Wound Care Plan

Blisters – Cardiac overload

Last Updated
19 May 2025
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Quick Overview

Reference ID Number: TWS-WCP-77

Categories

Blister

Scope of Practice (ScOP) Designation

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

Treatment Goals

Maintain Skin integrity and monitor fluid filled blisters and improve venous return whilst allowing the patient to go back to work

Aim of Dressing

Apply oil based emollients to improve skin integrity and light compression to aid in venous return

Frequency of Dressing Change

Everyday

Consult(s) / Diagnostic Test Required

Arterial and Venous Duplex, Ankle Brachial Index (ABI) + Toe Brachial Index (TBI), Cardiac Medical Team for authorisation to compress lower limbs

References

Shopping List

Dressing Pack (Large),Normal Saline,Inadine (10cm x10cm),Jelonet Roll (15cm x 2m),Zetuvit Plus (20cm x 40cm),Urgo K2 lite (20mmhg compression) – 25-32cm
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

    Acute management (a)

    Whilst awaiting formalised ABI and TBIs and whilst the wound is healing as to not soil the FarrowWraps

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    Step 1

    Clean the legs

    clean the patient's legs gently in the shower if possible. If the blisters burst this is not an issue. They should not be deroofed if it can be avoided.
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    Step 2

    Wrap legs (part 1)

    Cover areas that have broken in inadine and the rest with jelonet roll.
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    Step 3

    Wrap legs (part 2)

    Place zetuvit over blistered areas to capture any fluid if it leaks
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    Step 4

    Wrap the leg (part 3)

    Using the oval shapes as a guide pull them till they are ovals and this is the right amount of stretch for both layers of the lite compression to go up the leg at a 50% overlap.
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    Acute Management (B)

    If patient is unable to tolerate compression bandages

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    Alternative step

    Acute management (a)

    Complete all steps in 'Acute management (a)' except 'Step 4'
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    Step 4

    Measure for tubular bandage

    Measure the patient's calf, ankle and forefoot and choose appropriately sized tubular bandage to match the patient's circumfrences. You will need between 2 and 3 differences. Each piece should overlap the next piece by approx. 2cm. If the patient can tolerate one layer apply another layer in the exact same manner.
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    Longer term

    Once ABI/TBIs have been completed and the wound(s) has healed (or has scant exudate). This patient had one leg that could have full 40mmHg of compression and another that could only have 20mmHg. A different mmHg rated FarrowWrap was used for each leg to meet these demands.

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    Alternative step

    Acute management (a)

    Complete all steps in 'Acute management (a)' except 'Step 4'
    Products Used
    Step 4

    Measure for FarrowWrap

    Contact your local FarrowWrap measurement provider to organise for the patient to be measured appropriately
    Products Used