Wound Care with Montgomery Straps
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Wound Care with Montgomery Straps

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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?

  • To comply with hygiene regulations
  • To confirm efficient management of time
  • To ensure the straps are decorative
  • To avoid causing additional trauma to the wound (correct)

    • What should be documented immediately after medication administration?

  • Potential side effects of the medication
  • Reasons for refusal of medication
  • Date, time, dose, route, and site of administration (correct)
  • Patient's condition prior to administration

    • Which of the following is NOT considered an additional piece of personal protective equipment (PPE) relevant to wound care?

  • Hypoallergenic tape
  • Skin-barrier sheet
  • Clean disposable gloves
  • Gauze pads (correct)

    • What should be included in the assessment of the wound and surrounding area?

    <p>Presence of sutures or staples</p> Signup and view all the answers

    Which nursing diagnosis is most directly related to potential issues arising from improper wound care?

    <p>Impaired Skin Integrity</p> Signup and view all the answers

    What is a primary reason for documenting PRN medication administration?

    <p>To verify the reason for administration</p> Signup and view all the answers

    What action should be taken if a medication is refused by the patient?

    <p>Record the refusal and notify the primary care provider</p> Signup and view all the answers

    What is the main goal of confirming medical orders relevant to wound care during the assessment?

    <p>To validate the correct procedure and patient</p> Signup and view all the answers

    Which of the following elements is important in the outcome identification and planning phase for wound care?

    <p>Keeping the patient's skin free from irritation</p> Signup and view all the answers

    What are Montgomery straps primarily used for?

    <p>Securing dressings on wounds that require frequent changes</p> Signup and view all the answers

    Who is typically NOT permitted to apply Montgomery straps according to delegation considerations?

    <p>Nursing Assistive Personnel (NAP)</p> Signup and view all the answers

    What is a significant reason for assessing the patient's comfort level before wound care?

    <p>To prepare the patient for possible discomfort</p> Signup and view all the answers

    When should the Montgomery straps be replaced?

    <p>Only if they become loose or soiled</p> Signup and view all the answers

    Which of the following is essential to prevent contamination during wound care implementation?

    <p>Minimizing contact with the wound area</p> Signup and view all the answers

    What is the benefit of using Montgomery straps over traditional adhesive strips?

    <p>They reduce the risk of skin irritation during frequent dressing changes</p> Signup and view all the answers

    Which factor is NOT considered when delegating the application of Montgomery straps?

    <p>The availability of materials required for the task</p> Signup and view all the answers

    What is the primary purpose of hand hygiene in a medical setting?

    <p>To prevent the spread of microorganisms</p> Signup and view all the answers

    How often should wound dressings be checked to ensure patient safety?

    <p>Every shift</p> Signup and view all the answers

    What is the recommended action when ties and straps used for dressing become soiled?

    <p>Replace them as soon as possible</p> Signup and view all the answers

    What is the maximum duration a silicone-based skin barrier can remain in place?

    <p>7 days</p> Signup and view all the answers

    Which of the following observations indicates proper wound healing in a patient?

    <p>The wound area is clean and free from contamination</p> Signup and view all the answers

    Why is hand hygiene important before a procedure?

    <p>It prevents the spread of microorganisms.</p> Signup and view all the answers

    What is the purpose of identifying the patient before an intervention?

    <p>It ensures the correct patient receives the intervention.</p> Signup and view all the answers

    What is the rationale behind closing the curtains around the bed?

    <p>To maintain the patient's privacy.</p> Signup and view all the answers

    Why should the caregiver assess the patient for pain before wound care?

    <p>To administer medication before the procedure starts.</p> Signup and view all the answers

    What is the benefit of positioning the bed at elbow height for the caregiver?

    <p>It prevents strain on the caregiver's back and muscles.</p> Signup and view all the answers

    What role does the waterproof pad serve during wound care?

    <p>It protects underlying surfaces from any leakage.</p> Signup and view all the answers

    Why is it recommended to explain the procedure to the patient?

    <p>It relieves anxiety and facilitates cooperation.</p> Signup and view all the answers

    What is the purpose of having a waste receptacle nearby during wound care?

    <p>To allow for quick disposal of soiled dressings.</p> Signup and view all the answers

    What is the primary purpose of wearing clean gloves during wound care?

    <p>To prevent the spread of microorganisms</p> Signup and view all the answers

    Why is it important to clean and dry the skin around the wound?

    <p>To prevent irritation and injury</p> Signup and view all the answers

    What is the function of a skin protectant in wound care?

    <p>To minimize the risk of skin breakdown</p> Signup and view all the answers

    What should be noted on the dressing after it is secured?

    <p>Date and time of application</p> Signup and view all the answers

    When fastening the dressing with straps, what is crucial to avoid?

    <p>Securing too tightly</p> Signup and view all the answers

    What is the rationale for removing additional PPE after wound care?

    <p>To reduce contamination risk</p> Signup and view all the answers

    What should be done with the remaining equipment after the dressing is applied?

    <p>Dispose of it properly</p> Signup and view all the answers

    What is the significance of the string ties used in dressing application?

    <p>They hold the dressing in place</p> Signup and view all the answers

    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.
    • 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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    Related Documents

    Montgomery Straps, Applying PDF

    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.

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