Improving customer care

A CPD Guide To Venous Leg Health
Improving
customer care
in lower limb
chronic oedema
AIMS OF THIS TRAINING
This module, brought to you by Activa Healthcare, covers the use of
compression hosiery in lower limb chronic oedema.
Specifically, this module will help you to:
Identify customers who could benefit from your advice and
recommendations to stop the progression of oedema
Update your knowledge of the causes and symptoms of oedema
Understand the use of European compression hosiery.
Reflective questions
Think about the following areas:
How much do you know about the role of the lymphatic
system?
Do you know which hosiery is the most appropriate for
customers with lower limb chronic oedema?
Would you recognise a customer with lower limb chronic
oedema?
Many customers who receive repeat prescriptions for compression
hosiery will be suffering from chronic oedema, and pharmacists and
pharmacy support staff play an important role in helping these people
manage their condition. The role of pharmacy can include asking
customers if they are satisfied with the performance of their hosiery: is it
comfortable? Are they managing to put on and take off the garment?
Other customers may have undiagnosed symptoms of chronic oedema
– you should identify these people and refer them to their GP.
Chronic oedema is defined as swelling of a limb that
has lasted for more than three months. The limb is
often distorted and the oedema cannot be relieved
by elevation or the use of diuretics. It is often
accompanied by changes to the skin, such as:
• Thickening and
hardening of the
skin (hyperkeratosis)
• Non-pitting when
pressure is applied
• Hyper-pigmentation
• Contact and irritant
dermatitis.
The role of compression hosiery
You should also be
aware that customers
can be at risk of
developing cellulitis
(infection of skin) too.
Compression hosiery plays an important role in managing chronic
oedema by:
Lymphoedema
• Initially preventing a limb from swelling
• Maintaining the reduction in swelling of a limb or the reshaping of a
limb following intensive bandaging therapy.
Customers will often be prescribed European Class hosiery. Compared
to the British Standard, European hosiery has comparative levels of
compression per Class with a higher stiffness index to contain the
oedema in order to prevent recurrence or further deterioration of the
limb. By using the latest knitting technologies and materials, this stiffer
type of hosiery encourages the movement and re-absorption of excess
fluids, which can also lead to improved skin conditions. Garments, such
as ActiLymph, are available as European Class 1, 2 and 3 in below the
knee or thigh length styles.
For large or mis-shapen limbs, the new ActiLymph flat knit made to
measure hosiery may be the better option for the patient.
Chronic oedema
Many diseases of the venous and lymphatic systems can cause oedema.
The condition occurs when the lymphatic system cannot absorb fluid
and waste products from tissues fast enough, causing an imbalance and
a collection of fluid in the tissue spaces.
Sometimes chronic
swelling in the limbs
can occur because of
a failure in the lymphatic system caused by damage,
a genetic abnormality, cancer treatment, surgery,
injury or infection. This is known as lymphoedema.
Due to the failure of the lymphatic system, excess
fluid accumulates in the tissues, leading to swelling.
This produces the characteristic features of
lymphoedema, which are pale and unpigmented skin
that feels cool (and should not be confused with
normal swelling following an injury or surgery). If left
untreated, the limb will gradually become distorted
as the swelling increases.
Selecting hosiery to meet customer needs
The key to succeeding with the use of compression hosiery to manage oedema is to wear the hosiery daily – this is where
pharmacists and their staff can make a valuable contribution. By explaining to the customer how the stocking works, as well as its
beneficial effects, you can go a long way in making sure the hosiery makes a difference to their lives.
On a regular visit to collect her
prescription, a customer complains that
her compression stockings are very uncomfortable and
are digging in around the knee. She is also finding
them very difficult to put on as her ankles are swollen
and there appears to be swelling above the knee.
According to her PMR, she has been wearing British
Standard Class 2 below knee length stockings for the
last six months.
Customer 1
When measuring a customer for a repeat
pair of British Standard (BS) Class 2 below
the knee stockings, you notice that her measurements
are very different from her last assessment. She tells
you that her ankles and lower legs have become more
swollen and because of this, the hosiery is proving
difficult to put on and to wear for any length of time, so
she is regularly leaving them off. The hosiery is also not
very comfortable around her heels and toes.
Customer 2
Solution
Solution
The signs of ‘digging in’ around the knee and swollen
ankles indicate oedema, which can occur with
varicose veins. This customer may need a higher
compression and stiffer garment to help manage the
oedema, in which case you could suggest that she
may benefit from changing to ActiLymph European
hosiery. You could offer to discuss this with her GP.
This customer’s oedema has deteriorated, and BS
hosiery is no longer sufficient. This in turn has led
to poor concordance with the hosiery, causing
further deterioration of the limb. The customer’s
GP should be informed about this change and that
she may benefit from a stiffer garment with higher
compression, such as Actilymph European hosiery.
