Skill 9-11
Applying and Removing Graduated Compression Stockings
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Skill 9-11 Applying and Removing Graduated Compression Stockings
Graduated compression stockings are often used for patients at risk for deep vein thrombosis (DVT) and
pulmonary embolism, and to help prevent phlebitis. Manufactured by several companies, graduated compression
stockings are made of elastic material and are available in either knee- or thigh-high length. By applying pressure,
graduated compression stockings 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. An order is required from the patient’s health
care provider for their use.
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 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 nursing assistive personnel
(NAP) or to unlicensed assistive personnel (UAP), 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 in
your Supplemental Resources.
EQUIPMENT
Elastic graduated compression stockings in the ordered 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. Report 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, notify the health care provider 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 ordered to ensure correct fitting on
each leg (Muñoz-Figueroa & Ojo, 2015).
NURSING DIAGNOSIS
Determine related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing
diagnoses may include:
Ineffective peripheral tissue perfusion
Risk for impaired skin integrity
Deficient knowledge
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; patient will understand the rationale
for stocking application; and patient will remain free from deep vein thrombosis.
IMPLEMENTATION
ACTION
RATIONALE
1. Review the medical record and medical orders to
determine the need for graduated compression
stockings.
Reviewing the medical record and order 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 elastic 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,
usually elbow height of the caregiver (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 him or her lie down with legs
and feet well elevated for at least 15 minutes before
applying stockings.
Dependent position of 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
Helps maintain patient’s privacy. Powder and lotion
reduce friction and make application of stockings easier.
powder. If the skin is dry, a lotion may be used.
Powders and lotions are not recommended by some
manufacturers; check the package material for
manufacturer specifications.
8. Stand at the foot of the bed. Place hand inside
stocking and grasp heel area securely. Turn stocking
inside-out to the heel area, leaving the foot inside the
stocking leg (Figure 1).
Inside-out technique provides for easier application;
bunched elastic material can compromise extremity
circulation.
FIGURE 1. Pulling graduated compression stocking inside-out.
9. With the heel pocket down, ease the stocking foot
over the foot and heel (Figure 2). Check that the
patient’s heel is centered in heel pocket of stocking
(Figure 3).
FIGURE 2. Putting foot of stocking onto patient.
10. Using your fingers and thumbs, carefully grasp edge
of stocking and pull it up smoothly over ankle and calf,
toward the knee (Figure 4). Make sure it is distributed
evenly.
Wrinkles and improper fit interfere with circulation.
FIGURE 3. Ensuring heel is centered after stocking is on
foot.
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 toe section. If the stocking
has a toe window, make sure it is properly positioned.
Adjust if necessary to ensure material is smooth.
Ensures toe comfort and prevents interference with
circulation.
12. If the stockings are knee-length, make sure each
stocking top is 1 to 2 in below the patella. Make sure
the stocking does not roll down.
Prevents pressure and interference with circulation.
Rolling stockings may have a constricting effect on veins.
13. If applying 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
in below the gluteal fold (Figure 5). Adjust the stocking,
as necessary, to distribute the fabric evenly. Make sure
the stocking does not roll down.
Prevents excessive pressure and interference with
circulation. Rolling stockings may have a constricting
effect on veins.
15. Remove equipment and return patient to a position of
comfort. Remove gloves. Raise side rail and lower
bed. Place call bell and other essential items within
reach.
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.
FIGURE 4. Pulling stocking up leg.
16. Remove any other PPE, if used. Perform hand
hygiene.
FIGURE 5. Pulling stocking up over thigh.
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 top of stocking with your
thumb and fingers and smoothly pull stocking off
inside-out to heel. Support foot and ease stocking over
it.
EVALUATION
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.
The expected outcome has been met when the stockings are applied and removed, as indicated, with minimal
discomfort to the patient; patient exhibits a decrease in peripheral edema in the lower extremities; the patient
verbalizes an understanding of the rationale for stocking application; and remains free from deep vein thrombosis.
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
7/22/20 0945 Leg measurements: calf 14½ in, length heel to knee 16 in. Measurements equal bilaterally. Knee-high
graduated compression stockings (medium/regular) applied bilaterally. Posterior tibial and dorsalis pedis pulses + 2
bilaterally; capillary refill less than 2 seconds and skin on toes consistent with rest of skin and warm. Skin on lower
extremities is intact bilaterally.
—C. Stone, RN
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 primary care provider 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-resistant 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 ordered 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).
Remove stockings daily and inspect legs. Wash and air-dry, as necessary, according to 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 primary care provider.
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 deep vein thrombosis or phlebitis. Unilateral
swelling, redness, tenderness, pain, and warmth are possible indicators of these complications. Notify the
primary care provider of the presence of any symptoms.
Home Care Considerations
Make sure that the patient has an extra pair of stockings ordered during hospitalization before discharge (for
payment and convenience purposes).
Generally 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 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.
If putting on stockings is difficult, try wearing a pair of latex or rubber gloves, which will make it easier to grip
the stockings (Kim & Lee, 2015).
Evidence for Practice ▶
VENOUS THROMBOEMBOLISM PREVENTION
American Association of Critical-Care Nurses (AACN). (2010; updated 2016). AACN Practice alert. Preventing venous thromboembolism in
adults. Retrieved 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 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 ▶
VENOUS THROMBOEMBOLISM PREVENTION
Guyatt, G. H., Akl, E. A., Crowther, M., Gutterman, D. D., Schuünemann, H. J.; American College of Chest Physicians Antithrombotic
Therapy and Prevention of Thrombosis Panel. (2012). Executive summary: Antithrombotic therapy and prevention of thrombosis, 9th ed.:
American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2 suppl), 7S–47S.
This evidence-based guideline outlines best practices for the prevention of venous thromboembolism (VTE). The
use of mechanical methods of prophylaxis is included in the discussion.