Antiembolism Stockings
Many physicians routinely order antiembolism stockings (also called thromboembolic disease [TED] stockings) for all postoperative clients. These elastic stockings cover the foot (not the toes) and the leg, up to the knee or mid thigh. A firmly wrapped ACE bandage may also be applied, but stockings provide firmer and more even pressure against the leg’s blood vessels. They help ensure adequate return circulation
IN PRACTICE :NURSING CARE GUIDELINES 53-2
APPLYING A STRETCH-NET DRESSING TO A FINGER
• Read the manufacturer’s instructions regarding the particular type of dressing used. Rationale: There may be small variations between brands.
• Wear gloves if the client’s skin is not intact. Rationale: Standard Precautions are followed, to help prevent the spread of microorganisms.
• Cut a length of netting from the roll that is about 2.5 to 3 times the length of the finger Rationale: Extra length is required to complete the dressing and make sure it stays in place.
• Place the netting over the supplied metal tubing (applicator). Rationale: The applicator makes it possible to place the dressing over the finger.
• Place the tubing, with the netting on the outside, over the finger Hold the end of the netting in place at the base of the finger with one hand and gently pull the applicator tube, with the excess gauze netting, toward the end of the finger with the other hand. Rationale: This movement puts the first layer of netting in place on the finger.
• Gently pull the applicator tube about Ά inch away from the end of the finger, while still holding the base. Twist the applicator and netting, to cover the end of the finger. Rationale: This completes the first layer of the dressing and encloses the end of the finger.
• Push the applicator gently back toward the base of the finger gradually releasing the remainder of the netting and forming a double layer of netting on the finger like a stocking cap. Rationale: This encloses the entire finger in a double layer of gauze. The gauze stretches and will usually stay in place. It may be taped in place, if necessary.
• Repeat this process if a thicker dressing is required. Rationale: You can use as many layers as necessary for a thicker dressing.
• Change the dressing as needed. Rationale: It is important to keep wounds as clean as possible.
• Dispose of your gloves and document the procedure, including any pertinent observations. Rationale: Documentation is important, to provide continuity of care and safety for the client.
(venous circulation) to the heart and may help prevent blood clots (emboli or thromboemboli).
To give proper support, the stockings fit tightly without binding the leg or cutting off circulation. Stockings are available in various sizes. Measure the client’s thigh or calf according to the manufacturer’s instructions on the package, to select the size that ensures proper fit. Apply the stockings before the client gets out of bed or after the client has remained recumbent (lying down) for at least 15 minutes. Rationale: Doing so prevents pooling of fluid or blood in the leg, which increases the pressure from the stockings and alters their effect. In Practice: Nursing Procedure 53-1 describes the application of elastic stockings.
Unlike ACE bandages, these stockings do not become loose; thus, check the client’s peripheral neurovascular assessment (PNA) at least once every 2 hours. Remove the stockings at least once every 4 to 8 hours and examine the leg carefully for redness, pitting edema, or skin discoloration. Document your findings. Wash the client’s legs gently each day; apply lotion if the skin is dry and apply clean stockings.
FIGURE 53-2 · The pneumatic compression device (PCD) or sequential compression device (SCD) is frequently used following surgery to support the circulation.
Nursing Alert Some antiembolism stockings are designed to have 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. The key is to fit the client’s heel firmly into the heel pocket of the stocking.
The PCD Machine
Another type of device, called a pneumatic compression device (PCD), sequential compression device (SCD), or intermittent sequential compression device (ISCD), provides alternating pressure to the legs (Fig. 53-2). This device, which is used to support circulation, is used primarily for clients immediately after surgery and for those with circulatory disorders. The sleeves around the person’s lower legs contain multiple chambers, which alternately inflate and deflate, pushing blood through the veins. The inflation begins at the foot and moves up the leg, pushing blood toward the heart. When the top chamber is reached, the sleeve deflates and the cycle begins again.
