Compression Wrap Application Procedure Note (Multilayer)

Date/Time: [Date and time of procedure]

Location: [Location]

Performed by: [Clinician name and credentials]

Limb: [Right / Left] leg, [Anatomic extent] (Required: specify laterality and anatomic extent; do not leave unspecified.)

Procedure Summary

[1–2 sentence synopsis: multilayer compression wrap application to specified limb, primary indication, wrap system type/brand, and patient tolerance]

Indication and Clinical Goals

Primary indication: [Venous leg ulcer / Chronic venous insufficiency / Lymphedema / Clinically significant edema / Other]

Clinical goals: [Clinical goals for compression therapy]

[Brief supporting findings: edema severity, venous skin changes, wound presence] (Include only if explicitly mentioned.)

Contraindication and Risk Screening

(Document key safety assessments. Arterial perfusion screening is required and must not be omitted.)

• Arterial perfusion (required): [ABI/TBI value, date, and source; OR state unavailable/unreliable with reason and alternative assessment/plan] (If unavailable, insert "[ABI value needed]" and specify interim plan.)
• [ ] Cardiac status: [Heart failure history and current decompensation status]
• [ ] DVT risk: [Recent or suspected DVT status]
• [ ] Neuropathy/sensory loss: [Presence and distribution]
• [ ] Skin integrity: [Fragile skin, dermatitis, cellulitis, or other concerns]
• [ ] Allergies to wrap components: [Known allergies]
• [ ] Compression applied despite relative contraindication(s): [Clinical rationale and monitoring plan] (Include only if applicable.)

(For any positive finding, briefly note the risk mitigation plan.)

Baseline Limb Assessment

• Pain (pre-application): [Score 0–10, location, character]
• Edema: [Grade, pitting vs non-pitting, distribution]
• Skin inspection: [Color, temperature, integrity, venous changes, dermatitis, maceration]
• Wounds: [No open wounds; skin intact / Wound present with location, size, drainage, peri-wound description, primary dressing applied]
• Neurovascular status: [Pulses, cap refill, toe color/warmth, sensation] (Include if perfusion risk present.)

Materials and Wrap System

• System: [2-layer / 4-layer / Short-stretch / Other], brand/product: [Name]
• Ancillary materials: [Stockinette, padding type and placement, wound dressing if applicable]
• Target compression: [Standard / Modified] [Rationale if modified]

Procedure Technique

(Describe today's application only; do not copy forward prior technique without explicit confirmation.)

• Positioning: [Patient position, limb elevation status]
• Skin preparation: [Cleansing, emollient/barrier if applied]
• Landmarks: [Start point] to [End point]; heel [included / excluded]
• Layer application: [Padding placement, wrap pattern, tension approach, overlap]
• Secured with: [Securing method]
• Technique variations: [Accommodations for limb shape, fragile skin, or other circumstances] (Include only if applicable.)

Tolerance and Complications

• Tolerance: [Tolerated well / Symptoms noted]
• Complications: [None / Complications encountered]
• Interventions: [Actions taken if complications occurred] (Include only if applicable.)

Post-Application Assessment

• Pain (post-application): [Score 0–10]
• Toe/foot status: [Color, warmth, sensation, cap refill]
• Fit check: [No focal constriction / Adjusted]
• Mobility: [Ambulation status]

Patient Education

• Wear schedule: [Duration until next change, nighttime removal instructions]
• Activity/positioning: [Elevation, ambulation, and positioning instructions]
• Skin care: [Keep wrap clean/dry, bathing precautions]

Urgent warning signs reviewed:

• Severe or worsening pain not relieved by elevation
• Numbness/tingling or inability to move toes
• Toes becoming cold, pale, blue, purple, or markedly swollen
• Wrap slipping with tourniquet effect or deep indentation
• New spreading redness, fever, purulent drainage, or severe skin irritation
• New chest pain or shortness of breath

If warning signs occur: [Remove wrap immediately / Keep wrap on and call first]; contact: [Clinic number]; after-hours: [After-hours contact]

Written instructions provided: [Yes / No] Teach-back performed: [Yes / No] [Barriers if not possible]

Follow-Up Plan

• Next rewrap/dressing change: [Date or interval]
• Planned reassessments: [Repeat ABI/TBI, wound measurement, edema reassessment] (Include only those applicable.)
• Referrals: [Vascular, lymphedema therapy, wound clinic, or other referrals] (Include only if applicable.)
• Care team communication: [Messages or orders sent] (Include only if applicable.)

Signature

[Signature, credentials, date, and time]