Wound Care Plan

Ischaemic Toe (Arterial Disease) – multiple toes (with a heel pressure injury)

Last Updated
19 May 2025
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Quick Overview

Reference ID Number: TWS-WCP-29

Categories

Ischaemic Areas

Scope of Practice (ScOP) Designation

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

Treatment Goals

To inhibit wet necrosis from occurring and allow for demarcation to occur

Aim of Dressing

To keep the necrotic tissue dry and the dry out the tissue in direct contact with it to stop wet necrosis and the possibility of sepsis from occuring

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),Iodine (100ml) (AKA Betadine),Biatain Foam (Non-adhesive) (10cm x 10cm),Sterile Scissors,Zetuvit Plus (10cm x 20cm),Cotton Bandage and Crepe,Mepilex Heel (13cm x 20cm)
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

    Multiple toes

    Patient has multiple toes that are necrotic with a heel pressure injury.

     Swipe 
    Step 1

    Clean the foot

    Remove all the previous betadine paint (as much as possible). This could be using normal saline or in the shower if there are no open wounds
    Products Used
    Step 2

    Paint with betadine

    Paint everything from the forefoot to the toes in betadine. There is no such thing as too much betadine. Always look out for areas are wet as these will need to be watched to make sure they don't grow
    Products Used
    Step 3

    Paint heel with betadine

    This will allow the pressure injury to show itself and demarcate appropriately
    Products Used
    Step 4

    Apply heel protector

    Once the betadine has dried out on the heel apply the heel protector
    Products Used
    Step 5

    Apply toe spacers

    Once betadine has dried around the toes apply toe spacers. In this particular foot there was a large gap between the first and second toes so biatian foam was used but normal gauze spacers are used normally (see last photo in gallery)
    Products Used
    Step 6

    Cover toes with zetuvit

    When possible keep the toes exposed to stop sweat and moisture building up. ** at patient's request we covered it ** Lay zetuvit over the toes. and secure with cotton bandage and crepe.
    Products Used