TREATMENT
PROTOCOLS
Contents
Wound Cleansing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Choosing the Best Treatment. . . . . . . . . . . . . . . . . . . . . 4
Pressure Ulcer Treatment Matrix . . . . . . . . . . . . . . . . . . 5
Wound Care Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Alginate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Silver Alginate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Antimicrobial Powder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Silver Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Foam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hydrocolloid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hydrogel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hydrogel Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Polyacrylate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Transparent Film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 11
Tunneling and Undermining . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Skin Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1
Contents (continued)
Lower Extremity Wounds. . . . . . . . . . . . . . . . . . . . . . . 12
Arterial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Venous Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Neuropathic/Diabetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Ankle-Brachial Index (ABI). . . . . . . . . . . . . . . . . . . . . . 13
ABI Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Compression: A Real Example of its Use . . . . . . . . . . . . . . . . . . 14
Comparison of Compression Wraps . . . . . . . . . . . . . . . . . . . . . 16
Compression Stocking Classifications . . . . . . . . . . . . . . . . . . . . 17
Compression Protocols. . . . . . . . . . . . . . . . . . . . . . . . . 17
Four-Layer Compression Bandage System . . . . . . . . . . . . . . . . . 17
Unna Boot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Skin Care Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Dimethicone Barrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Second Generation Barrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2
Worth
remembering ...
Wound cleansing
removes bacteria
and surface
contaminants to
allow the wound
to progress more
rapidly from the
inflammatory to
the proliferative
phase.
While developing a treatment plan for wounds, you should
assess not only the wound, but the entire patient. The factors
that affect wound healing need to be included in the overall
treatment plan. A clean pressure ulcer with adequate innervation and blood supply will show evidence of healing within
two weeks. Failure to do so should prompt a re-evaluation of
the plan of care (POC), an evaluation of adherence to the
plan, and a possible modification of the plan.
Wound Cleansing
The Agency for Healthcare Research and Quality (AHRQ)
recommends that wounds be cleansed initially and at each
dressing change. Optimal wound healing cannot occur until
all foreign material is removed from the wound. Wound
cleansing removes bacteria and surface contaminants to allow
the wound to progress more rapidly from the inflammatory to
the proliferative phase. While cleansing, minimize chemical
and mechanical trauma because traumatized wounds are more
prone to infection and slower to heal. Cleansing protects the
healing wound and minimizes the risk of infection.
For clean, granulating wounds, normal saline is a good
flushing solution. Commercial wound cleansers utilize
cleansing agents for optimal removal of debris and bacteria.
These cleansers also utilize surface tension between the wound
and the debris, allowing for more effective cleansing. The
delivery method of commercial cleansers is between 4 to 15
pounds per square inch (PSI); 8 PSI is optimal. Wounds with
necrotic tissue, debris or drainage may need more frequent
wound cleansing. The challenge is to clean effectively while
not harming living tissue. Use of appropriate cleansing agents
and PSI will assist with this challenge.
Examples of products and their PSI
3
•
•
2
8
PSI
PSI
•
8.6 PSI
•
42 PSI
bulb syringe
35 ml syringe with a 19-gauge needle or
an angiocatheter
trigger spray bottle containing commercial
cleanser set on the stream setting
waterpik® set on number three
Topical antiseptics are chemicals that are damaging to
normal wound tissue and destroy fibroblasts. Fibroblasts are
responsible for building collagen and granulation tissue. If
you choose to use topical antiseptics for wound cleansing,
consider using the lowest concentration documented to be effective. Re-evaluate the wound as necessary. Once bacterial
contamination is eliminated, resume non-antiseptic cleansing.
Consider instituting policies that limit how long fibroblasttoxic agents can be used.
Choosing the Best Treatment
Remember the mnemonic W-O-U-N-D? Following is an
example of its use.
W
Wound healing status: If the wound is healing or progressing, an optimal
moist wound environment is the goal. If the wound is not healing, there may
be several reasons. However, adding a product that will stimulate the
process, such as collagen, may be necessary.
Microbial content: A wound that has an increased bacterial load or is showing signs of infection may need an antimicrobial dressing. There are many
antimicrobial dressings on the market that use silver or an iodine base for
antimicrobial activity. They are also available in just about every form, such
as silver hydrogels, powders, sheet dressings, foams and alginates.
