Weeping and edematous legs - unna boot?

[Goldentea]

I originally posted this in Home Health nursing, but I thought it would be more appropriate here...

I need some advice here. I have a pt. that has CHF that developed weeping with her swollen legs. I initially wrapped it in Kerlix and told pt. to keep elevating her legs; however, her skin got extremely irritated and reddened from the weeping. Pt's doctor referred her to go a lymph/wound clinic that is 1-2 hours away and family is reluctant to drive her there. I asked doctor for an order to use unna boot for pt, along with kerlix and ace bandage on top (along with order for antibiotic and increase lasix dosage). Doctor agreed. It has been one week since applying unna boot and pt's legs are still weeping, extremely red and painful, and now the weeping areas appear more open compared to before. Pt's legs are also extremely dry from the zinc paste. What else can I do for this pt to prevent her from being rehospitalized? I told family to make appt. to see doctor and make appt. to go to the lymph/wound clinic already. How long do I need to apply unna boot to see improvement or if there is a better dressing you recommend? Thanks!

[CrunchRN, ADN, RN]

Try to talk them into at least going to the wound clinic for a consultation and then you can do whatever they advice.

[mommy.19, MSN, RN, APRN]

I originally posted this in Home Health nursing but I thought it would be more appropriate here... I need some advice here. I have a pt. that has CHF that developed weeping with her swollen legs. I initially wrapped it in Kerlix and told pt. to keep elevating her legs; however, her skin got extremely irritated and reddened from the weeping. Pt's doctor referred her to go a lymph/wound clinic that is 1-2 hours away and family is reluctant to drive her there. I asked doctor for an order to use unna boot for pt, along with kerlix and ace bandage on top (along with order for antibiotic and increase lasix dosage). Doctor agreed. It has been one week since applying unna boot and pt's legs are still weeping, extremely red and painful, and now the weeping areas appear more open compared to before. Pt's legs are also extremely dry from the zinc paste. What else can I do for this pt to prevent her from being rehospitalized? I told family to make appt. to see doctor and make appt. to go to the lymph/wound clinic already. How long do I need to apply unna boot to see improvement or if there is a better dressing you recommend? Thanks![/quote']

There are many things to be considered here:

CHF status- while unna boots (including a Coban outer layer) are not considered active compression, it is still prudent to consider the amount of fluid that will be pushed back into systemic circulation from the lower extremities

Arterial status- does the patient have palpable or dopple-able pedal pulses? It sounds like enough edema is present to preclude palpating them, but this is an important factor in making the clinical decision to apply any type of compression to an extremity, no matter how mild

Is there a clinic closer to the patient?

If the patient is not improving, the dressing may be being applied improperly, the patient may not be compliant with elevation or diet, or cardiac function may have declined further, just a fee thoughts.

Sorry to answer your equations with questions, but you're on the right road thinking to compress venous insufficiency with compression wraps, and the patient will likely need some type of permanent garment after the acute phase of edema is gone, like juxta-lite circaids by medi (alternative to compression socks, also by rx).

Sent from my iPhone using allnurses.com

[CWONgal]

Goldentea, I am a little concerned after reading your post. Have you had formal wound care training? Did you have ABI or TBI results on your patient prior to considering wraps? You mentioned CHF...do you know when you aren't supposed to use the wraps? As mommy19 said does the patient have palpable pulses? Dopplerable pulses? Why did you ask for an antibiotic order? She really needs to be evaluated by a wound care clinic.

[kimcollins]

Just an FYI here. Unna boots are meant to work with an ambulatory pt. Is this pt ambulatory??

[mommy.19, MSN, RN, APRN]

Patients do not necessarily need to be ambulatory to receive therapeutic effect from the static compression of unna boots. As long as the patient has range of motion of the ankle as is able to activate the calf muscle pump, they will benefit. We have some patients who are unable to tolerate multilayer compression due to some degree of arterial disease, and they are god candidates for the use of unna boots even when non ambulatory or minimally ambulatory. Patient teaching is the key in these instances, and while it is ideal that the patient is ambulatory, sometimes nonambulatory status is not a definite contraindication. Sometimes it's not all black and white :)