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CHAPTER 32 Skin Integrity & Wound Healing
Procedure 32-3 ■ Taping a Dressing ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
■ Assess the skin surface (i.e., dry, damp, diaphoretic, oily, hairy, edematous, fragile, or impaired skin integrity). Fragile skin may require less adhesion, whereas damp or oily skin may require higher adhesion. ■ Assess the anticipated wear time. Tape adhesion gets stronger over time. Breathable tapes can be used longer. Occlusive plastic tapes build up moisture and are used when adhesion is intended for a shorter time. ■ Assess the patient’s history and current medical conditions. Review allergies or sensitivities to tapes. Review medical conditions that may be affected by adhesives. ■ Assess for activity level of the patient and the anticipated length of time the dressing will be needed. The more active the patient is, the more adhesion will be required.
Equipment ■ Nonsterile gloves ■ Tape (cloth, plastic, foam, silklike, etc.)
Delegation As a nurse, you are responsible for assessing the wound and evaluating interventions. However, this procedure may be del- egated to unlicensed assistive personnel (UAP). Preprocedure Assessments ■ Assess the degree of importance of the dressing. The more critical the dressing, the more adhesion will be required. ■ Assess the characteristics of the dressing material, weight and conformability, and the device or tubing to be held. Heavier dressings require higher adhesion. Bulky dressings may need high conformability or greater adhesion.
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation.
Procedure Steps 1. Perform hand hygiene. Don gloves. 2. Place the patient in a comfort- able position that provides easy access to the wound. 3. Ensure the skin surrounding the dressing is clean and dry. 4. Choose the type of tape based on wound size, location, amount of drainage or edema, frequency of dressing changes, patient’s activity level, and type of dressings used. Tapes come in many adhesive types and backings. Select the tape based on individ- ual characteristics. a. Choose tape of the width that is appropriate for the dressing. The larger the dressing, the wider the tape needed for securing. For example, a large abdominal dress- ing may require 3-inch tape, whereas a small incision on an extremity may need only 0.5-inch tape. b.Choose a tape that stretches if the area is at risk for distention, edema, hematoma formation, or movement. Skin distention under tape may cause blistering or skin tears.
5. Tear or cut strips that extend approximately 1 to 1.5 inches (2.5 to 4.0 cm) beyond the dressing, depend-
a. When taping over joints, apply the tape at a right angle to the direc- tion of joint movement, or at a right angle to a body crease. For example, tape a shoulder or knee horizontally, not lengthwise. b. Apply tape with an even amount tension on both sides, being care- ful not to pull at the edges. This reduces the risk of skin damage.
ing on the size of the dressing. To anchor the dressing to the skin.
6. Place the tape perpendicular to the incision and without pulling or stretching the tape. Fewer skin tension injuries occur with per- pendicular taping.
Too long, narrow Too short Too wide
A
B
Correct
Incorrect
C
Correct
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