NURSING MANAGEMENT IN THE
APPLICATION OF BINDER
Also known as self-closures, binders
are lengths of cloth or elasticized material
that encircle the chest, abdomen, or groin
to provide support, keep dressings in place
(especially for patients allergic to tape),
and reduce edema, tension on wounds
and suture lines, and breast engorgement
in mothers who aren’t breast-feeding.
Binders also promote patient comfort and
the healing process. Typically, cloth
binders are fastened with safety pins, and
elasticized binders are fastened with
Velcro.
ANATOMY OF THE SKIN
Phase 1: Hemostasis Phase
Hemostasis, the first phase of healing,
begins at the onset of injury, and the
objective is to stop the bleeding. In this
phase, the body activates its emergency
repair system, the blood clotting system,
and forms a dam to block the drainage.
During this process, platelets come into
contact with collagen, resulting in
activation and aggregation. An enzyme
called thrombin is at the center, and it
initiates the formation of a fibrin mesh,
which strengthens the platelet clumps into
a stable clot.
Phase 2: Defensive/Inflammatory Phase
If Phase 1 is primarily about coagulation,
the second phase, called the
Defensive/Inflammatory Phase, focuses on
destroying
bacteria
and
removing
debris—essentially preparing the wound
bed for the growth of new tissue.
THE STAGES OF WOUND HEALING
The body is a complex and remarkable
machine, and the dynamic process of
wound healing is a great example of how
our body’s different systems, along with the
proper wound care products, work
together to repair and replace devitalized
tissues. But how, exactly, does our body
heal?
When the skin is injured, our body sets into
motion an automatic series of events,
often referred to as the “cascade of
healing,” in order to repair the injured
tissues. The cascade of healing is divided
into these four overlapping phases:
Hemostasis, Inflammatory, Proliferative,
and Maturation.
The 4 phases of wound healing. Healing
begins with Hemostasis.
During Phase 2, a type of white blood cells
called neutrophils enter the wound to
destroy bacteria and remove debris. These
cells often reach their peak population
between 24 and 48 hours after injury,
reducing greatly in number after three
days. As the white blood cells leave,
specialized cells called macrophages
arrive to continue clearing debris. These
cells also secrete growth factors and
proteins that attract immune system cells
to the wound to facilitate tissue repair. This
phase often lasts four to six days and is
often associated with edema, erythema
(reddening of the skin), heat and pain.
Phase 3: Proliferative Phase
Once the wound is cleaned out, the
wound enters Phase 3, the Proliferative
Phase, where the focus is to fill and cover
the wound.
The Proliferative phase features three
distinct stages:
1) filling the wound;
2) contraction of the wound margins; and
3) covering the wound (epithelialization).
During the first stage, shiny, deep red
granulation tissue fills the wound bed with
connective tissue, and new blood vessels
are formed. During contraction, the
wound margins contract and pull toward
the center of the wound. In the third stage,
epithelial cells arise from the wound bed or
margins and begin to migrate across the
wound bed in leapfrog fashion until the
wound is covered with epithelium. The
Proliferative phase often lasts anywhere
from four to 24 days.
Phase 4: Maturation Phase
During the Maturation phase, the new
tissue slowly gains strength and flexibility.
Here, collagen fibers reorganize, the tissue
remodels and matures and there is an
overall increase in tensile strength (though
maximum strength is limited to 80% of the
pre-injured strength). The Maturation
phase varies greatly from wound to
wound, often lasting anywhere from 21
days to two years.
The healing process is remarkable and
complex, and it is also susceptible to
interruption due to local and systemic
factors, including moisture, infection, and
maceration (local); and age, nutritional
status, body type (systemic). When the
right healing environment is established,
the body works in wondrous ways to heal
and replace devitalized tissue.
Equipment
tape measure
binder of
appropriate size
and type
safety pins
gloves, if necessary
dressing materials
Commercial
elastic binders are
now commonly
used instead of
standard cotton
straight and
Scultetus binders
that require pins.
Disposable Tbinders are
available, and
scrotal supports
typically replace
binders for male
patients, except
after abdominalperineal resection.
Abdominal Binder
An abdominal binder is an important
surgical body garment used in the early
postoperative phase of surgeries like an
abdominoplasty (tummy tuck) or an
abdominal liposuction. An abdominal
binder serves many important functions,
especially in the early postoperative
stages of an abdominal surgical
procedure. An abdominal binder
provides compression and support to
both the upper and lower abdomen. It
helps improve blood circulation and
oxygen levels at the operative site,
increases healing and reduces swelling.
