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Wound Care Plan

Blisters – Cardiac overload

Last Updated
15 April 2026
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Quick Overview

Reference ID Number: WL-WCP-77

Categories

Blister

Scope of Practice (ScOP) Designation

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

Treatment Goals

To preserve skin integrity, monitor blister formation, optimise venous return, and facilitate safe return 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

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    Care Plans

    Acute management (a)

    Pending formal ankle-brachial index (ABI) and toe-brachial index (TBI) measurements, and throughout wound healing, to minimise contamination of FarrowWraps.

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    Step 1

    Clean the legs

    Perform gentle cleansing of the lower limbs in the shower if feasible. Spontaneous blister rupture is not a concern, but intentional deroofing should be avoided.
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    Step 2

    Wrap legs (part 1)

    Apply Inadine to areas of skin breakdown and cover remaining areas with Jelonet.
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    Step 3

    Wrap legs (part 2)

    Apply Zetuvit over blistered areas to absorb any exudate.
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    Step 4

    Wrap the leg (part 3)

    Utilise the oval indicators to guide stretch, ensuring they appear as ovals to achieve correct tension. Apply light compression in two layers with 50% overlap up the limb.
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    Acute Management (B)

    In cases where compression bandages are not tolerated

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    Alternative step

    Acute management (a)

    Complete all steps outlined 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 circumferences and select appropriately sized tubular bandages to match. Two to three different sizes may be required. Apply each section with approximately 2 cm overlap. If tolerated, apply a second layer in the same manner.
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    Longer term

    After ABI and TBI evaluation and when the wound is healed or producing minimal exudate, compression levels should be tailored per limb. One leg was managed with 40 mmHg and the other with 20 mmHg, utilising appropriately graded FarrowWrap systems.

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    Alternative step

    Acute management (a)

    Complete all steps outlined in ‘Acute Management (A)’ with the exception of Step 4.
    Products Used
    Step 4

    Measure for FarrowWrap

    Arrange measurement for the patient by contacting the local FarrowWrap provider.
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