O
Optimal moisture: A dry wound may need a product that will donate
moisture, such as a hydrogel or hydrogel impregnated gauze. The wound
may also need a product that will retain moisture, such as a transparent
film dressing.
A heavily draining wound may require an alginate, foam or a combination
of both.
U
Understand the periwound skin: When choosing a dressing for the
wound, examine the periwound skin closely. It may help you determine
whether to use an adhesive dressing or a nonadhesive alternative. Periwound
protection with barrier products like skin prepping wipes or barrier creams
should also be considered.
N
Amount of necrotic tissue in the wound bed: If a wound has a
significant amount of slough or eschar, debridement may be necessary.
There are dressings that will aid in the debridement process, such as
polyacrylate debriders. If the wound bed is free of necrotic tissue,
the goal is optimal moisture management.
D
Wound depth: Addressing the dead space in the wound bed is crucial to
preventing premature closure of the wound. The goal is to allow the wound
to close from the “bottom up” without abscess formation.
4
Pressure Ulcer Treatment Matrix
Note: Clinical judgment is required if the drainage is moderate.
Once the dressing choice is made, proceed with the following protocols.
5
Wound Care Protocols
ALGINATE (Maxorb® Extra)
Used for:
• Stage III and IV, full-thickness
• Moderate to heavy drainage
1.
2.
3.
4.
5.
6.
7.
Clean the wound with a wound cleanser (Skintegrity®)
at each dressing change.
Pat the periwound skin dry.
Apply an alginate dressing.
If necessary, cover the wound with dry gauze.
Secure the dressing with a composite island
(Stratasorb®), bordered gauze (Bordered Gauze), rolled
gauze, retention tape (Medfix Retention Dressing Sheet)
or net dressing (Elastic Net).
If the wound is draining heavily, use a foam dressing.
Change the dressing every 1 to 7 days, depending on the
amount of drainage.
SILVER ALGINATE (Maxorb® Extra Ag)
Used for:
• Stage III and IV, full-thickness
• Moderate to heavy drainage
1.
2.
3.
4.
5.
6.
7.
Clean the wound with an antimicrobial wound cleanser
(MicroKlenz®) at each dressing change.
Pat the periwound skin dry.
Apply a silver alginate dressing.
If necessary, cover the wound with dry gauze.
Secure the dressing with a composite island
(Stratasorb®), bordered gauze (Bordered Gauze), rolled
gauze, retention tape (Medfix Retention Dressing Sheet)
or net dressing (Elastic Net).
If the wound is draining heavily, use a foam dressing.
Change the dressing every 1 to 7 days, depending on the
amount of drainage.
6
ANTIMICROBIAL POWDER (Arglaes® Powder)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• Moderate to heavy drainage
1.
2.
3.
4.
5.
6.
Clean the wound with an antimicrobial wound cleanser
(MicroKlenz) at each dressing change.
Pat the periwound skin dry.
Sprinkle the silver powder on the wound bed.
Place gauze over the powder, if necessary.
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), rolled gauze,
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 1 to 5 days, depending on the
amount of drainage.
COLLAGEN (Puracol Plus)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• All levels of drainage
• Slow healing wounds
1.
2.
3.
4.
5.
6.
7.
7
Clean the wound with a wound cleanser (Skintegrity)
at each dressing change.
Pat the periwound skin dry.
Apply the collagen directly to the wound bed.
The dressing may be cut if necessary to match the
wound size.
If the wound is dry, the dressing may be moistened
with saline.
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), rolled gauze,
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 1 to 7 days, depending on
the amount of drainage.
SILVER COLLAGEN (Puracol® Plus Ag)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• All levels of drainage
• Slow healing wounds
1.
2.
3.
4.
5.
6.
7.
Clean the wound with an antimicrobial wound cleanser
(MicroKlenz®) at each dressing change.
Pat the periwound skin dry.
Apply a silver collagen dressing.
The dressing may be cut if necessary to match the
wound size.
If the wound is dry, the dressing may be moistened
with saline.
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), rolled gauze,
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 1 to 7 days, depending on
the amount of drainage.
FOAM (Optifoam®, Optifoam Ag)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• Moderate to heavy drainage
1.
2.
3.
4.
5.
Clean the wound with a wound cleanser (Skintegrity) at
each dressing change.
Pat the periwound skin dry.
Apply a foam dressing that is at least 1½ inches larger than
the wound.
