Chapter 53: Bandages and Binders (Complete)

Bandage

A long strip, wrapped around a body part, such as the elasticized ACE bandage (a roller bandage).

*a dressing applied over a wound is sometimes called a bandage as well

Binder

may be applied to support a body part

What are the purposes and therapeutic benefits of bandages, binders, and other support devices?

- Supporting a joint while allowing movement
- Supporting a limb, to relieve pain and pressure
- Immobilizing a joint or limb
- Supporting a wound or incision
- Holding dressings in place
- Holding a pad to absorb drainage
- Holding a splint in place
- Holding a cold or warm pack in place
- Providing compression
- Supporting circulation following hemorrhage
- Shaping a stump before fitting a prosthesis

Peripheral neurovascular assessment (PNA)

evaluating the status of an extremity encased in a bandage or a cast

What are some examples of PNA observations?

- skin color*
- finger or toe motion
- sensation in fingers or toes*
- distal pulses
- capillary refill*
- edema or swelling*
- pain*
- severe pressure or tightness
- skin temperature*

CMS-ET

The acronym of things to assess AT LEAST every 2 hours on patients who are using a bandage.

Color, Motion, Sensation, Edema, Temperature

NURSING CARE - binder and bandage

- Perform PNA on a limp distal to any bandage or binder at least every 2 hours. 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.

- 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.

- 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.

antiembolism stockings

also called TED (thromboembolic disease)sox; elastic stockings that cover the foot (not the toes) and the leg, up to the knee or mid-thigh.

*help ensure adequate return circulation to the heart and may help prevent blood clots

NURSING PROCEDURE - TED sox

Unlike ACE bandages, these stocking do not loosen: thus, check the client's PNA at least every 2 hours.

Remove them at least every 4-8 hours and exam the leg carefully for redness, pitting edema, or skin discoloration.

NURSING ALERT - TED sox

Some anti-embolism stockings are designed to leave a hole in the top, for examination of the toes. Other types have the hole in the bottom. Check the package to determine which type you are using. Be sure to fit the client's heel firmly into the heel pocket of the stocking

Pneumatic compression devices(PCD), sequential compression devices (SCD), or intermittent sequential compression devices (ISCD)

all enhance venous blood flow by providing intermittent periods of compression on the legs for the purpose of preventing deep vein thrombosis (DVT)

T-binder

a T-shaped strap used to hold a rectal/anal, perineal or vaginal dressing in place

abdominal binder

provides abdominal support and holds dressings in place

Hypoallergenic tape

sometimes used to hold dressings in place.

several different kinds allow ventilation and help to prevent skin maceration.

Maceration

Skin softening and breakdown due to moisture accumulation and lack of circulation

NURSING ALERT - Tape

Make sure the client is not allergic to acetone or to the tape used. Also, be very careful with acetone and other substances used to remove tape adhesive. Never use the substances near an open flame, the client's eyes, or on an open wound!

Montgomery straps

special adhesive strips that are applied when dressings must be changed frequently at the surgical site

These straps are taped to the skin at the distal ends, leaving enough room in the center to the dressing; the ties are left free.

NURSING ALERT - bandages

If the client complains of pain or itching while any bandage is in place, assess the area immediately for bleeding, exudates, swelling, or changes i skin color. Report abnormalities immediately.

NURSING CARE GUIDELINES - Applying a roller bandage

-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.
-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.

The nurse is preparing to apply an ace bandage to a client's left ankle after the client has been walking. What action should the nurse prioritize?

Have the client lie down for 15 minutes before wrapping

After applying a bandage to the upper right extremity, what is the first action by the nurse?

Check the circulation of the client's fingers.

The nurse is preparing to apply a large stretch-net bandage to a client's torso. What action should the nurse perform first?

Explain the procedure to the client.

The nurse is collecting data from a client with a bandage on the lower extremity. What observations made by the nurse should be immediately reported to the charge nurse or provider?

Toes are cold to touch.
Toes are cyanotic.
Edema is present in the foot and toes.

The client's bandage has become soiled. What is the appropriate action by the nurse to avoid spreading microorganisms?

Replace the bandage with a new one.

A client had tapes applied to hold her dressing in place. The nurse applied acetone to the skin at the edges of the tape. Why did the nurse need to do so?

To loosen up the adhesion.

RATIONALE: Acetone is added to the skin at the edges of the tape to loosen up the adhesion and aid in easy removal. It is not used to hold the tape in place, as an antiseptic, or to relieve the itching sensation.

A client complains of itching when his hand is wrapped with a bandage. What should the nurse assess for immediately?

Presence of Bleeding

RATIONALE: If a client complains of pain or itching while any bandage is in place, the nurse should assess the area immediately for bleeding, exudates, swelling, or changes in skin color. There is no need for immediate assessments for rise in body temperature, fall in blood pressure, or macular eruptions on the skin.

When assessing a client whose leg is wrapped in a bandage, the nurse notices that her toes are colder than the rest of her body. What immediate step should the nurse take in such a case?

