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Bendaggio elastocompressivo
| Posted on March 3, 2020 at 1:50 PM |
Bendaggio Elastocompressivo B.E.C.
Il bendaggio elastocompressivo, rappresenta la terapia primaria delle ulcere da stasi dove diventa fondamentale l'applicazione sulla superficie cutanea di una pressione esterna capace di contrastare le pressioni intravenose patologiche. Il bendaggio elastocompressivo ha effetti terapeutici sul macro e microcircolo in caso di insufficienza venosa cronica. Il confezionamento di un bendaggio elastocompressivo provoca una riduzione del calibro venoso e dei reflussi patologici aumentando la velocità laminare del sangue refluo, riduce il sovraccarico valvolare, migliora il trasporto linfatico, riduce l'edema interstiziale. A differenza delle bende che utilizzeremo, confezioneremo un bendaggio elastocompressivo o un bendaggio contenitivo. Per l'elastocompressione impiegheremo bende con una componente elastica predominante, tale da dare alla benda un allungamento fino al 140 % della sua lunghezza. La memoria dell'elastico provocherà una pressione costante soprattutto a riposo ma accomoderà l'espansione muscolare a lavoro. Il bendaggio elastocompressivo sfrutta quindi la memoria elastica e il suo impiego è preferibile nei pazienti ipomobili o allettati. Nei pazienti deambulanti in linea di massima è preferibile un bendaggio elastocontenitivo, confezionato con bende a corta estensibilità o addirittura senza elastico. Questo bendaggio che come quello elastocompressivo dovrà partire dalle teste metatarsali e arrivare almeno fino al cavo popliteo, formerà sull'arto una sorta di stivaletto aderente che oltre a dare una leggera pressione a riposo non permetterà all'arto di espandersi riducendo l'edema. In fase di deambulazione lo stivaletto contenitivo si opporrà all'espansione di lavoro della muscolatura producendo una forza uguale e contraria che avrà come risultato uno strizzamento dei muscoli amplificando l'effetto della pompa muscolare responsabile del ritorno venoso. Questo tipo di bendaggio trova impiego in pazienti che mantengono l'autonomia del cammino e può rimanere in sito per parecchi giorni. Si utilizzano sistemi di bendaggio multistrato, sfruttando bende medicate come quelle alla cumarina o all'ossido di zinco aventi effetti anti edemigeni e ristrutturanti per la pelle. Per questi tipi di bende contenenti pasta o colla occorrerà tenere presente l'effetto di accorciamento delle bende stesse nel momento in cui si essiccano. Pertanto, è sconsigliabile un bendaggio a spirale che rischierebbe di strozzare l'arto bendato. Utilizzare la tecnica a “cerniera”: mezzo giro avanti e mezzo indietro.
Il mondo delle bende
I bendaggi hanno proprie caratteristiche che li rendono adatti a svolgere particolari azioni terapeutiche, quindi a seconda del momento causale dovrà essere applicato il bendaggio più adatto . Per questo motivo dobbiamo distinguere diverse categorie di bende.
1. BENDE DI FISSAZIONE
(fissano una medicazione, un catetere, un ago ad una parte del corpo): Anaelastiche (bende di garza orlata). Non sono estensibili.
Elastiche
- A tessitura elastica. Sono tutte quelle la cui estensibilità è unicamente dovuta alla trama del tessuto e che non contengono fibre di elastomeri.
- Ad elasticità permanente. Sono costituite da una bassa percentuale di filo di gomma, nylon o poliuretano. Mantengono la loro elasticità anche dopo ripetuti lavaggi .Il loro stato originale rimane invariato anche dopo l'estensione, ottenendo una forza relativamente elevata sui tessuti bendati.
· Coesive .Il potere coesivo (capacità dei singoli strati di aderire gli uni agli altri ma non alla pelle) è dato da gocce di lattice disposte sulla benda che, quando vengono a contatto tra loro, si attaccano. Possono causare problemi di allergia.
2. BENDE DI SUPPORTO (supportano un apparato , un'articolazione) :
· Bende tipo ideal; contengono il 65% di cotone e il 35% di poliammide .Hanno elastico nella tramatura ed orli cuciti che possono causare lacci di contenzione. Sono economiche
· Bende ideal; rispettano le norme DIM 61232 perciò devono avere gli orli tessuti a bordo macchina, che non si sfilano e non causano lacci, ed inoltre devono contenere minimo 80% di cotone ed il restante materiale deve essere viscosa (fibra naturale). Queste bende, proprio per le loro caratteristiche possono essere utilizzate per bendaggi elastocompressivi leggeri.
· Bende adesive. Sono sempre autoaderenti. La stoffa, che può essere elastica, è ricoperta da una massa adesiva (ossido di zinco, caucciù o polialcrato). Le bende all'ossido di zinco, autoaderenti, a corta estensibilità sono indicate per i bendaggi a lunga permanenza.
3. BENDE COMPRESSIVE
Per compressione intendiamo l'applicazione di una pressione attraverso una tensione data dall'uso di appropriate bende. Le bende ad azione compressiva hanno diverse caratteristiche che ci permettono di utilizzarle in base alle caratteristiche del paziente e all'azione terapeutica che si vuole ottenere.