Secure the dressing with rolled gauze, retention
tape (Medfix Retention Dressing Sheet) or net dressing
(Elastic Net).
Change the dressing every 1 to 7 days, depending on the
amount of drainage.
8
HYDROCOLLOID (Exuderm Odorshield®,
Exuderm® Satin)
Used for:
• Stage II, partial-thickness
• Shallow Stage III and IV, full-thickness
• Moist to moderate drainage
1.
2.
3.
4.
5.
6.
7.
Clean the wound with a wound cleanser (Skintegrity)
at each dressing change.
Pat the periwound skin dry.
Apply a hydrocolloid dressing that is at least 2 inches
larger than the wound.
If it is a sacral wound, or an ulcer located in the sacral or
coccyx area, use a sacral or butterfly-shaped dressing.
Border the dressing with retention tape (Medfix Retention
Dressing Sheet) if the dressing does not have a border or
additional support is needed.
Change the dressing every 3 to 5 days, depending on the
amount of drainage, and if the dressing is loose or soiled.
Use an adhesive remover while changing the dressing to
ease discomfort.
HYDROGEL (SilvaSorb® Antimicrobial Gel,
Skintegrity)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• Dry-to-moist
1.
2.
3.
4.
5.
6.
7.
9
Clean the wound with a wound cleanser (Skintegrity) at
each dressing change.
Pat the periwound skin dry.
Use a hydrogel to line the wound bed (do not completely
fill the cavity) or dampen the gauze. If using hydrogel
impregnated gauze, line the wound so that the gauze is
covering the entire wound bed.
If necessary, cover the wound with dry gauze.
To address bioburden in the wound, us an antimicrobial gel.
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), rolled gauze,
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 1 to 3 days, depending
on the amount of drainage.
HYDROGEL SHEET (Dermagel)
Used for:
• Skin tears
• Stage II, partial-thickness
• Shallow Stage III and IV, full-thickness
• Dry to moderate drainage
1.
2.
3.
4.
5.
Clean the wound with a wound cleanser (Skintegrity)
at each dressing change.
Pat the periwound skin dry.
Apply a hydrogel sheet that is at least 2 inches larger than
the wound.
Secure with retention tape (Medfix Retention Dressing Sheet),
net dressing (Elastic Net) or rolled gauze.
Change the dressing every 3 to 5 days, depending on the
amount of drainage, and if the dressing is loose or soiled.
POLYACRYLATE (TenderWet® Active)
Used for:
• Stage II, partial-thickness
• Stage III and IV, full-thickness
• All levels of drainage
• Necrotic tissue, eschar and slough
• May be used in place of wet-to-dry dressings
1.
2.
3.
4.
5.
Apply a polyacrylate (TenderWet Active Superabsorbent
Polymer) pad to the wound bed.
If the wound is flat or shallow, apply a pad so that it slightly
overlaps the periwound skin.
If the wound is a cavity, the pad should be placed inside the
wound, in direct contact with the wound bed.
Secure the dressing with a composite island (Stratasorb),
bordered gauze (Bordered Gauze), rolled gauze,
retention tape (Medfix Retention Dressing Sheet) or
net dressing (Elastic Net).
Change the dressing every 24 hours.
10
TRANSPARENT FILM (Arglaes Antimicrobial Film,
SureSite®)
Used for:
• Stage I, Lower extremity ulcers
• Stage II, partial-thickness
• All levels of drainage
• Secondary dressing
1.
2.
3.
4.
5.
Clean the wound with a wound cleanser (Skintegrity)
at each dressing change.
Pat the periwound skin dry.
Cover the wound with a transparent dressing that
is at least 2 inches larger than the wound.
To address bioburden in the wound, use an
antimicrobial film.
Change the dressing every 1 to 5 days, depending on the
amount of drainage, or if the dressing is loose or soiled.
Special Considerations
Tunneling and Undermining
In general, wounds with tunneling should not be covered with
an occlusive dressing. Depending on the characteristics of the
wound, specifically drainage, the tunnel may be loosely filled
with a dry gauze packing material. If the wound is not draining, a hydrogel impregnated into the packing-strip may be
appropriate. The goal is to address the tunnel, but never pack
it tightly. Consider your ability to realistically retrieve the
material placed in the wound. If the tunnel is narrow and
long, for example, an alginate rope that may come apart
might not be the best choice.
