking leg (Figure 1).	The inside-out technique provides for easier application; bunched elastic material can compromise extremity circulation.
9. With the heel pocket down, ease the foot of the stocking foot over the patient's foot and heel (Figure 2). Check that the patient's heel is centered in the heel pocket of the stocking (Figure 3).	Wrinkles and improper fit interfere with circulation.
10. Using your fingers and thumbs, carefully grasp the edge of the stocking and pull it up smoothly over the ankle and calf, toward the knee (Figure 4). Make sure it is distributed evenly.	Easing the stocking carefully into position ensures proper fit of the stocking to the contour of the leg. Even distribution prevents interference with circulation.
11. Pull forward slightly on the toe section. If the stocking has a toe window, make sure it is properly positioned. Adjust if necessary to ensure the material is smooth.	This ensures toe comfort and prevents interference with circulation.
12. If the stockings are knee-length, make sure each stocking top is 1 to 2 inches below the patella. Make sure the stocking does not roll down.	This prevents pressure and interference with circulation. Rolling stockings may have a constricting effect on veins.
13. If applying a thigh-length stocking, continue the application. Flex the patient's leg. Stretch the stocking over the knee.	This ensures even distribution.
14. Pull the stocking over the thigh until the top is 1 to 3 inches below the gluteal fold (Figure 5). Adjust the stocking, as necessary, to distribute the fabric evenly. Make sure the stocking does not roll down.	This prevents excessive pressure and interference with circulation. Rolling stockings may have a constricting effect on veins.
15. Remove equipment and return the patient to a position of comfort. Remove gloves. Raise side rails and lower the bed. Place the call bell and other essential items within reach.	This promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Having the call bell and other essential items within reach promotes safety.
16. Remove any other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Removing Stockings
17. To remove stocking, grasp the top of stocking with your thumb and fingers and smoothly pull the stocking off inside-out to heel. Support the patient's foot and ease the stocking over it.	This preserves the elasticity and contour of the stocking. It allows assessment of circulatory status and condition of skin on lower extremity and for skin care.

Evaluation

The expected outcomes have been met when the stockings have been applied and removed, as indicated, with minimal discomfort to the patient; the patient has exhibited a decrease in peripheral edema in the lower extremities; the patient has verbalized an understanding of the rationale for stocking application; and the patient has remained free from DVT.

Documentation

Guidelines

Document the patient's leg measurements as a baseline. Document the application of the stockings, size stocking applied, skin and leg assessment, and neurovascular assessment.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient's leg measurements are outside the guidelines for the available sizes: Notify prescriber. Patient may require custom-fitted stockings.
Patient has a lot of pain with application of stockings: If pain is expected (e.g., if the patient has a leg incision), it may be necessary to premedicate the patient and apply the stockings once the medication has had time to take effect. If the pain is unexpected, notify the health care team because the patient may be developing a deep vein thrombosis.
Patient has an incision on the leg: When applying and removing stockings, be careful not to hit the incision. If the incision is draining, apply a small bandage to the incision so that it does not drain onto the stockings. If the stockings become soiled by drainage, wash and dry according to instructions.
Patient is to ambulate with stockings: Place skid-proof socks or slippers on before patient attempts to ambulate.

Special Considerations

General Considerations

Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be obtained to ensure correct fitting on each leg (Muñoz-Figueroa & Ojo, 2015). The manufacturer whose stockings are being used provides directions for measuring. Some stockings fit either leg; others are designated right or left. An improperly fitting stocking is uncomfortable and ineffective and possibly even harmful (Muñoz-Figueroa & Ojo, 2015).
Remove stockings daily and inspect and bathe legs and feet. Wash and air-dry the stockings, as necessary, according to the manufacturer's directions.
Assess the patient's extremities at least every shift for skin color, temperature, sensation, swelling, and the ability to move. If complications are evident, remove the stockings and notify the health care team.
Evaluate stockings to ensure the top or toe opening does not roll with movement. Rolled stocking edges can cause excessive pressure and interfere with circulation.
Despite the use of elastic stockings, a patient may develop DVT or phlebitis. Unilateral swelling, redness, tenderness, pain, and warmth are possible indicators of these complications. Notify the health care team of the presence of any symptoms.

