For which purpose would the nurse use hypoallergenic tape or Montgomery straps in postoperative skin care quizlet?

Applying a Roller Bandage (Arm or Leg) • Wear gloves if the client has any nonintact skin or a rash. Consult your team leader if you are not sure. Rationale: It is important to protect yourself and others from the spread of infection. • Follow your facility's protocol regarding dressings and dressing changes. The provider's orders indicate the specific part to wrap. A wound care specialist may order the frequency and specific instructions for dressing changes, if needed (see Chapter 58). All instructions should be in the nursing care plan. Rationale: The dressings will usually be changed when the bandage is rewrapped. It is important to follow all instructions; these are part of wound treatment or of the client's disorder. Complete instructions in the nursing care plan are available to all staff. • In many cases, a roller (ACE) bandage will be applied to support a body part (see Fig. 53-1). A wound may or may not be present. Rationale: The basic wrapping of the roller bandage is the same, whether or not a wound exists. • Use the correct bandage width, which is determined by the part to be wrapped. Generally, a bandage wider than 7.5 cm (3 in) is difficult to keep in place on an arm or leg. (Wider bandages may be used on the chest or abdomen.) More than one roller bandage may be used, if necessary. Simply overlap ends. Rationale: If a bandage is too narrow, it will pinch and bind. If too wide, it will fold over. In either case, the effectiveness of the bandage will be compromised. • Explain to the client what you plan to do and provide privacy. Wear gloves, if necessary. Rationale: Ensure the client's cooperation and follow Standard Precautions. • Elevate the extremity to just above the level of the client's body if the client is recumbent. If the client has been sitting or walking and the foot or leg is to be wrapped, ask the client to lie down for at least 15 minutes before wrapping the bandage. If an arm is to be wrapped, elevate it above the client's heart level. Support the limb while wrapping. Rationale: Elevation helps prevent congestion of blood and lymph in the area to be wrapped. Blood that may have pooled in the legs needs to be returned to the circulation. Otherwise, edema could interfere with the effectiveness of the bandage or cause pain and/or damage the limb. • Make sure the bandage is rolled before beginning to wrap. Rationale: This helps ensure that even pressure is applied and will be more convenient for you. • Begin wrapping the bandage at the client's toes or fingers and move toward the hip or shoulder. Rationale: Wrapping toward the heart enhances venous return. • Wrap the bandage firmly, but not too tightly. Stretch the bandage very slightly while wrapping. Rationale: This gives support, but helps prevent the bandage from being wrapped too tightly and cutting off circulation. • Overlap each layer about half the width of the previous strip. Do not allow any gaps between strips. Keep the bandage free of wrinkles or folds. Rationale: Overlapping ensures more even pressure. Wrinkles can quickly cause skin irritation and/or breakdown. • Anchor the top with hypoallergenic tape or the attached Velcro strips (located at each end of the ACE bandage). Clips or pins are no longer used. Rationale: Pins or clips may scratch the client. • Check the circulation of the client's toes or fingers after applying the bandage. (See this procedure [CMS-ET] in Data Gathering in Nursing 53-1.) Rationale: A bandage that is too tight can cut off circulation and quickly cause tissue damage. If too loose, it will not provide support and will usually fall down. • Dispose of soiled dressings and gloves appropriately. Wash or sanitize your hands. Rationale: Used dressings are grossly contaminated. • Check the client's peripheral neurovascular status within 1 hour and at least every 2 hours after that. Rewrap, if necessary. Rationale: It is important to make sure the bandage is applied appropriately. • Document the procedure, noting the client's reactions. Rationale: Provide communication and ensure continuity of care. • Release the bandage at least every 4 hours, unless ordered otherwise. At this time, help the client exercise the extremity and give skin care. Rationale: Releasing the bandage allows skin inspection; exercise and skin care increase circulation and help prevent deformities and discomfort.

Applying a T-Binder • Wash the hands before and after applying or adjusting a binder. Use Standard Precautions. If the client's skin is intact, gloves are not necessary. • Be sure the T-binder is a size appropriate for the client. Apply the binder firmly enough to hold a dressing in place, but not too tightly. Rationale: Using an incorrect size will not be effective and may constrict circulation or cause other damage. If the dressing is not applied firmly in place, bleeding could occur, support will not be effective, or the dressing's movement could irritate and/or contaminate the area. • Rewrap the binder every 2 to 4 hours and check the dressing. Rationale: The client's movements tend to loosen the binder. When rewrapping the binder, assess the client's skin and check the dressing for amount and character of drainage. Check the wound at the same time.

