Today's Wound Clinic - Winter 2008 - (Page 50) instruction Figure 4: Example of paste bandage. Courtesy AAWC. Figure 5: Simple post op shoe can allow room for bandages and protect foot. Figure 6: Severe sliding of multilayered wrap after 1 week. may require twice-weekly applications. The length of wear of the outer wrap will drive the choice of primary ulcer dressing used. Examples: DYNA-FLEX (J&J, Somerville, NJ ), Profore, Proguide (Smith and Nephew, Largo, Fla), and Coban 2 Layer (3M, St. Paul, Minn). Paste bandages. Historically referred to as the Unna Boot, these paste bandages consist of roll gauze impregnated with zinc oxide, gelatin, and in some cases calamine. A self-adherent elastic wrap is applied over the paste wrap and the entire bandage dries to a semi-rigid bandage, providing approximately 30 mm Hg at the ankle. Unna boots can remain in place for up to 1 week and cannot be removed at night or for bathing. Examples: Viscopaste (Smith and Nephew, Largo, Fla) and Unna-Flex (Convatec, Skillman, NJ) (See Figure 4). Short-stretch bandage. Like the bandages previously mentioned, the short-stretch variety are applied from the base of the toes to the knees or above. Padding is applied directly to the skin, overwrapped by layers of dressing. Short-stretch wraps work well with the calf pump during ambulation and exercise. Although comparatively expensive, they are reusable and washable. Because of the rapid edema loss typically noted, they often need more frequent reapplication than other compression options. Examples: Comprilan (BSN Medical, Hamburg, Germany) and LoPress (Hartmann, Rock Hill, SC). 50 Winter 2007 Today’s Wound Clinic Problems with wraps. Long-term management of edema often requires the patient to wear compression socks or stockings. Worn faithfully, the stockings can mean the difference between maintaining and not maintaining ulcer healing. Compression stockings come with inherent difficulties, not the least of which is cost. Ironically, the Center for Medicare and Medicaid Services (CMS) will pay Additionally, another more enduring challenge with stocking use is that appropriate application requires flexibility and dexterity, making use difficult for some patients. Orthotic devices. Another long-term alternative for compression are orthotic devices consisting of inelastic straps that overlap and are secured with Velcro®. These devices are easier to apply, are durable, and therefore may be more cost effective than stockings. Examples: Farrow Wrap®(Farrow Medical Innovations, Bryan, Tex), CirCaid®, (Coloplast Corp. Minneapolis, Minn). Types of compression used throughout a patient’s treatment may change as the edema is better controlled and the wound heals. for stockings only when the patient has an ulcer, as part of the Surgical Dressing Policy. Further, because compression can be adjusted as the edema reduces and the nature of the treatment lends to drainage and soilage, a disposable system may be preferred. Stockings are a lifetime necessity. More than one pair is required, not unlike personal socks or stockings. This may cause patients to enter a cycle of repeated ulcerations if they cannot afford the stockings. CAVEATS FOR CARE Managing the patient requiring compression demands a definite level of competency and skill on the part of the staff and necessitates close attention to detail and patient follow-up. The following are important considerations in the management of the compressed patient. Constant assessment. Changes in edema levels and the potential for high ulcer exudate (especially early in the treatment) require frequent assessment of the patient, leg, and ulcer. Care visits may need to be scheduled twice weekly early on, progressing to weekly unless the patient has home health care and the agency providing the care can provide the appropriate type of wrap as well as the skill level of the nurse changing the wraps in the home setting. Calf and ankle measurements should be assessed
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