Community-Based Care Considerations

Make sure that the patient has an extra pair of stockings during hospitalization before discharge (for payment and convenience purposes).
In general, it is best to take time to wash stockings by hand; stockings may be laundered with other “white” clothing. Avoid excessive bleach. Remove from dryer as soon as “low-heat” cycle is complete to avoid shrinkage. Stockings may also be air-dried; lay on a flat surface to prevent stretching. Check the manufacturer's directions.
Take all jewelry off before putting on stockings as rings and bracelets can snag on the compression hose, causing rips and tears.
Instruct the patient to remove the stockings and contact their health care provider if they experience numbness, tingling, pins and needles, pain or soreness in the foot or leg, or a pale/cool/discolored foot or leg, as these indicate the stockings are too tight (Canterbury District Health Board, 2018).
Instruct the patients to contact their health care provider if a rash develops on their toes or feet, as this could be the result of an allergy to the elastic fibers in the stockings (Canterbury District Health Board, 2018).

EVIDENCE FOR PRACTICE

Venous Thromboembolism Prevention

American Association of Critical-Care Nurses (AACN). (2016). Practice alert. Preventing venous thromboembolism in adults. https://www.aacn.org/clinical-resources/practice-alerts/venous-thromboembolism-prevention

The American Association of Critical-Care Nurses provides Practice Alerts. Practice Alerts are succinct, dynamic directives that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment. Almost all hospitalized patients have at least one risk factor for venous thromboembolism (VTE). VTE, a common complication, contributes to excess length of stay, excess charges, and mortality. This Venous Thromboembolism Prevention Practice Alert supports the use of mechanical methods of prophylaxis, including graduated compression stockings, to reduce the risk of VTE. Nurses must select the correct size of stockings, properly apply them, and ensure that they are removed for only a short time each day.

EVIDENCE FOR PRACTICE

Graduated Compression Stockings and Venous Thromboembolism Prevention

Hospitalized patients are at increased risk of developing deep vein thrombosis (DVT) in the lower limb and pelvic veins related to prolonged immobilization, surgery, and other comorbidities (Sachdeva et al., 2018; Wilson et al., 2018). Patients with a DVT are at increased risk of developing a pulmonary embolism (Morton & Fontaine, 2018). Expected nursing practice includes interventions to prevent venous thromboembolism (AACN, 2016). Does the use of graduated compression stockings decrease the risk of DVT?

Related Evidence

Sachdeva, A., Dalton, M., & Lees, T. (2018). Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews, 11(11), CD001484. https://doi.org/10.1002/14651858.CD001484.pub4

This systematic review aimed to evaluate the effectiveness and safety of graduated compression stockings in preventing deep vein thrombosis (DVT) in hospitalized patients. Multiple databases were searched for randomized controlled trials involving graduated compression stockings (GCS) alone, or GCS used along with any other DVT prophylactic method. Twenty randomized controlled trials were identified; 10 included patients undergoing general surgery; 6 included patients undergoing orthopedic surgery; 3 trials included patients undergoing neurosurgery, cardiac surgery, and gynecologic surgery; and 1 included medical patients. GCS were applied on the day before or on the day of surgery and were worn until discharge, or the participants were fully mobile. Analysis of the pooled data from the studies indicated GCS are effective in reducing the risk of DVT in hospitalized patients who have had general and orthopedic surgery, with or without other methods of thromboprophylaxis. Data also indicated that GCS probably reduce the risk of proximal DVT and may reduce the risk of pulmonary embolism. There were insufficient data to assess the effectiveness of GCS in reducing the risk of DVT in medical patients. The authors concluded wearing GCS reduced the overall risk of developing DVT and may reduce the risk of pulmonary embolism among surgical patients.

Relevance for Nursing Practice

Expected nursing practice includes incorporation of best practice evidence. Use of graduated compression stockings are indicated for the prevention of venous thromboembolism. Nurses must ensure safe and accurate implementation of use of these devices to support quality patient care and outcomes.

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Skill 9-10

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE