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Questions and Answers
What is the primary purpose of assessing the integrity of any straps currently in use before wound care?
What is the primary purpose of assessing the integrity of any straps currently in use before wound care?
What should be documented immediately after medication administration?
What should be documented immediately after medication administration?
Which of the following is NOT considered an additional piece of personal protective equipment (PPE) relevant to wound care?
Which of the following is NOT considered an additional piece of personal protective equipment (PPE) relevant to wound care?
What should be included in the assessment of the wound and surrounding area?
What should be included in the assessment of the wound and surrounding area?
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Which nursing diagnosis is most directly related to potential issues arising from improper wound care?
Which nursing diagnosis is most directly related to potential issues arising from improper wound care?
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What is a primary reason for documenting PRN medication administration?
What is a primary reason for documenting PRN medication administration?
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What action should be taken if a medication is refused by the patient?
What action should be taken if a medication is refused by the patient?
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What is the main goal of confirming medical orders relevant to wound care during the assessment?
What is the main goal of confirming medical orders relevant to wound care during the assessment?
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Which of the following elements is important in the outcome identification and planning phase for wound care?
Which of the following elements is important in the outcome identification and planning phase for wound care?
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What are Montgomery straps primarily used for?
What are Montgomery straps primarily used for?
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Who is typically NOT permitted to apply Montgomery straps according to delegation considerations?
Who is typically NOT permitted to apply Montgomery straps according to delegation considerations?
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What is a significant reason for assessing the patient's comfort level before wound care?
What is a significant reason for assessing the patient's comfort level before wound care?
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When should the Montgomery straps be replaced?
When should the Montgomery straps be replaced?
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Which of the following is essential to prevent contamination during wound care implementation?
Which of the following is essential to prevent contamination during wound care implementation?
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What is the benefit of using Montgomery straps over traditional adhesive strips?
What is the benefit of using Montgomery straps over traditional adhesive strips?
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Which factor is NOT considered when delegating the application of Montgomery straps?
Which factor is NOT considered when delegating the application of Montgomery straps?
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What is the primary purpose of hand hygiene in a medical setting?
What is the primary purpose of hand hygiene in a medical setting?
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How often should wound dressings be checked to ensure patient safety?
How often should wound dressings be checked to ensure patient safety?
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What is the recommended action when ties and straps used for dressing become soiled?
What is the recommended action when ties and straps used for dressing become soiled?
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What is the maximum duration a silicone-based skin barrier can remain in place?
What is the maximum duration a silicone-based skin barrier can remain in place?
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Which of the following observations indicates proper wound healing in a patient?
Which of the following observations indicates proper wound healing in a patient?
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Why is hand hygiene important before a procedure?
Why is hand hygiene important before a procedure?
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What is the purpose of identifying the patient before an intervention?
What is the purpose of identifying the patient before an intervention?
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What is the rationale behind closing the curtains around the bed?
What is the rationale behind closing the curtains around the bed?
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Why should the caregiver assess the patient for pain before wound care?
Why should the caregiver assess the patient for pain before wound care?
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What is the benefit of positioning the bed at elbow height for the caregiver?
What is the benefit of positioning the bed at elbow height for the caregiver?
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What role does the waterproof pad serve during wound care?
What role does the waterproof pad serve during wound care?
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Why is it recommended to explain the procedure to the patient?
Why is it recommended to explain the procedure to the patient?
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What is the purpose of having a waste receptacle nearby during wound care?
What is the purpose of having a waste receptacle nearby during wound care?
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What is the primary purpose of wearing clean gloves during wound care?
What is the primary purpose of wearing clean gloves during wound care?
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Why is it important to clean and dry the skin around the wound?
Why is it important to clean and dry the skin around the wound?
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What is the function of a skin protectant in wound care?
What is the function of a skin protectant in wound care?
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What should be noted on the dressing after it is secured?
What should be noted on the dressing after it is secured?
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When fastening the dressing with straps, what is crucial to avoid?
When fastening the dressing with straps, what is crucial to avoid?
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What is the rationale for removing additional PPE after wound care?
What is the rationale for removing additional PPE after wound care?
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What should be done with the remaining equipment after the dressing is applied?
What should be done with the remaining equipment after the dressing is applied?
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What is the significance of the string ties used in dressing application?
What is the significance of the string ties used in dressing application?
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Study Notes
Wound Care with Montgomery Straps
- Documentation: Keep thorough documentation of medications for future reference.
- Montgomery Straps: Made from non-allergenic tape with ties, used to secure dressings for wounds needing frequent changes.
- Supplies: Clean gloves, skin protectant wipes, skin-barrier sheets, dressings, cleansing solution (normal saline, gauze pads).
- Considerations: Montgomery strap application is not delegated to nursing assistive personnel or unlicensed assistive personnel.
- Assessment: Assess the patient's wound to determine need for cleaning and dressing changes, assess their comfort and pain level, assess the current dressing (intact, drainage, bleeding, saturation) and the wound appearance for signs of healing.
- Nursing Diagnosis: Impaired Skin Integrity, Acute Pain, Delayed Surgical Recovery, Risk for Infection
- Outcome Identification and Planning: Prevent skin irritation and injury, ensure wound remains clean and trauma-free, promote comfort and minimize pain, progress towards optimal wound healing.
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Implementation:
- Perform hand hygiene and appropriate PPE.
- Identify the patient.
- Organize equipment within reach.
- Ensure patient privacy by closing curtains and providing explanations before the procedure.
- Assess pain level and administer pain medication if necessary.
- Ensure a waste receptacle is readily available.
- Position the bed at a comfortable height.
- Assist the patient to a comfortable position.
- Carry out wound care and dressing changes according to established procedures and orders.
- Cleanse the wound and dry the skin.
- Apply a skin protectant to the skin.
- Apply the skin barrier sheet, ensuring the openings for the ties are at the edge of the dressing.
- Secure the ties like shoelaces, not too tightly.
- Record date/time of application on the straps and the dressing.
- Dispose of equipment and ensure patient comfort.
- Remove PPE and perform hand hygiene.
- Monitor wounds every shift, more frequently if more complex or dressings become saturated quickly.
- Replace ties and straps when soiled or every 2-3 days.
- Replace skin barrier as needed.
- Evaluation: Patient's skin remains clean, dry, intact, and free from irritation and injury. Wound is clean, free from contamination and trauma. Patient experiences minimal to no pain and shows signs of progressive wound healing.
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Description
This quiz covers the essential aspects of wound care using Montgomery straps. It includes guidelines for documentation, the application of Montgomery straps, necessary supplies, and patient assessment criteria. Ideal for nursing students and professionals looking to enhance their knowledge in wound management.