BINDERS
A binder is a wide, flat piece of fabric that is applied to support a specific body part or to hold a dressing in place. Commonly used binders include the arm sling (see Nursing Procedure 43-1) and the T-binder, a T-shaped strap (see Fig. 53-3). Some binders are made of elasticized material. Most use hook-and-loop fasteners (Velcro). In Practice: Nursing Care Guidelines 53-3 highlights information about applying binders.
Key Concept Occasionally, a breast binder will be ordered for a woman after childbirth. However; usually the client is instructed to wear a good support bra instead.
IN PRACTICE :NURSING CARE GUIDELINES 53-3
APPLYING A 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 binder is a size appropriate for the client. Rationale: Using an incorrect size will not be effective and may cause damage.
• Apply the binder firmly enough to give support but not too tightly Rationale: If the dressing is not applied firmly in place, bleeding could occur, or the dressing’s movement could irritate the area.
• If using a binder to hold a client’s body part in place or a dressing in place, be sure it is firm enough to be effective. Rationale: A binder that is too tight might cause unnecessary discomfort or constrict circulation. A binder that is too loose will not support or hold the body part or dressing in place.
• Fasten the binder from the bottom up, to give upward support. Rationale: Applying it from the top down will exert downward pressure and defeat the purpose of the binder.
• Make sure the binder has not slipped upward. Rationale: This could hinder breathing and impair gas exchange.
• Make sure the binder has not slipped down. Rationale: This would loosen the binder and not give adequate support.
• 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.
T-Binder
A T-binder gets its name from its shape. Although not used frequently today, the nurse may see a T-binder used in home care. A T-binder can also be fabricated as a first aid measure. It is used to hold rectal or perineal dressings in place. It may also be used to hold a perineal pad in place for the incontinent or menstruating female client. The top longer band is placed around the client’s waist and the perineal strap is brought between the legs (Fig. 53-3). It is fastened with Velcro or may be pinned in place in an emergency. (Be very careful not to stick the client or yourself with the pins.)
FIGURE 53-3 • The T-binder comes in two configurations. Shown here is the female version. (The perineal strap is split in the middle to accommodate the male anatomy.)
Abdominal Binder
An abdominal binder is a wide, flat piece of fabric that is secured around the trunk of the client’s body to support the abdomen or dressings on the abdomen. Most frequently, the binder is secured with Velcro. The abdominal binder is most often used after abdominal surgery to hold large dressings in place. Rarely, it is used after childbirth, particularly after cesarean delivery.
To apply the abdominal binder, place the center of the binder at the level of the client’s waistline on his or her back. Wrap the ends of the binder snugly over the client’s abdomen and secure it with the Velcro straps. In Practice: Nursing Care Guidelines 53-4 provides information on the general nursing care of the client with a bandage or binder. Remember, the binder is secured at the bottom first, working upward. Rationale: This provides the most support.
Nursing Alert It is important to check the position of the binder frequently particularly if the client is mobile. The binder could move up and inhibit respiration or could slip down and lose its effectiveness.
Tape
Instead of bandages and binders, strips of hypoallergenic tape sometimes are used to hold a client’s dressings in place. Tape also may be used to give support, as for sprained ankles, fractured ribs, or fractured toes. There are several kinds of tape that allow ventilation and help to prevent skin maceration (skin softening and breakdown due to moisture accumulation and lack of circulation).
To provide more comfort, clip the client’s hair close to the skin (particularly on hairy body areas) before applying large tape dressings because hairs stick to the tape and make removal painful. Always remove tape in the direction of hair growth for less discomfort. If tape is difficult to remove, carefully apply acetone to the skin at the edge of the applied strip to loosen the adhesion. Keep moistening the skin close to the adhesive as you gently peel off the tape.
Nursing Alert Be careful with acetone and other substances used to remove tape adhesive. Never use these liquids near an open flame, the client’s eyes, or on an open wound! Be alert that some clients may be allergic to tape or to acetone. Also, remember that acetone will remove nail polish and paint from surfaces and may damage other surfaces, such as latex or plastic.