Customer advice
ActiLymph European Hosiery
Customer benefits:
Softer garment makes it easy to put on and take off
Comfortable to wear as it moulds to the shape of the limb
Stiffer garment helps to control oedema in the lower limb
by providing a containment around the limb
Elasticated heel offers compression and support
A general guide to compression levels and use
of ActiLymph European Hosiery
Class 1: 18-21 mmHg
Prevention for customers with
early/mild oedema.
Class 2: 23-32 mmHg
Provides medium compression
and should be used for moderate
to severe oedema.
Class 3: 34-46 mmHg
Provides strong compression
for severe oedema.
Contraindications
Compression hosiery is not suitable for everybody, and special
care should be taken with the following people. Those who
have:
Diabetes or rheumatoid arthritis, as micro-vascular disease
may be present
Toe sack prevents oedema without restriction
Diabetes may have peripheral neuropathy, which may cause
problems if the stockings are too tight
A wide top band with silicone beads gives an improved
grip, preventing the stocking from slipping
Significant arterial disease
Available as below the knee and thigh length in colours
sand and black.
Congestive heart failure, as compression could lead to
cardiac overload
A known sensitivity to the fabric of the stocking.
Stiffness index refers to the resistance or stretch that the hosiery has when the person’s limb tries to expand
within it. A higher stiffness index works by providing a more rigid cuff around the limb, similar to the way
an inelastic bandage functions.
A customer with varicose veins is wearing BS
Class 2 thigh length stockings but is also finding
that her legs are aching and swollen and the skin feels hard.
The GP suggested she tried elevating her legs as often as
possible and prescribed diuretics which did help for a while,
but do not seem to make a difference any more.
Customer 3
Solution
It could be that this customer is suffering from chronic
oedema and she should be referred to the GP with a
recommendation to change the type of hosiery to
ActiLymph European thigh length stockings.
Hosiery advice
If customers look after their hosiery effectively, they will
continue to get maximum effects and benefits, and the
hosiery will look and feel good. When issuing a
prescription for ActiLymph, you could give the following
advice:
• Remember to be re-measured every six months for
new hosiery
• Machine or hand wash hosiery (up to 40ºC)
• Do not tumble dry or iron the hosiery and keep it away
from direct heat
• Dry flat if possible
• Look out for foot problems such as rough skin or
toenails and calluses, as these can damage the hosiery
• Check footwear for any signs of damage, as this could
lead to damage of the hosiery too.
“The role of pharmacy
can include asking
customers if they are
satisfied with the
look and feel of
their hosiery.”
Support from Activa Healthcare
Customer care
How to apply compression hosiery
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There is an online Hosiery Selector designed to help
pharmacists provide customers with the correct and
best compression products. It automatically matches
the customer’s measurements with an Activa product
when the measurements and product type are
entered. The Activa Hosiery Selector is available at:
www.activahealthcare.co.uk/selector
CPD for Pharmacists &
Pharmacy technicians
This module can be used as a trigger for
one of your CPD entries. The following
questions will help you to get the most out
of this module.
Reflect
Revisit the questions from the beginning of
the module.
Plan
Some customers may find
compression hosiery difficult to apply,
especially if they suffer from limited mobility or
hand dexterity.
Problems such as trying to get the stocking over the heel, bunching of
the stocking which prevents the material from stretching or trying to
pull the stocking on can cause distress to the customer and stop them
from wearing the compression hosiery.
In these cases, recommend that the customer uses a specialist
applicator such as ActiGlide. You could help the customer further by
showing them how to use this applicator to help put on the hosiery.
Skincare and exercise
Do I need to improve my knowledge of the
use of compression hosiery in the
management of chronic oedema?
Which customers should I be targeting for
advice on the use of compression hosiery?
Act
Can my staff play a role in helping
customers with chronic oedema get the
best from their compression hosiery, or
even help to identify customers who are
suffering from chronic oedema?
Evaluate
Do I have any further learning needs on
this topic?
Promoting skincare as a vital part of chronic oedema treatment is
another area where pharmacists and pharmacy staff can make a
difference to a customer’s quality of life. Offer customers the following
advice and information:
The skin should be kept healthy by keeping it clean, hydrated,
moisturised and intact at all times. This will help to maintain the
lymphatic vessels beneath the skin layer but also minimise the risk of
any bacterial infection that could lead to cellulitis.
Emollients can be used for cleaning the skin as well as helping to
reduce the loss of water from the skin surface and increasing
hydration. Customers should gently apply the emollient to the skin in
the same direction as hair growth and in sufficient quantity (depending
on the severity of the skin damage). They should avoid rubbing the
emollient into the skin and should be advised not to use cosmetic skin
cleansers or moisturisers.
Encourage customers to regularly inspect their skin and look out for
any changes such as redness, breaks in the skin surface or signs of a
fungal infection, especially between the toes. They should report any
changes to their GP to prevent progression into a serious condition.
Encouraging customers to keep mobile and take gentle exercise can
also help them to manage chronic oedema.
Also in this series:
Improving
customer
care in
compression
hosiery
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without the written permission of the publishers,
Activa Healthcare in association
with CIG Healthcare Partnership.
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