The wound care nurse prepares wound care supplies. Which client assessment data cues the nurse to provide Montgomery ties to promote wound healing?

Question

1. Heavy exudate
2. Deep laceration
3. Femoral dressing
4. Wound dehiscence

Answer 1

1
1. The client with heavy exudate needs Montgomery ties because, to remove and contain the exudate, the nurse needs to provide frequent dressing changes. Mont-gomery ties provide a method of securing the dressing to the client and, thereby, faci-litate frequent dressing changes involving wound care protocols without frequent tape removal that potentially irritate surrounding skin and exacerbate the wound.
2. A deep laceration often requires varying amounts of surgical repair after cleansing. After approximating the laceration with sutures or staples, the nurse applies a dry dressing. If the client is obese or the wound requires frequent dressing changes, Montgomery straps can be indicated.
3. A femoral dressing usually covers the crease created by the hip and thigh and, thus, the area does not lend itself to Montgomery straps. Because of leg movement and the close proximity to the groin, a simple dressing works best.
4. Wound dehiscence requires surgical repair. If tension on the suture line is an issue, the client can benefit from a binder because the Montgomery straps are not intended to support the incision.