Compression bandages in management of venous ulcers
Pain and assess
Ask the client how previous compression bandages have felt
Assess skin for bandaging that has been too tight
PQRST before applying compression bandages and throughout application
Confirm where is the wound before dressing down the bandages
Acknowledge pain and provide reassurence
Advise on analgesia and when to take it
Provide analgesia
Comfort
Provide reassurence in a uncomfortable position in application
Allow the patient to find the most comfortable position considering the patient's leg ulcer and the requirements needed to apply compression bandaging
Apply recommended padding underneath compression dressing
Apply bandaging considering the clients footware if possible
Nutrition
Encourage a balanced diet
Diabetic
Referral to orthotics for foot support such as moonboots and other mobility aids
No nutritional requirements follow the use of compression bandages in the management of venous ulcers.
Dietition referral
Skin integrity
Wound chart
Apply skin barrier creams before applying compression bandage
Size
Depth
Pallor
Photos if appropriate
Accurate documentation
District nursing referral for monitoring
Assess for swelling
Provide extra bandaging incase it gets wet etc
Hygiene
Asceptic technique in application
5 Moments of hand hygiene
Patient education on washing with compression bandaging
Always wash and dry wound before application of compression bandaging
Vitals
Temp
Fever/Infection
Temp flushes
Swab site and send away before application of compression bandaging
HR
Increased^
Infection
BP
Hypotensive
Dehydration
Hypertensive
Infection
Encourage fluids
Need for antibiotics
Need for antibiotics
Fluid balance
Assess skin for signs of dehydration limiting wound healing
Assess the clients reported fluid intake and encourage balanced fluids for adequate hydration for cellular perfusion
Assess for Signs of edema prior to application
DRSABCS ALWAYS
History of heart failure
Educate of caffieneated fluids as a loop diuretic
Mobility
Educate of tips for mobility with the compression bandages
They may need to elevate theirs legs
Phisotherapy referral
Assess mobility on entering appt room with patient
Oxygen and supply.
Compression bandages are tight to promote blood flow and prevent swelling
Make sure the compression bandages are not too tight
Venous leg ulcers are associated with poor vascular function
Health and safety
Accurate assessment of wound for infection and compression bandages to ensure they aren't too tight and interviening as indicated at these issues
Aseptic technique
Accurate equipment and application
Patient education for home management
Referrals and follow up bookings complete
Cultural safety
Privacy
Consent to touch
Do they have or desire whanau presence
Tapu and Noa
Clean VS unclean items
Pillows for body should be blue
Respectful conversation
Is humour appropriate for this client
Diagnosis of condition affecting veins such as PVD
Smoking status