Montgomery Straps, Applying PDF

‘–‰‘‡”›–”ƒ’•ǡ’’Ž›‹‰ 575 DOCUMENTATION Document the administration of the medication immediately after administration, including date, time, dose, route of administration, and site of administration on the CMAR/MAR or record using the required format. If using a bar-code system, medi...

‘–‰‘‡”›–”ƒ’•ǡ’’Ž›‹‰ 575 DOCUMENTATION Document the administration of the medication immediately after administration, including date, time, dose, route of administration, and site of administration on the CMAR/MAR or record using the required format. If using a bar-code system, medication administra- tion is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason the medication was omitted and ensures that the primary care provider is aware of the patient’s condition.  ͕͔͚     Montgomery straps are prepared strips of nonallergenic tape with ties inserted through holes at one end. One set of straps is placed on either side of a wound, and the straps are tied like shoelaces to secure the dressings. When it is time to change the dressing, the straps are untied, the wound is cared for, and then the straps are retied to hold the new dressing. Often a skin barrier is applied before the straps to protect the skin. The straps or ties need to be changed only if they become loose or soiled. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. These straps allow the nurse to perform wound care without the need to remove adhesive strips, such as tape, with each dressing change, thus decreasing the risk of skin irritation and injury. DELEGATION CONSIDERATIONS Application of Montgomery Straps is not delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP). Depend- ing on the state’s nurse practice act and the organization’s policies and procedures, this procedure may be delegated to licensed practical/voca- tional nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. EQUIPMENT Clean disposable gloves Commercially available Mont- Additional PPE, as indicated gomery straps or 2- to 3-inch Dressings for wound care, as hypoallergenic tape and strings ordered for ties 576 SKILL 106 Cleansing solution, usually Skin-protectant wipe normal saline Skin-barrier sheet (hydrocol- Gauze pads loidal or nonhydrocolloidal) ASSESSMENT Assess the situation to determine the need for wound cleaning and a dressing change. Assess the integrity of any straps currently in use. Replace loose or soiled straps or ties. Confirm any medical orders relevant to wound care and any wound care included in the nursing plan of care. Assess the patient’s level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to prior dressing changes and the effectiveness of interventions employed to minimize the patient’s pain. Assess the current dressing to determine if it is intact. Assess for excess drainage or bleeding or saturation of the dressing. Inspect the wound and the surrounding tissue. Assess the appearance of the wound for the approximation of wound edges, the color of the wound and surrounding area, and signs of dehiscence. Assess for the presence of sutures, staples, or adhesive closure strips. Note the stage of the healing process and characteristics of any drainage. Assess the surrounding skin for color, temperature, and edema, ecchymosis, or maceration. NURSING DIAGNOSIS Impaired Skin Integrity Acute Pain Delayed Surgical Recovery Risk for Infection OUTCOME IDENTIFICATION AND PLANNING Patient’s skin is free from irritation and injury. Care is accomplished without contaminating the wound area, caus- ing trauma to the wound, and/or causing the patient to experience pain or discomfort. Wound continues to show signs of progression of healing. IMPLEMENTATION ACTION RATIONALE 1. Review the medical orders Reviewing the order and plan of for wound care or the nurs- care validates the correct patient ing plan of care related to and correct procedure. Prepara- wound care. Gather neces- tion promotes efficient time sary supplies. management and an organized approach to the task.  ‘–‰‘‡”›–”ƒ’•ǡ’’Ž›‹‰ ǦǦǦ 577 ACTION RATIONALE 2. Perform hand hygiene and Hand hygiene and PPE prevent put on PPE, if the spread of microorganisms. indicated. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Assemble equipment on Organization facilitates perfor- overbed table within reach. mance of the task. 5. Close the curtains around the This ensures the patient’s bed and close the door to the privacy. Explanation relieves room, if possible. Explain anxiety and facilitates coopera- what you are going to do and tion. why you are going to do it to the patient. 6. Assess the patient for pos- Pain is a subjective experience sible need for nonphar- influenced by past experi- macologic pain-reducing ence. Wound care and dressing interventions or analgesic changes may cause pain for some medication before wound patients. care dressing change. Admin- ister appropriate prescribed analgesic. Allow enough time for the analgesic to achieve its effectiveness before beginning the procedure. 7. Place a waste receptacle at a Having a waste container handy convenient location for use means that the soiled dressing during the procedure. may be discarded easily, without the spread of microorganisms. 8. Adjust bed to comfortable Having the bed at the proper working height, usually height prevents back and muscle elbow height of the caregiver strain. (VISN 8, 2009). 9. Assist the patient to a com- Patient positioning and use of a fortable position that provides bath blanket provide for comfort easy access to the wound area. and warmth. Waterproof pad pro- Use a bath blanket to cover tects underlying surfaces. any exposed area other than the wound. Place a waterproof pad under the wound site. 578 SKILL 106 ACTION RATIONALE 10. Perform wound care and a Wound care aids in healing and dressing change as outlined protects the wound. in Skills 55 through 57 and Skill 185, as ordered. 11. Put on clean gloves. Clean Gloves prevent the spread of the skin on either side of microorganisms. Cleaning and the wound with the gauze, drying the skin prevents irritation moistened with normal and injury. saline. Dry the skin. 12. Apply a skin protectant to Skin protectant minimizes the the skin where the straps risk for skin breakdown and will be placed. irritation. 13. Remove gloves. Tape is easier to handle without gloves. Wound is covered with the dressing. 14. Cut the skin barrier to the Skin barrier prevents skin irrita- size of the tape or strap. tion and breakdown. Apply the skin barrier to the patient’s skin, near the dress- ing. Apply the sticky side of each tape or strap to the skin barrier sheet, so the openings for the strings are at the edge of the dressing. Repeat for the other side. 15. Thread a separate string Ties hold the dressing in place. through each pair of holes Tying too tightly puts additional in the straps, if not already stress on the surrounding skin. in place. Tie one end of the Recording date and time pro- string in the hole. Fasten the vides a baseline for changing other end with the opposing straps. tie, like a shoelace (Figure 1). Do not secure too tightly. Repeat according to the FIGURE 1 Tying Montgomery straps.  ‘–‰‘‡”›–”ƒ’•ǡ’’Ž›‹‰ 579 ACTION RATIONALE number of straps needed. If commercially prepared straps are used, tie strings like a shoelace. Note date and time of application on strap. 16. After securing the dress- Recording date and time provides ing, label dressing with communication and demonstrates date and time. Remove all adherence to plan of care. Proper remaining equipment; place patient and bed positioning pro- the patient in a comfortable motes safety and comfort. position, with side rails up and bed in the lowest position. 17. Remove additional PPE, if Removing PPE properly reduces used. Perform hand the risk for infection transmission hygiene. and contamination of other items. Hand hygiene prevents the spread of microorganisms. 18. Check all wound dressings Checking dressings ensures the every shift. More frequent assessment of changes in patient checks may be needed if the condition and timely intervention wound is more complex or to prevent complications. dressings become saturated quickly. 19. Replace the ties and straps Replacing soiled ties and straps whenever they are soiled, or prevents growth of pathogens. every 2 to 3 days. Straps can Minimizing removal of skin bar- be reapplied onto skin bar- rier prevents skin irritation and rier. Skin barrier can remain breakdown. A silicone-based in place up to 7 days. Use adhesive remover allows for the a silicone-based adhesive easy, rapid, and painless removal remover to help remove the without the associated problems skin barrier. of skin stripping (Denyer, 2011; Benbow, 2011). EVALUATION Patient’s skin is clean, dry, intact, and free from irritation and injury. Patient exhibits a clean wound area free of contamination and trauma. Patient verbalizes minimal to no pain or discomfort. Patient exhibits signs and symptoms indicative of progressive wound healing.