Caratteristiche delle bende
1. Elasticità
· Anaelastiche. Non sono estensibili. Offrono il miglior supporto durante il lavoro muscolare, cioè hanno un'alta pressione in attività e una bassa pressione a riposo. I bendaggi anaelastici vengono sempre eseguiti senza tensione.
· Mono elastiche solo in senso longitudinale per aggiunta di fili elastici nell'ordito. Bielastiche elastiche in senso longitudinale e trasversale per aggiunta di fili elastici sia all'ordito che alla trama
2. Estensibilità
(capacità di allungamento dell'elastico limitatamente alla capacità di allungamento del tessuto a cui è associato) L'estensibilità è data dal rapporto tra la lunghezza della benda in tensione e la lunghezza della benda a riposo.
· Corta estensibilità :estensibili dal 40 al 70 % .Adatte a pazienti deambulanti, la loro energia di recupero è bassa, come è bassa la loro pressione a riposo. A muscolo attivo danno un supporto soddisfacente, cioè hanno un'elevata pressione in movimento. Si possono quindi portare sia a riposo che in movimento.
· Media estensibilità : estensibili dal 70 al 140%.Presentano una uguale pressione di riposo e di lavoro.
· Lunga estensibilità: estensibili oltre il 140 %. Contengono fili di poliuretano e materiali elastici, di conseguenza sviluppano una elevata pressione a riposo. Per questa ragione non devono mai essere portate durante la notte. Utili per pazienti allettati
3. Compressione
La pressione di compressione è la pressione esercitata sul tessuto dalla benda compressiva. In genere viene misurata in mm hg e dipende dal tipo di benda e dal tipo di tensione data da chi la applica . Esistono pertanto bende a compressione:
· Leggera
· Media
· Forte
Caratteristiche del bendaggio
L'applicazione ad un arto può essere di tipo:
Bendaggio Fisso (con bende all'ossido di zinco, adesive).Ha una durata di 5- 15 giorni.
- Ha un indice di guarigione intorno al 22%.
- Garantisce un'ampia azione di lavoro ed una bassa pressione a riposo.
- Ha un alto potere di ridurre l'edema
Però :
- Sussiste la possibilità che, riducendo l'edema, si riduca la pressione del bendaggio(se posizionato in presenza di edema dopo 24 - 48 ore può diventare insufficiente)
- Ha uno scarso potere assorbente delle secrezioni
- Si può verificare macerazione della cute, dermatite da contatto o irritativa
- Può emanare cattivo odore
- Può esser scarsamente accettato e tollerato dal paziente
Viene utilizzato per:
- edemi di diversa natura
- indurimenti infiammatori
- ulcere con poco secreto
- varicoflebite
- mantenimento dopo T.V.P.
- linfoedemi
- profilassi delle patologie venose in gravidanza
Bendaggio Mobile (si utilizzano bende non adesive a corta estensibilità oppure bende non adesive a lunga estensibilità).Ha una durata di 12-48 ore
- Garantisce pressioni molto variabili e poco stabili
- L'efficacia può essere limitata dalla facile dislocazione delle bende.
Tuttavia :
- E' semplice da eseguire
- E' ben tollerato dal paziente
- E' utile nella gestione iniziale dell'edema.
- E' utile in caso siano necessari frequenti accessi alla ferita
Viene utilizzato per :
- ulcere con produzione medio-alta di essudato
- fase iniziale del trattamento dell'edema
- prevenzione T.V.P.(trombosi venosa profonda)
- Sostegno dopo stripping
Bendaggio Multistrato (fino a quattro strati utilizzando bende sovrapposte di vario tipo)
- Rende fisso un bendaggio realizzato con benda elastica non adesiva
- Garantisce una compressione sostenuta, assicurando una pressione di circa 40 mm hg alla caviglia ,decrescente a 17 mm hg al ginocchio.Può essere lasciato in situ fino a 7 giorni. Questo bendaggio ha una capacità di assorbimento sufficiente a garantire il controllo dell'essudato fino ad una settimana senza necessità di cambiare il bendaggio.
- Può essere utilizzato su pazienti con una circonferenza della caviglia superiore ai 18 cm ,ma è stato studiato per dare i migliori risultati su caviglie con una circonferenza tra i 18 ei 25 cm
- Controindicato in caso di microangiopatia diabetica in stato avanzato o patologia arteriosa con indice ABI inferiore a 0,8.
· 1° strato: benda assorbente in viscosa, simile al cotone di Germania ma più morbida. Tecnica di bendaggio: a spirale
· 2° strato: benda in viscosa e cotone, serve a consolidare il primo strato ed è sufficientemente ruvida da far aderire meglio la terza benda. Tecnica di bendaggio: a spirale
· 3° strato: benda elastica a lunga estensibilità, viene applicata con tecnica a lisca di pesce. Si esercita una pressione di 23mm hg
· 4° strato: benda coesiva flessibile .Per il suo alto contenuto di lattice non deve essere posizionata a diretto contatto con la cute. Tale benda esercita una pressione di 17mm hg. Pertanto la pressione complessiva esercitata alla caviglia risulta essere di 40mm hg. Tecnica di bendaggio: a spirale
Il bendaggio : modalità di confezionamento
Nel trattamento delle ulcere rivestono grande importanza le procedure che si seguono nel compiere il bendaggio. Un esercizio costante e l'apprendimento della tecnica sono i fattori che fanno della benda un insostituibile presidio terapeutico. L'operatore ha la possibilità di scegliere la benda che meglio si adatta alla patologia che deve affrontare, ma nell'esecuzione del bendaggio deve seguire alcune regole imprescindibili.
