Applying Elastic Stockings for CNAs: Step-by-Step Guide and Exam Tips

Elastic stockings, sometimes called compression stockings or TED hose (from the brand name Thrombo-Embolic Deterrent), are tight-fitting stockings designed to squeeze the legs gently. That gentle squeezing pressure does something important: it keeps blood moving through the veins rather than pooling in the lower legs. For residents who spend long stretches in bed or in a wheelchair, this pressure helps prevent two serious complications, deep vein thrombosis and edema.

Deep vein thrombosis (DVT) means a blood clot has formed inside one of the deep veins in the leg. This can happen when blood moves slowly or pools for extended periods. A DVT is dangerous not only because of the clot in the leg, but because that clot can break loose and travel to the lungs, causing a pulmonary embolism, which is potentially fatal. Edema is swelling from fluid buildup in the tissue, and while less immediately dangerous than DVT, it causes discomfort and can lead to skin breakdown over time.

Applying an elastic stocking is an official NNAAP skill listed by name on the exam checklist. The technique matters more than you might expect from something that resembles putting on a sock.

Why This Skill Matters on the CNA Exam

The NNAAP evaluator is watching for several specific behaviors during this skill: whether you inspect the leg before applying the stocking, whether the stocking is applied while the resident is lying flat, whether the heel pocket is positioned correctly, and whether you smooth out all wrinkles after application. Each of these is a distinct scored item, not just background context.

The skin inspection step is particularly important to evaluators because it reflects clinical judgment. Applying a compression stocking over a wound or area of breakdown can make the condition significantly worse. Demonstrating that you check before applying shows you understand why you are doing what you are doing, not just how to do the physical steps.

Check with your state's testing provider for the exact checklist items used in your area, as NNAAP test content can vary by state.

What You Need

• Knee-high elastic stocking in the correct size for the resident (check the care plan or ask the nurse)
• Gloves if the resident has any open skin, wound, or drainage on the leg
• A flat surface or bed with the resident lying down

When to Apply Stockings

The best time to apply compression stockings is in the morning, before the resident gets out of bed. When a person is lying flat, their legs are at the same level as the rest of their body and blood does not pool in the feet and ankles. As soon as someone stands or sits up, gravity pulls blood toward the lower extremities, and the veins fill up quickly. Applying the stockings before that happens means you are compressing a leg that is not yet swollen, which makes the stocking more effective and easier to put on.

If a resident has already been sitting or standing for a while and their legs are swollen, you may need to elevate the legs for a few minutes before application or ask the nurse. Never force a stocking onto a significantly swollen leg without guidance.

Step-by-Step: Applying One Knee-High Elastic Stocking

1. Wash your hands. Proper hand washing is scored at the start of every NNAAP skill.
2. Identify the resident and explain the procedure. Confirm the resident's identity and tell them you are going to apply a compression stocking. Let them know the stocking will feel snug and that they should tell you if they feel any pain, pinching, or numbness.
3. Position the resident lying flat. Have the resident lie flat on their back if possible. If they cannot lie completely flat due to a medical condition, position them as flat as they can comfortably tolerate. This is a scored step, applying the stocking with the resident upright is considered incorrect technique on the NNAAP exam.
4. Expose the leg and inspect the skin. Fold back the blanket or sheet to expose the leg you are working on while keeping the rest of the body covered for warmth and privacy. Look carefully at the entire leg: the foot, ankle, calf, and the back of the leg. You are looking for:
   • Redness or discoloration
   • Swelling or puffiness that seems unusual
   • Open wounds, blisters, or skin breakdown
   • Bruising, warmth, or areas that look different from the other leg
   If you see any of these, do not apply the stocking. Cover the leg, tell the resident you are going to check with the nurse first, and report your findings before proceeding. Document what you observed.
5. Prepare the stocking using the inside-out technique. Hold the stocking at the top opening and fold it down, turning it inside-out as you go, stopping when you reach the heel pocket. The toe section and foot should now be accessible from the outside and the calf section is gathered and bunched near the heel. This technique gives you precise control over heel placement, which is the hardest part of applying this type of stocking correctly.
6. Slide the stocking over the toes and foot. Hold the stocking open at the toe end and slide it over the resident's foot, pulling it back toward the heel. The toe seam or opening should sit right at the tips of the toes, allowing them to be visible and have room to move freely. Toes that are bunched under stocking fabric can develop pressure sores.
7. Position the heel pocket exactly at the heel. This is the most important technical step. The heel pocket is the rounded, slightly reinforced section of the stocking designed to sit over the heel bone. If it sits too far up the foot, the stocking will be too short at the top and may roll down. If it sits too far back, it bunches at the ankle. Hold the stocking at the heel and ease it into position until the heel pocket cups the heel perfectly.
8. Pull the stocking up the leg smoothly. Once the heel is positioned, pull the gathered calf section of the stocking up the leg toward the knee. Work in small sections, smoothing as you go. The goal is a completely flat, wrinkle-free stocking from toes to just below the knee. If the stocking is knee-high, the top band should sit two finger widths below the bend of the knee, not on the joint itself.
9. Check for wrinkles throughout. Run your hand along the entire stocking from foot to top. Any wrinkle or fold creates a tight band of pressure against a small area of skin. Over hours, this can cause significant tissue damage, especially in residents with reduced sensation or fragile skin. Smooth out every wrinkle before you consider the application complete.
10. Check the toes. Look at the visible toes. They should have normal skin color (pink in lighter-skinned residents, appropriate color for the resident's skin tone). They should not look pale, bluish, or dusky. Ask the resident if they feel any numbness, tingling, or unusual tightness. If they report symptoms or if the toes look compromised, remove the stocking immediately and notify the nurse.
11. Instruct the resident on reporting symptoms. Tell the resident clearly that they should use the call light if they notice any numbness, tingling, pain, or if a foot or toe changes color. These are signs that the stocking may be too tight or incorrectly positioned.
12. Cover the resident and finish. Replace the blanket or sheet. Ensure the call light is within reach. Wash your hands. Document that the stocking was applied, which leg, the time, and a brief description of the skin condition you observed before application.

