Journal of Community Nursing - page 48

2013,Vol 27, No 4
Step 1
As part of holistic assessment, the
patient’s skin and limb should be
examined for the signs listed on
the CHROSS Checker chart. If any
are present, they should be ticked
accordingly. For example, if the limb
presents with ankle flare, this box
should be ticked in column 1
Figure 8)
. If the user requires further
information, the CHROSS Checker key
cards can be consulted
Figures 6 and 7
If multiple signs and symptoms
are present, the tick at the lowest
point of the chart represents the
most severe condition and it will
fall into a coloured background that
indicates if preventative (green),
intermediate (orange), or intensive
(red) management is required.
Step 2
Within the colour band of the lowest
tick, move across into the step 2
column. Step 2 confirms the presence
or absence of chronic oedema. In the
example provided (
Figure 8
), ankle flare
is present without oedema, so the‘no’
arrow in the green-coloured box should
be checked and followed across into the
step 3 column (
Figure 8
Step 3
Step 3 is where a recommendation is
made of the most appropriate hosiery to
manage the skin changes seen, as part
of an overall care plan. In the example
of ankle flare without oedema, given in
Figure 8
, the recommendation would be
Activa British Standard hosiery class 1
(14–17mmHg) if mild disease is present,
or class 2 (18–24mmHg) for moderate
disease. Although the cards provide
a guide, it is the responsibility of the
clinician to use their judgement and
expertise to grade the severity of disease
present, and make an appropriate
hosiery selection based upon this.
These compression
recommendations are repeated on the
reverse side of the key cards (
Figure 7
so that both parts of the kit can be used
together or separately in practice.
Compression therapy is a key
component of managing venous and
lymphovenous disease (Hardy,
2010). It enhances the functioning of
the calf muscle pump and also helps
to close faulty veins on calf muscle
relaxation, preventing the backflow
of blood. As a result of these actions,
it improves venous return and helps
to redistribute blood and fluid from
the lower limb back into the central
sections of the body, reducing venous
congestion and blood pressure (Torra i
Bou and Moffatt, 2008). Compression
has been seen to relieve thesymptoms
of venous and lymphovenous disease
and accelerate the healing rate of
venous ulcers, thereby improving the
general skin condition of the patient
(Moffatt, 2007). It is also known that
compression can improve lymphatic
transport and re-absorption of
lymph into the lymphatic system
(Foldi et al, 2006).
In limbs with chronic oedema,
and/or leg ulceration, compression
bandaging (most commonly short-
stretch [inelastic]) is usually used to
reduced limb volume and promote
healing. Once limb volume has
reduced and/or ulceration healed,
compression hosiery is commonly
prescribed to maintain limb volume
and shape, and to prevent ulcer
recurrence (Hardy, 2006). If hosiery is
not used following intensive therapy
episodes, the improvements gained
may be compromised (Timmons and
Bianchi, 2008). For patients with limbs
that do not fit standard sizes, made-to-
measure products are available.
There now exists a large range of
compression hosiery garments which
can be used at all stages of venous and
lymphatic disease development. For
patients with early stage skin changes
and no oedema who require preventive
treatment, the use of British Standard
hosiery is appropriate. British Standard
hosiery is lighter and cosmetically
acceptable, with many different styles
Figure 6.
CHROSS Checker key card (front) showing information on ankle flare.
Ankle flare
Distension of the small veins of the foot,
around the ankle
Chronic venous hypertension
Prevention: skin care, compression hosiery
Ankle flare
Hosiery recommendation
With oedema
Without oedema
European Class hosiery
Mild disease:
Class 1 (18–21mmHg)*
Moderate disease:
Class 2 (23–32mmHg)*
*If limb measurements do not match stock sizes,
use ActiLymph
Made to Measure hosiery
British Standard hosiery
Mild disease:
Class 1 (14–17mmHg)**
Moderate disease:
Class 2 (18–24mmHg)**
**if limb measurements do not match stock sizes,
use Credalast
Made to Measure hosiery
Figure 7.
CHROSS Checker key card (reverse) showing information on ankle flare.
1...,38,39,40,41,42,43,44,45,46,47 49,50,51,52,53,54,55,56,57,58,...116