Compressione decrescente. Se si utilizza una benda elastica non bisogna estenderla in modo eccessivo nella zona distale(malleolare) e non dare alcuna pressione nella zona prossimale del bendaggio (sotto il ginocchio).
Pieghe. Tra uno strato e l'altro del bendaggio è importante non lasciare spazi vuoti. Le pieghe possono favorire l'insorgenza di lesioni da decubito
Uniformità del bendaggio. Se si utilizza una benda a corta estensibilità non si devono sovrapporre molti più strati nella zona distale rispetto a quella prossimale.
Corretta posizione durante il bendaggio. Il piede va tenuto a 90°
Bendaggio fissato saldamente, ma senza impedire il movimento . La benda deve essere fissata intorno alla parte distale del piede con un doppio giro, quindi avvolta a spirale fin sopra la caviglia, per poi ritornare a coprire il tallone; la fasciatura continua lungo la gamba con ogni giro che copre la metà del giro precedente. E' molto importante includere il tallone nella fasciatura per evitare l'effetto emostatico della caviglia con conseguente edema del piede. Attenzione anche a fissare il bendaggio con cerotti: si può provocare un "effetto laccio".
Protezione delle aree a rischio. Le aree a rischio (cresta tibiale, tendini estensori, tendine achilleo) devono essere protetti da eventuali danni del bendaggio.
Protezione della cute. La cute, soprattutto nell'anziano o in caso di edema imponente, deve essere protetta impiegando sostanze grasse e/o eventualmente ammortizzatori.
Requisiti della compressione ideale
Estendersi in modo uniforme dalla base delle dita alla tuberosità tibiale. Garantire un gradiente di pressione decrescente dalla caviglia al polpaccio. Garantire un gradiente di pressione adeguato all'entità dell'edema coesistente e ai caratteri dell'ulcera. Garantire una pressione uniformemente distribuita sulle circonferenze anatomiche. Mantenere la pressione originariamente applicata fino al cambio della medicazione successiva. Essere confortevole e ben tollerata dal paziente. Svolgere una funzione complementare alla medicazione, soprattutto per quanto riguarda la funzione assorbente. Non essere irritante né allergizzante sulla cute. Non causare limitazioni alla vita di relazione del paziente per cattivi odori o difficoltoso uso di calzature normali. Il grado di cicatrizzazione sotto bendaggio è maggiore che in sua assenza, la contenzione elastica accelera la cicatrizzazione (A) Knight C.A. ,Mc Cullooch J. 1996
Le calze elastiche
L'elastocompressione, oltre che con un bendaggio può essere effettuata anche attraverso l'utilizzo della calza elastica. Distinguiamo tre tipi di calze elastiche :
· Preventive
· Antitrombo
· Terapeutiche
Le calze agiscono attraverso una tensione predeterminata della fibra elastica .L'operatore deve misurare il diametro (all'altezza della caviglia e del cavo popliteo) e la lunghezza della gamba a seconda del tipo di calza da impiegare. Solo in questo modo la terapia risulterà efficace .
Calze preventive
Si misurano in DEN ,ossia il calibro della fibra elastica con cui vengono intessute. Distinguiamo 3 tipi di calze :40 DEN, 70 DEN ,140 DEN. Questo tipo di calze va impiegato a scopo preventivo e in assenza di patologia e il suo uso deve essere proporzionato ai fattori di rischio. I fattori professionali, soprattutto la stazione eretta e la temperatura, vanno tenuti in grande considerazione. Le calze preventive garantiscono una pressione che ,a seconda del numero di denari, varia da 12 a 18 mm hg.
Calze antitrombo
Prevengono la trombosi venosa profonda .Vengono impiegate nel periodo perioperatorio, indossate prima dell'intervento e rimosse alla piena mobilizzazione. Determinano una compressione di 18 mm hg. Non sono indicate nel trattamento delle ulcerazioni cutanee.
Calze terapeutiche
Si misurano in mm hg e sono suddivise in 4 categorie o classi (K).
· Classe 1 = 15 - 21 mm hg
· Classe 2 = 23 - 32 mm hg
· Classe 3 = 34 - 46 mm hg
· Classe 4 = > 49 mm hg
E' necessario istruire il paziente sull'uso, sulle modalità con cui indossare la calza e sull'igiene della cute. La calza deve essere indossata al mattino, prima della comparsa dell'edema, e mantenuta il più a lungo possibile. Le calze elastiche vanno rimosse durante il riposo notturno, perché la riduzione del tono muscolare determina una ridotta protezione dalla compressione.
Inf. D.Bellini
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