Alert the team leader to this condition at once.

RATIONALE: The nurse should immediately report the incident to the team leader because it could mean the circulation has been cut off, which requires emergency intervention. Applying hot compresses, applying alternating hot and cold compresses, or soaking the area in lukewarm water should not be undertaken without the order of the primary care provider.

Which should the nurse keep in mind when applying a bandage to a client's extremity?

Overlap each layer about half the width of the strip.

RATIONALE: Each layer of the bandage should overlap at least half of the width of the strip in order to keep the pressure even. The bandage should be wrapped firmly but not tightly. If the wrapping is too tightly, it might cut off circulation. Anchoring the top of the bandage with pins might scratch the client. The bandage need not be released every 2 hr. It should be released every 4 hr for skin inspection.

A nurse is caring for a 35-year-old client who has been hospitalized with an injury to his leg. What specific measure should the nurse take after application of a bandage to the client's leg?

Monitor the circulation and nerve function of the extremity.

RATIONALE: Monitoring the circulation and nerve function of the extremity is essential to prevent and manage complications that can arise due to improper application of the bandage or binder. Continuous moving of the legs and application of hot compresses will only complicate the condition. Recording the blood pressure and temperature is essential but not specific to the condition mentioned.

Which type of bandage or binder should the nurse use for the client who requires alternating pressure to the legs?

Intermittent sequential compression device

RATIONALE: An intermittent sequential compression device is preferred for clients who require alternating pressure to the legs because they support circulation to the legs. An all- cotton elastic roller bandage is a simple bandage that mainly helps in providing support to specific parts of the body. Antiembolism stockings ensure adequate return circulation but do not provide alternating pressures to the leg. A Montgomery strap is a binder that is useful when the dressings are frequently changed.

A 15-year-old client is brought to the hospital with a sprained ankle. Which binder should the nurse choose?

3M Micropore Tape

RATIONALE: 3M Micropore tapes are best for providing support for sprained ankles. They allow ventilation and help in preventing skin macerations. Montgomery straps are preferred in cases where frequent dressing changes are required, whereas abdominal straps are used in clients who have undergone abdominal surgery or childbirth. T- binders are indicated for supporting rectal or perineal dressings in place.

An elastic bandage is applied to a client's lower limb. How does this bandage help to increase return circulation to the heart?

It puts gentle pressure on the tissue.

RATIONALE: An elastic bandage puts gentle pressure on the tissue. This prevents pooling of the blood and increases venous return to the heart. It does not cause contraction of the calf muscles. An elastic bandage that is too tight may constrict the blood vessels and impede circulation instead of enhancing it. An increase in the local temperature would increase the circulation; however, an elastic bandage does not increase the local temperature.

A nurse is caring for a client with a Montgomery strap. What is the purpose of the Montgomery strap?

To enable frequent dressing changes and to not have to remove the tape from the client's skin with each change.

RATIONALE: Montgomery straps are often used when frequent dressing changes are necessary. These bandages allow dressings to be changed without having to remove the tape from the client's skin with each change, thereby avoiding damage and preserving skin integrity under the bandage. A T- binder supports a specific body part and holds a dressing in place. An elastic roller bandage supports dressing and exerts pressure over a bleeding point. Antiembolism stockings ensure adequate return circulation to the heart and prevent blood clots.

A client has a broken right arm after falling off a skateboard. What signs and symptoms would indicate that the client has a circulatory disturbance?

-Pain with movement of fingers
-Pale, white fingers
-Complaints of numbness and tingling in hand.

RATIONALE: Signs and symptoms include any abnormal color changes in fingers and hands, such as pale, white, cyanotic, or mottled appearance; complaints of pain with movement of hands and fingers; complaints of tingling, numbness, pain, or itching; presence of edema or swelling of the hands and fingers; and change in temperature of the extremity in comparison with the general temperature of the client's body.

T/F: A rationale for application of a bandage or binder would include providing compression to promote venous return or prevent edema.

TRUE

T/F: . The term for evaluating the status of an extremity encased in a bandage or a cast is peripheral neurovascular assessment (PNA) and would include sensation in fingers or toes and distal pulses.

TRUE

T/F: The purpose of antiembolism stockings is to promote venous circulation and prevent blood clots

TRUE

T/F: A recurrent bandage is wrapped with continuous application in the same place, such as a wrist.

FALSE

T/F: A commonly used bandage is an elastic roller bandage called the all cotton elastic (ACE) bandage.

TRUE

A __________________________ is a wide, flat piece of fabric that is applied to support a specific body part or to hold a dressing in place.

binder

_________________ is the skin softening and breakdown due to moisture accumulation and lack of circulation.

Maceration

When assess a client's hand or foot for edema, if an indentation remains, this is known as __________________.

pitting

The peripheral neurovascular assessment should be performed at least every _____________ hours, or more often when a clienthas a bandage in place.

TWO

A ________________ bandage occurs when wrapping a limb in ascending path, partially covering the previous wrapping while moving up the limb.

SPIRAL