What the Examiner Looks For

• Resident is positioned lying flat before the stocking is applied
• Skin is inspected before the stocking goes on
• CNA does not apply stocking over identified skin issues without checking with the nurse
• Stocking is gathered using the inside-out technique before application
• Heel pocket is positioned correctly over the heel
• Stocking is pulled up smoothly with no wrinkles or folds
• Toes are checked for color and circulation after application
• Resident is told to report numbness, tingling, or color changes
• Call light is placed within reach
• Hands are washed at the end

Common Mistakes to Avoid

• Applying the stocking while the resident is sitting or standing. This is one of the most commonly marked errors. When the resident is upright, their legs are already partially engorged with blood from gravity. The stocking is harder to pull on and less effective at preventing pooling because it is already full. Always apply before the resident gets up.
• Skipping the skin inspection. It takes less than 30 seconds to look at the leg. Skipping it and applying a stocking over a wound or compromised area is both a patient safety failure and a scored omission on the exam. Make it a non-negotiable first step every time.
• Misplacing the heel pocket. The heel pocket needs to sit over the heel, not at the arch and not halfway up the ankle. If it is off by even a little, the rest of the stocking will not lie flat, the ankle area will bunch, and a pressure point will form. Take your time on this step.
• Leaving wrinkles in the stocking. A wrinkle may look minor but it acts like a tight band cutting across the skin. Over the course of a day, it can cause an indentation or a pressure injury. Smooth the entire stocking every time, from toes to top band.
• Not checking the toes after application. Pale or blue toes indicate compromised circulation and require immediate removal of the stocking. This check is on the evaluator's checklist and takes only a few seconds. Never skip it.
• Forgetting to tell the resident what to report. Residents with reduced sensation may not feel numbness right away, but those who do need to know it is something to act on. A brief verbal instruction to report tingling, pain, or color changes is part of safe application and is scored.

Printable Practice Checklist

Use this checklist when practicing with a lab partner. Check off each step as you complete it.

1. Washed hands
2. Identified resident and explained procedure
3. Positioned resident lying flat
4. Exposed leg while keeping rest of body covered
5. Inspected skin: no redness, swelling, breakdown, or wounds
6. Gathered stocking inside-out to heel pocket
7. Slid stocking over toes and foot
8. Positioned toe opening at tips of toes
9. Positioned heel pocket exactly at heel
10. Pulled stocking up leg smoothly toward knee
11. Smoothed all wrinkles from toes to top band
12. Checked toes for normal color and circulation
13. Instructed resident to report numbness, tingling, or color changes
14. Replaced blanket or sheet
15. Placed call light within reach
16. Washed hands
17. Documented application and skin findings

Applying elastic stockings takes a specific rolling technique that is easier to learn by watching and doing. Find CNA training programs near you to practice this skill before your exam.

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