The wound care nurse prepares wound care supplies. Which patient assessment datum cues the nurse to provide Montgomery straps to promote wound healing?
a. Heavy exudate
b. Deep laceration
c. Femoral dressing
d. Wound dehiscence
A
The patient with heavy exudate will need repeated dressing changes and Montgomery ties will allow access to the wound while protecting the skin. The repeated removal of an adhesive ban-dage in this situation could damage the skin. A deep laceration often requires varying amounts of surgical repair after cleansing. After approximating the laceration with sutures or staples, the nurse would apply a dry dressing. A femoral dressing usually covers the crease created by the hip and thigh; 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. Wound dehiscence requires surgical repair. If tension on the suture line is an issue, the patient can benefit from a binder to support the incision.
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