Wound Care Professional - Compression wrap impregnated with paste (Unna boot)

Abstract

Purpose:

Management of chronic lower extremity venous disease with leg ulcers and dermatological skin conditions such as chronic eczema and dermatitis. This is only appropriate where compression, occlusive wrap is indicated. Classified as inelastic-rigid compression therapy.

Policy:

Documentation confirming lower extremity venous disease

Compression wrap applied by skilled, trained clinician per order by physician, provider, or prescribing authority

Unna boot is indicated only for ambulatory patients who must be encouraged to walk daily

The most significant feature of the Unna boot is rigidity

Upon ambulation, the rigid compression wrap restricts outward movement of calf muscle directing the contraction force inward to improve calf muscle pump

Prior to application, the patient should be assessed to rule out lower extremity arterial disease. Compression wrap can be used if the patient's Ankle Brachial Index (ABI) is equal or greater to 0.80 mmHg

Compression wrap can remain in place for up to 7 days.

Precautions:

The patient must be ambulatory for use of compression wrap impregnated with paste

Inelastic wrap does not stretch

Compression approximately 20 mmHg when ambulating

Do not apply tightly; allow for possible swelling of leg

Assessment to rule out arterial disease is vital. Failure to detect significantly reduced arterial blood flow can result in pressure necrosis, amputation of limb or even death

Do not apply if ABI is less than 0.80 mmHg; or if patient has diabetic advanced small vessel disease

Promptly remove if patient develops pain, swelling, itching, excessive drainage, foul odor; pale, cool or numbness of extremity distal to wrap; becomes wet, soiled, or slippage occurs

Does not accommodate moderate to high exudative wounds and fluctuating edema

Do not get compression wrap wet. Cover with plastic protector for bathing

If very thin ankle or prominent tibial crest, apply extra padding to prevent pressure necrosis

The skin of leg ulcer patients is easily sensitized to topical medicaments, including preservatives. Sensitization should be suspected in patients, particularly where there is deterioration of the surrounding skin

Common ingredients include calamine, zinc oxide, glycerin, or gelatin

Review contraindications for compression wrap (manufacturer instructions for use).

Steps

1. Gather supplies to bring to patient's room. Knock on the door before entering. Introduce yourself. Call patient by their name and confirm patient by checking their armband. Provide privacy to the patient and explain procedure.
2. Prepare a clean, dry workspace. Place trash bag within reach. Wash hands; apply gloves.
3. Wash and dry extremity. Remove and discard gloves in trash bag.
4. Apply clean gloves. Assess leg and wounds. Provide prescribed wound treatment, if indicated, according to the wound dressing procedure. Remove and discard gloves in trash bag.
5. Apply clean gloves. Gently apply moisturizer to skin for added protection. Remove and discard gloves in trash bag.
6. Apply clean gloves. Measure ankle circumference. If less than 18cm, apply padding.
8. Open paste bandage package and read instructions for use.
9. Place the patient's foot in dorsiflexion position (90°).
10. Place the end of paste bandage at the base of metatarsal heads (base of toes), plantar surface. Begin wrapping bandage loosely around the patient's foot, heel and leg in a spiral fashion, lateral to medial.
11. Wrap leg with 50-75% overlapping layers. Do not use tension during bandage wrapping.
12. Apply smoothly by molding bandage with hands during wrapping. Cut the bandage as needed to prevent wrinkles, pleats and folds. Restart wrapping where bandage was cut.
13. Continue wrapping to 1” below the knee (approximately two fingers distance below the posterior bend of the knee). Remove and discard gloves in trash bag.
14. Apply clean gloves. Cover paste bandage by wrapping with roll gauze, adhesive, or tubular bandage to prevent soiling of clothing. Secure with tape. Initial and date the compression wrap.
15. Place soiled supplies in trash bag. Remove and discard gloves in trash bag. Wash hands. Place the patient in a comfortable position.
16. Document in the patient's medical record:
Wound assessment and dressing change.
Application of compression wrap, assessment findings and patient's tolerance of application.
17. Reassess bandage when dry (2-3 hours). It becomes stiff and rigid. Observe exposed foot area for adequate circulation (color, pulse, warm or cool).
18. FREQUENCY OF CHANGE
Wear time may range from 3 to 7 days.
Change if becomes saturated with wound drainage, wet from bathing, or becomes loose.
19. REMOVAL
Manual: Unwrap bandage carefully
Using bandage scissors, cut on the side opposite the ulcer.
Use caution to keep scissors away from the anterior tibial area to prevent trauma.
Begin at the bottom of the boot and cut upward to the ankle

Key points

Apply in the morning when any edema is at lowest.
Always assess associated pain from bandaging.
If applied too tightly, the bandage may cause the patient discomfort and/or act like a tourniquet when it dries. If applied too loosely, the paste bandage is ineffective.
May apply additional layers by wrapping back down the leg.
As the volume of the leg decreases, the boot loses effectiveness.