Wound Care

126 Nurse to Nurse
Table 4–8 Indications and Contraindications of Four-Layer
Bandages
Indications Contraindications
Patient or caregiver unable to Patient or caregiver has poor
adhere to other treatment for personal hygiene
edema control
Patient or caregiver unable to Patient has significant arterial
independently wrap lower occlusive disease, ABI less than 0.8
extremity daily
Patient awaiting custom garment Active cellulitis
Lower extremity infected wounds
• During application the wrap should be cut to avoid pleats,
folds, or wrinkles that may cause damage to the skin.
• Use calamine-free wraps in patients allergic or sensitive to
calamine. Evaluate before wrapping.
• Patients with inverted champagne bottle leg—narrow ankle
and large calf—will most likely need ankle padding with
dressings (e.g., ABD pad) or cotton cast material to avoid
overpressurizing the calf.
• Four-Layer bandage (Tables 4–8 and 4–9)
— If applied correctly, this system provides 40 mmHg ankle
pressure graduating to 17 mmHg at the calf.
— Apply every 4 to 7 days or more frequently if excessive
exudate is present.
— Change immediately if the patient experiences severe
pain, excessive exudate, or foul odor.
• Expected outcomes
— Wrap remains in place for 7 days
— Lower extremity edema is controlled
— Measurements of ankle and calf circumference are
decreased
• Additional information on four-layer bandages