If there is undermining, the wound care dressing (such as
hydrogel gauze) should be loosely tucked inside the wound so
that it comes in direct contact with the entire wound bed.
Skin Tears
Choosing a wound care dressing for a skin tear will depend
upon several factors. If a skin flap is present, after routine
cleansing the flap should be approximated, or brought together. Then, continue dressing the wound as necessary. If a
skin flap is not present, the area should be considered an open
wound and treated as such. Since skin tears are directly related
11
to the lack of both internal and external hydration, restoring
and maintaining fluid balance must be addressed. Dressings
such as hydrogel sheets provide protection, help maintain an
optimal moist wound environment and minimize adherence
to the wound.
Lower Extremity Wounds
Arterial Wounds
In general, do not use compressing or constricting garments
and avoid temperature extremes when treating arterial
wounds. If the blood flow status is unknown, a diagnostic
evaluation such as an ankle brachial index (ABI) is necessary
before treatment can be completed. If perfusion is found to be
compromised, yet adequate for healing, choose a dressing
based on the actual wound characteristics. If the blood flow is
determined to be inadequate for healing, surgical revascularization should be considered. Until blood flow is restored, the
wound should be kept clean, dry and free from infection.
Venous Insufficiency Wounds
When treating venous wounds, the key to healing lies in
compression. It is very important that this system is applied
correctly. Applying a compression wrap requires training.
Blood flow status must be evaluated and deemed adequate
before compression garments or dressings may be used. The
wound itself will need to be dressed based on its specific
characteristics, such as drainage and size. The lower extremity,
in general, may need additional moisturization and barrier
protection.
Neuropathic/Diabetic Wounds
Wounds that occur on the feet, or specifically the tips of the
toes, are often neuropathic/diabetic in nature. Treatment will
focus on the actual wound assessment, but there are a few
points to be aware of. Typically, these wounds are surrounded
with a callous that must be removed for the wound to close.
Many times serial debridement of the callous is required. Relieving pressure from the wound by wearing offloading
footwear, for example, will decrease callous buildup. Diabetes
control and close monitoring of blood sugars and A1C are
necessary for wound healing. Another important factor, as
with all lower extremity wounds, is assessing blood flow.
Assessment measures such as Doppler or color scanning may
be necessary in someone with diabetes.
12
Ankle-Brachial Index (ABI)
An ABI is the comparison of the blood flow pressures in
the lower leg to those in the upper arm. This measurement
screens patients for significant arterial flow problems to
the extremities. An ABI will identify patients for whom
compression would not be appropriate. This test might not
be accurate for diabetics, whose vessels are often calcified,
resulting in a false positive.
ABI Procedure
Items needed: Appropriately-sized blood pressure cuff, Doppler,
Acoustic Gel.
Procedure:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Place the patient in a supine position 5 to 15 minutes before
the test.
Obtain brachial systolic pressure in each arm using a blood
pressure cuff and a doppler probe.
Record the highest brachial systolic pressure.
Place a cuff around the affected ankle.
Apply acoustic gel over the dorsalis pedis or posterior tibial pulse.
At approximately a 45-degree angle, lightly touch the doppler
probe to the skin at either pulse location. Listen for the pulse.
Inflate the cuff higher than the brachial systolic pressure.
Slowly deflate the cuff, listening for the return of the pulse.
The point at which the arterial signal returns is recorded as
the systolic ankle pressure.
Repeat the procedure over the other pedal pulse to obtain
the ankle pressure on the affected extremity. Use the higher
of the two values.
To determine the ABI, divide the higher of the two ankle pressures
by the higher of the two brachial pressures. If only one ankle
pressure could be obtained, use it.
Ankle Pressure
= ABI
Brachial Pressure
Interpretation of the Ankle-Brachial Index:
>1.3
0.95 to 1.3
0.80 to 0.95
<0.8 to 0.5
<0.5
13
Abnormally high range (more studies needed)
Normal range
Compression is considered safe at this level
Indicates mild to moderate arterial disease
Severe arterial insufficiency
Compression: A Real Example of its Use
Mrs. PJ enters your hospital with her family and a vague
description of “poor circulation and a lot of swelling in both
of her legs.” You note a small shallow wound on her left lower
extremity. She is 76-years-old and obese. She has stress incontinence that is managed by a pant and liner system. She also has
dementia and is no longer able to perform her activities of
daily living (ADLs). After the initial assessment, you realize
that more information is needed before you can begin appropriate treatment. When you call her primary care physician’s
office, you are told that she has been diagnosed with lowerextremity venous disease (LEVD).
