Page 1716 - Saunders Comprehensive Review For NCLEX-RN

sitting or standing, constrictive
clothing, or crossing the legs when
seated.
c. Instruct the client to elevate the legs
above the level of the heart for 10 to 20
minutes every few hours each day.
d. Instruct the client in the use of an
intermittent sequential pneumatic
compression system, if prescribed
(used twice daily for 1 hour in the
morning and evening).
e. Advise the client with an open ulcer
that the compression system is applied
over a dressing.
4. Wound care
a. Provide care to the wound as
prescribed.
b. Assess the client’s ability to care for the
wound, and initiate home care
resources as necessary.
c. If an Unna boot (dressing constructed of
gauze moistened with zinc oxide) is
prescribed, the PHCP will change it
weekly.
d. The wound is cleansed with normal
saline before application of the Unna
boot; povidone-iodine and hydrogen
peroxide are not used, because they
destroy granulation tissue.
e. The Unna boot is covered with an
elastic wrap that hardens to promote
venous return and prevent stasis.
f. Monitor for signs of arterial occlusion
from an Unna boot that may be too
tight.
g. Keep tape off the client’s skin.
h. Occlusive dressings such as
polyethylene film or a hydrocolloid
dressing may be used to cover the
ulcer.
5. Medications
a. Apply topical agents to the wound as
prescribed to debride the ulcer,
eliminate necrotic tissue, and promote
healing.
b. When applying topical debriding
agents, apply an oil-based agent such
as petroleum jelly on surrounding skin

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