With all these improvements, the patient
is able to get out of bed sooner and
walk around more easily. This further
improves breathing and promotes the
healing process and a speedy recovery.
•
An abdominal binder may be indicated
and prescribed in other surgical
procedures and situations, such as
during pregnancy in certain situations,
after the delivery of a baby and to
support weak abdominal muscles due
to aging. It may also be used for obesity
or paralysis.
•
Preparation of Equipment
Measure the area that the binder
must fit, and obtain the proper size and
type of binder from the central supply
department.
Implementation
• Check the doctor’s order.
• Perform hand hygiene and put on
gloves, as needed.
• Confirm the patient’s identity using at
least two patient identifiers according
to your facility’s policy.
• Provide privacy and explain the
procedure to the patient.
• Raise
the patient’s bed to a
comfortable working height to avoid
muscle strain when applying the binder.
• Position the patient in a supine position,
with his head slightly elevated and his
knees slightly flexed to decrease tension
on the abdomen.
• Assess the patient’s condition.
• Remove the dressing and inspect the
wound or suture line, if appropriate.
• Redress the wound and then remove
and discard your gloves.
Types
• Straight abdominal binder
How to Apply: Place the patient in a
supine position. Ask the patient to lift
upward, using the legs, or roll the
patient onto the binder. It should be
smooth so that wrinkles do not cause
pressure on the patient’s skin. Overlap
the edges of the binder snugly over the
abdomen. Holding it in place, fasten
the binder with safety pins or Velcro.
•
Scultetus abdominal binder
How to Apply: Place the binder
underneath the supine patient, being
careful to check for underlying
wrinkles. Lace the lower tail in a slightly
oblique direction up the abdomen.
Lace the tail on the opposite side in a
similar way. Continue lacing in this
interlocking fashion until all the tails
have been neatly and securely
placed.
•
Elastic net binder:
How to Apply: Elastic net binders are
used to hold dressings in place and not
for support. These binders come in a
variety of circumferences. Begin by
gathering the net in your hands, stretch
it and slip it upward over the feet and
legs to the position around the
abdomen.
Applying An Abdominal Binder
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•
•
•
•
Accordion-fold half of the binder, slip it
under the patient, and pull it through
from the other side. Make sure the
binder is straight, free of wrinkles, and
evenly distributed under the patient. Its
lower edge should extend well below
the hips.
Overlap one side snugly onto the other.
Starting at the lower edge, close the
Velcro closure.
Make darts in the binder, as needed.
Avoid making the binder too tight
around the diaphragm because it may
interfere with breathing. Then insert one
finger under the binder’s edge to
ensure a snug fit that’s still loose enough
to avoid impaired circulation and
patient discomfort.
For maximum support, wrap the binder
so that it applies even pressure across
the body section. Eliminate all wrinkles,
and avoid placing pressure over bony
prominences (as shown below).
How to Measure
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•
•
The proper measurement of the
abdominal binder for a comfortable fit
that applies the right amount of
compression is important.
The measurements and sizing must be
done prior to having the surgical
procedures. Measurements are taken
next to the skin without clothing.
A stage 1 garment is worn for the first
two weeks postoperatively. It is bigger
and less tight to accommodate any
initial swelling. A second stage garment
is worn 2-8 weeks postoperatively or
longer; it is a smaller and tighter binder.
Precautions
•
Individuals who are allergic to latex
should use a latex-free abdominal
binder. This will prevent an allergic
reaction, which can include a rash,
itching or swelling of the face, tongue
and throat, and shortness of breath and
difficulty breathing. This is a medical
emergency. Immediate medical care
must be administered if any of these
symptoms occur.
Applying A Breast Binder
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Wash and thoroughly dry under
pendulous breasts. Place 4″ × 4″ gauze
pads under breasts, as necessary, to
prevent skin irritation.
Slip the binder under the patient’s chest
so that its lower edge aligns with the
waist.
Straighten the binder to distribute it
evenly on either side. Place the binder
so that the patient’s nipples are
centered in the breast tissue. This
position
ensures
proper
breast
alignment and support and produces
faster tissue involution.
Arm Sling
To make an arm sling from muslin, fold of
cut a 36-ich square of fabric diagonally.
Slings are applied in two ways:
Method 1: with the patient facing you,
place one end of the triangle over the
unaffected shoulder and the long straight
border under the hand of the injured side.