The gold standard of LEVD treatment is to use adequate
compression. However, before any form of compression is
applied, her arterial perfusion status must be determined.
If the lower extremity has either arterial or mixed (arterial and
venous) disease, applying compression is usually contraindicated and could lead to negative results. A fairly simple diagnostic test, the ABI, is often what is required to determine if
compression is appropriate. Her ABI is 0.85; while not ideal,
it is adequate and appropriate for compression.
There are several different ways to address wounds on the
lower extremity. As with Mrs. PJ, the initial assessment led to
further investigation and some detective work on the part of
the nurse. Obtaining all of the information from the family
as well as the primary care physician’s office allowed Mrs. PJ
to receive the best treatment for her LEVD. Since the wound
was small, had some drainage, and there was a concern for
bioburden, a silver alginate dressing and a four-layer
compression wrap was the dressing chosen. The entire
dressing is changed every 5 to 7 days.
The dressing chosen is based on factors such as:
•
® The wound’s characteristics.
® The frequency of dressing changes.
®
®
A daily wound dressing is not the best choice with a
compression wrap that is typically left in place for
seven days.
The ability of the patient or caregiver to apply
the dressing.
Reimbursement issues.
14
There are no studies that indicate a specific type of dressing,
or frequency of dressing change, that is appropriate for all
LEVD wounds. In addition to dressing choice, it is wise to
consider a short course of topical antimicrobial if the ulcer
has a high level of bacteria.
One of the most common complaints echoed by clinicians
is “my patient is noncompliant, and they will not leave
their compression system in place because they say it hurts.”
Realize that edema associated with LEVD can be very painful.
The challenge is to persuade your patient to continue the
treatment until the edema is reduced. Discuss with your
patient that this pain is not uncommon and usually lessens
over time with treatment. Talk with the primary physician
about prescribing appropriate analgesics for the first several
weeks of therapy.
How much compression is enough compression? It is documented that some compression therapy is more effective than
no compression therapy for the treatment of LEVD wounds.
High compression (30 to 50 mmHg) is more effective than low
compression; however, there are no differences in the effectiveness of the different types of products available for high compression therapy.
The most commonly used products for compression are wraps
or stocking-like products. Bandaging wraps should not be
applied by an inexperienced clinician. Proper technique is crucial and requires training. Wraps that are applied incorrectly
can apply too much compression to the wound, leading to
limb loss or damage. Too little compression can cause a delay
in healing, or even a decline in the wound’s condition.
15
Comparison of Compression Wraps
Performance
Characteristics
Type of
Compression
Examples
Amount of
Compression
Application of
Compression
Long-stretch
elastic bandages
Matrix,
SureWrap, Ace®
17 mmHg
pressure
Figure-eight from the Not reusable. It
toe to the knee, with loses its stretch
a 50 percent overlap. after the first
application.
Zinc paste
bandages
(inelastic
compression)
Primer® Boot,
Unna® Boot,
Dome Paste
Bandage
Initial pressure is
29.8 mmHg.
However, it falls
to 10.4 mmHg at
24 hours.
Applied in an overlapping fashion from
the toe to the knee,
with a 50 percent
overlap.
Not reusable.
Light-compression, support
Medigrip,
Tubigrip
12 to 15 mmHg
pressure in a
single layer.
Cannot apply graduated compression as
it does not conform
to the leg.
Washable, but not
dryer safe, for up
to 6 months.
Multilayer
FourFlex, ThreeFlex, Profore®,
Dynaflex
40 mmHg
pressure for up
to one week.
Refer to package insert for instructions.
Not reusable.
Cohesive or Self
adherent bandage
Co-Flex®,
Coban®,
Flex-wrap®
23 mmHg
pressure
Applied at 50
percent stretch,
with a 50 percent
overlap in
a spiral.
Not reusable.
Used with other
products to produce therapeutic
compression.
High Elastic
Compression
Setopress®,
Surepress®
Up to 40 mmHg
pressure
Refer to individual
package for instructions.
Can be washed up
to 20 times.
16
Compression Stocking Classifications
Class
Description
Ankle
Pressure
Indication
Class 1
Light support
20 to 30 mmHg
Treatment of varicose veins.
