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Wound Care Plan

Epidermal Breakdown

Last Updated
15 April 2026
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Quick Overview

Reference ID Number: WL-WCP-20

Categories

Epithelial Ulceration

Scope of Practice (ScOP) Designation

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

Treatment Goals

To support epithelial cell growth.

Aim of Dressing

By reducing moisture at the affected area and applying compression, epidermal integrity may be supported.

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

    Small focal ulceration present on the distal limb.

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    Step 1

    Prepare Sterile Field

    Prepare a sterile field and arrange all sterile products using aseptic technique.
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    Step 2

    Clean wound bed

    Gently cleanse the affected area, as it may be very tender. If the area is very tender consider using a Debrisoft pad
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    Step 3

    Apply cream

    Apply Hyalo4 generously to the affected area.
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    Step 4

    Apply Mesalt to the wound.

    Do not be concerned about contact between Mesalt and Hyalo4, as the cream will be absorbed and the dressing will subsequently absorb exudate until the next change.
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    Step 5

    Apply zetuvit

    Application of the cream prior to dressing placement may result in adherence of the Zetuvit, as the cream is not absorbed into the pad.
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    Step 6

    Apply Tubular form

    Gently apply tubular form
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    Step 7

    Put on Urgo k2 Lite

    Using the printed oval markers as a guide, apply stretch until they form true ovals, indicating appropriate tension. Apply both layers of light compression up the leg with a 50% overlap.
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    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.
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    New Step 6

    Apply tubular bandage

    f compression bandaging is not tolerated or chosen by the patient, obtain measurements of the forefoot, ankle, and calf, and apply 2–3 tubular bandage sections with ~2 cm overlap, e.g. size B from forefoot to above ankle and size C from ankle to below knee.
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    Once ABI/TPI's have been completed

    Following completion of ABI/TBI testing and vascular clearance for compression, the appropriate level of mmHg should be determined and a compression wrap prescribed.

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    Alternnative (b) - Long Term

    Apply alternative compression

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

    Apply ' Wrap' (FarrowWrap OR ReadyWrap)

    Measurement should be undertaken by a suitably trained clinician to ensure appropriate sizing is selected for the patient.
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