Loop upward, positioning the other ends of
the triangle over the affected shoulder. Tie
or pin the ends to one side of the neck,
using a square not, or pin smoothly, using a
safety pin. Do not secure a sling at the
back of the neck because this could exert
pressure. Fold the corner flat and neatly at
the elbow, and pin.
Method 2: with the patient facing you,
place the sling across the body and
underneath the arms. Bring the corner of
the sling that is under the unaffected arm
to the back. Bring the lower corner up over
the affected shoulder to the back, and tie.
Fold the sling neatly at the elbow, and pin.
Stump and Prosthesis Care
Patient care immediately after limb
amputation includes monitoring drainage
from the stump, managing pain, reducing
edema, positioning the affected limb,
assisting with exercises prescribed by a
physical therapist, and wrapping and
conditioning the stump. Postoperative
care of the stump varies slightly,
depending on the amputation site (arm or
leg) and the type of dressing applied to
the stump (elastic bandage or plaster
cast).
Limb amputation and stump
healing, patient care includes routine daily
care, such as proper hygiene and
continued muscle-strengthening exercises.
As the patient recovers from the physical
and psychological trauma of amputation,
he will need to learn correct procedures
for routine daily care of the stump and any
prosthesis he might have. A plastic
prosthesis—the most common type—
typically must be cleaned, lubricated, and
checked for proper fit.
Equipment
For Postoperative Stump Care
gloves
pressure dressing
abdominal (ABD)
pad
suction equipment,
if ordered
1″ adhesive tape
or bandage clips
trochanter roll (for
a leg)
elastic stump
shrinker or 4″
elastic bandage
Optional:
tourniquet (as a
last resort to
control bleeding)
overhead trapeze
For Ongoing Stump or Prosthetic Care
mild soap or
alcohol pads
stump socks or
athletic tube
socks
two washcloths
two towels
appropriate
lubricating oil
Implementation
• Confirm the patient’s identity using at
least two patient identifiers according
to your facility’s policy.
• Explain the procedure to the patient.
• Perform hand hygiene and put on
gloves.
• Perform routine postoperative care.
Frequently assess respiratory status and
level of consciousness, monitor vital
signs and IV infusions, check tube
patency, and provide for the patient’s
comfort, pain management, and
safety.
Monitoring Stump Drainage
• Because gravity causes fluid to
accumulate at the stump, frequently
check the amount of blood and
drainage on the dressing. Notify the
doctor if accumulations of drainage or
blood increase rapidly. If excessive
bleeding occurs, notify the doctor
immediately and apply a pressure
dressing or compress the appropriate
pressure points. If this doesn’t control
bleeding, use a tourniquet only as a
last resort.
•
Tape the ABD pad over the moist part
of the dressing as necessary. Doing so
provides a dry area to help prevent
bacterial infection.
Positioning the Extremity
• Elevate the extremity for the first
24 hours to reduce swelling and
promote venous return.
• To prevent contractures, position
an arm with the elbow extended
and the shoulder abducted.
• To correctly position a leg,
elevate the foot of the bed slightly
and place a trochanter roll
against
the
hip to
prevent
external rotation.
Nursing Alert
Don’t place a pillow under the thigh to flex
the hip because this positioning can cause
hip flexion contracture. For the same
reason, tell the patient to avoid prolonged
sitting.
•
•
After a below-the-knee amputation,
maintain knee extension to prevent
hamstring muscle contractures.
After any leg amputation, place the
patient on a firm surface in the prone
position for at least 2 hours a day, with
his legs close together and without
pillows under his stomach, hips, knees, or
stump,
unless
this
position
is
contraindicated. This position helps
prevent hip flexion, contractures, and
abduction; it also stretches the flexor
muscles.
Assisting with Prescribed Exercises
• After arm amputation, encourage the
patient to exercise the remaining
arm to prevent muscle contractures.
Help the patient perform isometric and
range-of-motion (ROM) exercises for
both shoulders, as prescribed by the
physical therapist, because use of a
prosthesis requires both shoulders.
• After leg amputation, stand behind
the patient and, if necessary, support
him with your hands at his waist during
balancing exercises.
• Instruct the patient to exercise the
affected and unaffected limbs to
maintain muscle tone and increase
muscle strength. The patient with a leg
amputation may perform push-ups, as
ordered (in the sitting position, arms at
his sides), or pull-ups on the overhead
trapeze to
strengthen
his
arms,
shoulders, and back in preparation for
using crutches.