General Nursing Care of the Client with a Bandage or Binder • Wear gloves, if the client's skin is not intact. Rationale: Help prevent the spread of infection. • Perform peripheral neurovascular assessment (PNA) on a limb distal to any bandage or binder at least every 2 hours (or more frequently, as ordered). Danger signs include complaints of severe pain or tightness, as well as cyanosis or mottling of the skin, pallor, duskiness, coldness, numbness, swelling, tingling, or loss of sensation, and pulses that are difficult or impossible to palpate. Rationale: Bandages or binders may compress nerves and/or blood vessels, if applied too tightly. They may also become too tight, if swelling occurs. Checking the PNA helps prevent permanent injury to tissue or the limb, due to loss of circulation or compression. • If the original application of a bandage or binder was performed by a nurse at the direction of a primary provider, the nurse may readjust or loosen it, if it becomes too tight. (If the provider placed the original device on the client, a specific order is needed to remove, adjust, or loosen it.) Rationale: The nurse must practice within the scope of practice. It is important not to injure the client. • Remove bandages, as ordered, to periodically observe the skin, dressings, or wounds. Usually, this is done every 4 hours, but more frequent observations may be ordered, and a dressing change must be done if there is excessive drainage. Rationale: The nurse should inspect the skin and wound area for irritation, breakdown, infection, irritation, or drainage. Provide skin care and dressing changes, as needed and ordered. Careful documentation about all aspects of the wound is vital (see Chapter 58). Report any adverse signs immediately. • Elastic bandages should be applied with the greatest compression on the most distal point of the limb, with pressure gradually decreasing as the bandage is applied, moving up the limb toward the heart. Rationale: This promotes venous return. Incorrectly applied elastic bandages can lead to edema and impaired circulation. Compartmental syndrome can also occur, and may cause permanent nerve damage (see Chapter 77). • Replace soiled bandages. Rationale: A clean bandage helps prevent the spread of microorganisms and makes the client more comfortable. • Instruct the client or caregiver how to apply bandages and how to assess for impaired circulation, if the client will continue to use these after discharge. Rationale: Client education facilitates compliance and helps prevent complications.
URSING PROCEDURE 53-1 Applying Antiembolism Stockings (TED sox)
Supplies and Equipment
Stockings in the correct size
Talcum powder or baby powder
Tape measure
Gloves, if necessary
Steps
Follow LPN WELCOME Steps and Then
1. If the client's skin is intact, gloves are not needed. Measure the client's extremity to determine the proper stocking size. Rationale: Stockings that are too tight may interfere with circulation. Stockings that are too loose do not encourage venous return.

Use a tape measure and the package chart to determine proper stocking size for the client.
2. Assist the client to a supine position. Allow at least 15 minutes before applying stockings, if the legs have been down. Rationale: Stockings are best applied early in the morning before the client gets out of bed; otherwise, the veins become distended and edema often occurs.
3. Apply a small amount of powder to the client's feet and legs, if not contraindicated. Rationale: Powder reduces friction and allows easier application of stockings.
4. Grasp the stocking's heel and turn the stocking inside out. Slip the client's foot, toes, and heel into the stocking. Center the heel in the stocking's heel pocket; be sure the heel is seated in this pocket. Slip the stocking opening over (or under) the toes, so the toes are mostly exposed. Slide the stocking over the client's foot. Rationale: This action allows application without bunching of the stocking on the client's foot, which constricts circulation.

Grasp the stocking's heel and turn it inside out.

Put the client's toes, foot, and heel into the stocking. Proper positioning of the stocking on the client's foot prevents injury. The heel pocket is the guide as to whether the toe hole should be on the top or the bottom of the foot.

Adjust the stocking, making sure the heel is firmly seated in the heel pocket. (Craven & Hirnle, 2007.)

Ease the stocking over the calf and leg.
5. Support the client's ankle and ease the stocking smoothly over the calf and the remainder of the leg. Rationale: Smooth application prevents the formation of wrinkles, which can impede circulation.
6. Pull forward slightly on the stocking's toe section. Note that the toe holes are on the top of these stockings. Rationale: This eases pressure on the client's toes and nails.
7. Instruct the client to report any extreme discomfort. Rationale: Early reporting of complaints aids in preventing complications.
Follow ENDDD Steps
Special Reminders
• Check with the client at least every 4 hours, to make sure the stockings are not too tight. Check PNA regularly.
• The stockings must be removed at least every 8 hours and the legs washed and inspected. Sometimes, the client may leave the stockings off when he or she is in bed (depending on the specific order). Rationale: It is important to observe the condition of the skin and check the circulation in the legs. The stockings may be too tight, thus restricting circulation.
IN PRACTICE
NURSING PROCEDURE 53-2 Applying Montgomery Straps
Supplies
Gloves
Dressing
Wound care supplies, as ordered
Montgomery straps
Steps
Follow LPN WELCOME Steps and Then
1. Choose Montgomery straps (see Fig. 53-4) of the appropriate length. Two or more sets may be required for a very large dressing. Assist the client into a supine position. Position the Montgomery straps and open each to one side. Rationale: The straps must be spaced far enough apart to accommodate the dressing to be applied. They are opened out of the way to facilitate wound care and the application of the new dressing. Use as many sets of straps as needed.
2. To perform a dressing change, open the straps without removing the tape from the skin. Remove the old dressing and dispose of it properly. Perform prescribed wound care. Cover the incision with a new dressing. Rationale: Wound care must be performed correctly, as ordered. Covering the incision helps keep the incision free of microorganisms.

Use two or more sets of straps to secure a large, bulky dressing.
3. Secure the ends of the straps across the dressing with ties, buckles, or the Velcro closures. Rationale: Make sure the dressing is securely supported.
4. Leave straps in place until they become soiled or need to be changed or removed. Then, carefully remove the tape (see previous discussion related to tape). Rationale: The straps should be removed very carefully and only when necessary, to preserve the integrity of the skin and to avoid further irritation or possible skin breakdown.
Follow ENDDD Steps
Special Reminder
• Documentation is particularly vital when doing dressing changes. Factors to be included in documentation are presented in Data Gathering in Nursing 58-1. It is important to address all these factors in your documentation. Usually, the computer will provide a check list for this purpose. Note also if the client complains of severe pain. In some cases, a line is drawn around a wound, so it can be determined if it is becoming smaller or larger each day. Rationale: Because the wound is covered, the observations of the nurse are vital (see Data Gathering in Nursing 58-1).

For which purpose would the nurse use hypoallergenic tape or Montgomery straps?

Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Which of the following actions should the nurse take when applying the stockings?

Which of the following locations should the nurse secure the urinary catheter tubing?