Wound Care Plan

Epidermis Breakdown

Last Updated
19 May 2025
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Quick Overview

Reference ID Number: TWS-WCP-20

Categories

Epithelial Ulceration

Scope of Practice (ScOP) Designation

Registered Nurse (RN),Enrolled Nurse (EN),Medical Officer

Treatment Goals

To aid in the growth of epithelial cells

Aim of Dressing

By drying out the affected area and apply compression this will encourage the epidermis to regain its integrity.

Frequency of Dressing Change

Everyday

Consult(s) / Diagnostic Test Required

Arterial and Venous Duplex, Angiogram (after Vascular Surgery Consult) +/- Stenting/Ballooning

References

Shopping List

Dressing Pack (Small),Normal Saline,Mesalt Gauze (7.5cm x 7.5cm),Hyal04 Cream – Skin (25g),Tubular Form – Size G ( 51 – 60 cm),FarrowWrap

Associated Tutorials

Vasculitis – with FarrowWraps
Page Table of Contents

    Product Selection Disclaimer:

    The wound care products being currently used are a suggestion ONLY. They do not take into account your patient's individual needs which you must assess. No funding from medical companies has been provided and wound care products are chosen on their merit and what is available on the NSW Health State Wound Care Contract. Where an exact brand name product is not available we suggest you review the alternative tab or use another wound care product from its category eg. Hydrofibre

    Photo Gallery

    Care Plans

    Isolated Epithelial Ulceration

    A small area of ulceration on a distal limb

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    Step 1

    Prepare Sterile Field

    Prepare all sterile products on the field
    Products Used
    Step 2

    Clean wound bed

    Clean the affected area - gently. It will be very tender. If the area is very tender consider using a Debrisoft pad
    Products Used
    Step 3

    Apply cream

    Lather on the Hyalo4 cream
    Products Used
    Step 4

    Put mesalt onto wound

    Products Used
    Step 5

    Apply zetuvit

    Because you put the cream on first the zeutvits will stick to the cream. This particular cream will not be absorbed into the pad.
    Products Used
    Step 6

    Apply Tubular form

    Gently apply tubular form
    Products Used
    Step 7

    Put on Urgo k2 Lite

    Put on Urgo K2 Lite compression bandage
    Products Used

    Alternate compression to

    If Patient Unable to tolerate 20mmHg of compression as described in 'Isolated Epithelial Ulceration' care plan try the following.

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    Alternnative (a)

    Apply alternative compression

    Complete 'Isolated Epithelial Ulceration' up to but NOT including step 6.
    Products Used
    New Step 6

    Apply tubular bandage

    Where the patient can not tolerate or does not choose to wear the compression bandage measure the patient's calf, ankle and forefoot and fit 2 -3 pieces of tubular bandage up the patient's let with an overlap of 2cm. e.g 1 piece of size 'b' from forefoot to 2cm above the ankle and then 1 piece of size 'c' from ankle to 2cm below the knee
    Products Used

    Once ABI/TPI's have been completed

    Once ABI/TPI's have been completed and a vascular surgeon has deemed that the patient can have formalised compression an appropriate mmHg rate should be selected and a 'Wrap' purchased.

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    Alternnative (b) - Long Term

    Apply alternative compression

    Complete 'Isolated Epithelial Ulceration' up to but NOT including step 6.
    Products Used
    Alternnative (a)

    Apply ' Wrap' (FarrowWrap OR ReadyWrap)

    Patient should be measured by an appropriately trained clinician to make sure the correct size is selected for the patient.
    Products Used