Wrapping A Stump
Proper stump care helps protect the
limb, reduces swelling, and prepares the
limb for a prosthesis. As you perform the
procedure, teach it to the patient.
Start by obtaining two 4″ elastic bandages.
Center the end of the first 4″ bandage at
the top of the patient’s thigh. Unroll the
bandage downward over the stump and
to the back of the leg (as shown below).
Make three figure-eight turns to
adequately cover the ends of the stump.
As you wrap, be sure to include the roll of
flesh in the groin area. Use enough
pressure to ensure that the stump narrows
toward the end so that it fits comfortably
into the prosthesis.
Use the second 4” bandage to
anchor the first bandage around the waist.
For a below-the-knee amputation, use the
knee to anchor the bandage in place.
Secure the bandage with clips or adhesive
tape. Check the stump bandage
regularly, and rewrap it if it bunches at the
end.
Elastic Bandage Application
Elastic bandages exert gentle, even
pressure on a body part. By supporting
blood vessels, these rolled bandages
promote venous return and prevent
pooling of blood in the legs. They’re
typically used in place of antiembolism
stockings to prevent thrombophlebitis and
pulmonary embolism in postoperative or
bedridden patients who can’t stimulate
venous return by muscle activity.
Elastic bandages also minimize joint
swelling
after
trauma
to
the
musculoskeletal system. Used with a splint,
they immobilize a fracture during healing.
They can provide hemostatic pressure and
anchor dressings over a fresh wound or
after surgical procedures such as vein
stripping.
Equipment
elastic bandage
of appropriate
width
gauze pads or
absorbent cotton
tape, pins, or selfclosures
Optional: gloves.
Bandages usually
come in
2″ to 6″ (5- to 15cm) widths and
4′ and 6′ (1.2- and
1.8-m) lengths.
The 3″ (7.6-cm)
width is adaptable
to most
applications. An
elastic bandage
with self-closures is
also available.
Preparation of Equipment
Select a bandage that wraps the affected
body part completely but isn’t excessively
long. Generally, use a narrower bandage
for wrapping the foot, lower leg, hand, or
arm and a wider bandage for the thigh or
trunk. The bandage should be clean and
rolled before application.
Implementation
• Verify the doctor’s order.
• Perform hand hygiene and put on
gloves, if indicated.1,2,3
• Confirm the patient’s identity using at
least two patient identifiers according
to your facility’s policy.4
• Examine the area to be wrapped for
lesions or skin breakdown. If these
conditions are present, consult the
doctor before applying the elastic
bandage.
• Explain the procedure to the patient,
provide privacy, and answer any
questions to decrease anxiety and
increase cooperation.
• Position the patient with the body part
to be bandaged in normal functioning
position to promote circulation and
prevent deformity and discomfort.
• Avoid applying a bandage to a
dependent
extremity.
If
you’re
wrapping an extremity, elevate it for 15
to 30 minutes before application to
facilitate venous return.
• Apply the bandage so that two skin
surfaces don’t remain in contact when
wrapped. Place gauze pads or
absorbent cotton as needed between
skin surfaces, such as between toes
and fingers and under breasts and
arms, to prevent skin irritation.
• Hold the bandage with the roll facing
upward in one hand and the free end
of the bandage in the other hand.
Hold the bandage roll close to the part
being bandaged to ensure even
tension and pressure.
• Unroll the bandage as you wrap the
body part in a spiral or spiral-reverse
method. Never unroll the entire
bandage before wrapping because
this could produce uneven pressure,
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•
which interferes with blood circulation
and cell nourishment.
Overlap each layer of bandage by
one-half to two-thirds the width of the
strip.
Begin wrapping an extremity at the
most distal part and work proximally to
promote venous return. Wrap firmly but
not too tightly. As you wrap, ask the
patient to tell you if the bandage feels
comfortable. If he complains of
tingling, itching, numbness, or pain,
loosen the bandage.
When wrapping an extremity, anchor
the bandage initially by circling the
body part twice. To prevent the
bandage from slipping out of place on
the foot, wrap it in a figure eight
around the foot, the ankle, and then
the foot again before continuing. The
same technique works on any joint,
such as the knee, wrist, or elbow.
Include the heel when wrapping the
foot, but never wrap the toes (or
fingers)
unless
absolutely
necessary because
the
distal
extremities are used to detect
impaired circulation.