Montgomery Straps
Tape straps or Montgomery straps may be used if frequent dressing changes are needed. These straps allow the dressing to be changed without having to remove tape from the client’s skin with each change (Fig. 53-4). This measure helps prevent skin irritation because the tape remains in place when the dressings are changed.
IN PRACTICE :NURSING CARE GUIDELINES 53-4
GENERAL NURSING CARE OF THE CLIENT WITH A BANDAGE OR BINDER
• Wear gloves and follow Standard Precautions if the client’s skin is not intact. Rationale: It is important to 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 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 of the extremity occurs. Checking the neurovascular status helps to prevent permanent injury to tissue or limb, due to loss of circulation or to compression.
• If the original application of a bandage or binder was performed by a nurse at the direction of a primary healthcare provider the nurse may readjust or loosen it, if it becomes too tight. (If the primary healthcare provider placed the original bandage or binder on the client, the nurse must have a specific order to remove, adjust, or loosen it.) Rationale: The nurse must practice within the scope of practice, as set by law. It is important not to injure the client.
• Remove bandages or binders periodically to observe the skin, dressings under the bandage, or wounds, if present. Common practice is every 4 hours, but observations may be ordered more frequently Rationale: The nurse should inspect the condition of the skin and any wound to observe for skin breakdown, infection, or wound drainage and to provide skin care and dressing changes, as needed.
• 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: Applying the bandage in this manner promotes venous return. Incorrectly applied elastic bandages can lead to edema and impaired circulation. Compartment syndrome can also occur, and may cause permanent nerve damage.
• Replace bandages or binders that become soiled. Rationale: A clean bandage or binder helps to prevent the spread of microorganisms and makes the client more comfortable.
• Instruct the client or caregiver on how to apply bandages or binders and how to assess for impaired circulation, if the client will continue to use these after discharge. Rationale: Client education facilitates compliance and helps to prevent complications.
FIGURE 53-4 • Montgomery straps may be used when dressings must be changed frequently. Their use allows changing of dressings without removing the tape each time.
The adhesive end of each strap is applied to the client’s skin, far enough apart so the dressing will easily fit in between. The dressing is held in place by the nonadhesive end of each strap, which is tied, buckled, or fastened with
Velcro to the other straps over the dressing. Change the dressing as often as needed without removing the tape from the skin each time. See In Practice: Nursing Procedure 53-2.
Nursing Alert If the client complains of pain or itching while any bandage is in place, assess the area immediately for bleeding, exudates, swelling, or changes in skin color Report abnormalities to your team leader immediately. Many people today are allergic to tape.
NCLEX Alert It will be important during the exam to show you understand your role in observing for and documentation of abnormal findings in a patient with a bandage or binder, as this relates to nursing actions that prevent complications.
KEY POINTS
• Elastic roller bandages may be used to encourage and support circulation after surgery. They are often used to support joints.
• Because elastic roller bandages apply direct pressure, they may be used to help control bleeding.
• When used, binders and bandages should be rewrapped every 2 to 4 hours. The client’s skin should be observed and cleansed at this time.
• Antiembolism stockings should never be allowed to bunch or roll up. This could lead to constricting circulation in the leg. Be sure to seat the client’s heel in the heel pocket of the stocking.
• When applying antiembolism stockings or an elastic roller bandage to an extremity, apply even pressure over the extremity. They are applied from the toes or fingers upward toward the heart.
• Peripheral vascular status is checked frequently, at least every 2 hours, when bandages or binders are used.
• Binders are used to supply support for specific body parts. Types of binders include T-binders and abdominal binders. Check circulation when binders are used.
• When a client requires frequent dressing changes, Montgomery straps or large binders can be used to avoid repeated tape removal and subsequent skin irritation with each dressing change.
