Order Applying Montgomery Straps

Order Applying Montgomery Straps
Order Applying Montgomery Straps
1. Review the medical orders for wound care or the nursing
plan of care related to wound care.
2. Gather the necessary supplies and bring to the bedside
stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you are
going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic
pain-reducing interventions or analgesic medication before
wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for analgesic to
achieve its effectiveness before beginning procedure.
7. Place a waste receptacle at a convenient location for use
during the procedure.
8. Adjust bed to comfortable working height, usually elbow
height of the caregiver (VISN 8, 2009).
9. Assist the patient to a comfortable position that provides
easy access to the wound area. Use a bath blanket to cover
any exposed area other than the wound. Place a waterproof
pad under the wound site.
10. Perform wound care and a dressing change as outlined in
Skills 8-1 through 8-4, as ordered.
11. Put on clean gloves. Clean the skin on either side of the
wound with the gauze, moistened with normal saline.
Dry the skin.
12. Apply a skin protectant to the skin where the straps will
be placed.
13. Remove gloves.
14. Cut the skin barrier to the size of the tape or strap. Apply
the skin barrier to the patient’s skin, near the dressing.
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.
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