Class 2
Medium support
30 to 40 mmHg
Treatment and
prevention of LEVD.
Class 3
Strong support
40 to 50 mmHg
Treatment of LEVD.
Class 4
Very strong support
50 to 60 mmHg
Treatment of LEVD with
the close supervision
of a certified wound
specialist.
Compression Protocols
FOUR-LAYER COMPRESSION BANDAGE SYSTEM
(FOURFLEX)
1.
2.
3.
4.
5.
6.
17
Clean the surface of the wound bed with a commercial
cleanser (Skintegrity) or normal saline at each dressing change.
Pat the periwound skin dry.
Apply the barrier cream (Nutrashield) to the entire lower
extremity. Begin above the toes and extend to below the knee.
Apply the cream to the wound margins and avoid the area
between the toes.
Apply the appropriate wound dressing.
Apply the four-layer compression bandage system.
Layer #1 - Cast Batting - Apply in a spiral with a 50 percent
overlap. Begin just above the toes. Do not stretch. This
layer applies padding and provides for absorbency.
Layer #2 – Short Stretch Crepe - Apply in a spiral with a 50
percent overlap over the first layer. Do not stretch. This
layer smoothes down the first layer and provides additional
absorbency.
Layer #3- Long Stretch Bandage - Apply at a 50 percent stretch
in a figure 8, covering the 2nd layer.
Layer #4- Self-Adherent Wrap - Apply in a spiral at a 50 percent
overlap and a 50 percent stretch. Make sure that you release
several feet of dressing and then roll it back up before applying it.
Change the dressing every 5 to 7 days, or when the drainage
breaks through the top layer. It may be necessary to change the
four-layer wrap more frequently in the beginning as the drainage
initially increases.
UNNA BOOT
1.
2.
3.
4.
5.
Clean the surface of the wound bed with a commercial
cleanser (Skintegrity) or normal saline at each dressing
change.
Pat the periwound area dry.
Apply the unna boot bandage. Beginning just above the
toes, apply the wrap in a spiral fashion, stopping just below
the gatch of the knee.
Cover the unna boot with a self-adherent bandage
(CoFlex). Begin just above toes and wrap in a spiral at
50 percent stretch with a 50 percent overlap.
Change every 5 to 7 days, or when the drainage strikes
through the secondary dressing.
Skin Care Protocols
DIMETHICONE BARRIER (Remedy® Nutrashield)
Used for:
• Stage I
• Prevention
1.
2.
3.
4.
5.
Clean the wound as necessary.
Apply a dimethicone moisture barrier to the wound
and surrounding area.
If the area is on the lower extremity, elevate the
patient’s heels.
If the wound is in the perineal area, this barrier
may be used as part of incontinence care.
Apply the barrier to the wound daily or every
8 to 12 hours, as needed.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
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SECOND GENERATION BARRIER (Remedy Calazime®)
Used for:
• Stage I, partial-thickness
• Dermatitis related to venous disease of the
lower extremity
• Multiple open areas related to incontinence
1.
2.
3.
4.
5.
Clean the wound as necessary.
Apply a protectant paste to the wound and surrounding area.
If the area is on the lower extremity, elevate the
patient’s heels.
If the wound is in the perineal area, this barrier
may be used as part of incontinence care.
Apply the barrier to the wound daily or every
8 to 12 hours, as needed.
Note: All products shown in italics are distributed by Medline Industries, Inc.
and are used for example purposes only.
References:
Blair SD, Wright DDI, Backhouse CM, et al. Sustained compression and healing
of chronic venous ulcers. British Medical Journal. 1988;297:1159-1161.
Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg
ulcers: guideline for management of wounds in patients with lower extremity
venous disease. Wound Ostomy and Continence Nurses Society. 2005;4(2):13.
Larson-Lohr V, Fleck CA. Modern Wound Dressings: Principles, form and
function. In: Sheffield PJ, Smith APS, Fife CE, eds. Wound Care Practice.
2nd Edition. Best Publishing. Flagstaff, AZ. 2007:921-946
Moffatt CJ. Compression bandaging – the state of the art. Journal of Wound
Care. 1992;1(1):45-50.
Moffatt CJ, Dickson D. The charing cross high compression four-layer bandage
system. Journal of Wound Care. 1992;2(2): 91-94.
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