Wound Care
Binders & Bandages
Use of Heat and Cold
Module 8, Part A, B and C
WHY IS WOUND CARE DONE?
General purposes of dressings
• Protecting a wound from microorganism
contamination
• Aiding hemostasis
• Promoting healing by absorbing drainage and
debriding a wound
• Supporting or splinting the wound site
• Protecting the client from seeing the wound
• Promoting thermal insulation to the wound surface
• Providing maintenance of high humidity between
the wound and dressing
Definitions
• Abscess – a cavity containing pus and
surrounded by inflamed tissue, formed as a
result of suppuration in a localized infection.
Healing usually occurs when an abscess drains
or is incised.
• Collagen – a protein consisting of bundles
of tiny reticular fibrils, which combine to
form the white, glistening, inelastic fibers
of tendons, ligaments, and fasciae.
• Debridement – removal of dirt, foreign objects,
damaged or dead tissue, and cellular debris from
a wound or a burn to prevent infection and to
promote healing.
• Eschar – a scab or dry crust resulting from a
thermal or chemical burn, infection, or
excoriating skin disease.
• Exudate – fluid, cells, or other substances that
have been slowly exudated, or discharged, from
cells or blood vessels through small pores or
breaks in cell membranes. Perspiration, pus, and
serum are sometimes identified as exudates.
• Fibroblast – a flat, elongated undifferentiated cell
in the connective tissue that gives rise to various
precursor cells, such as the chondroblast,
collagenoblast, and osteoblast, that form the
fibrous, binding, and supporting tissue of the body.
• Fistula – an abnormal passage from an internal
organ to the body surface or between two internal
organs, caused by a congenital defect, injury,
infection, the spreading of a malignant lesion,
radiotherapy of a cancerous growth, or trauma
during childbirth.
• Granulation – any soft, pink, fleshy projections
that form during the healing process in a wound
not healing by first intention.
• Inflammation – the protective response of the
tissues of the body to irritation or injury.
– May be acute or chronic; its cardinal signs are redness,
heat, swelling, and pain, accompanied by loss of
function.
• Maceration – the softening and breaking down of
skin from prolonged exposure to moisture.
– May be caused by prolonged exposure to amniotic
fluid in a post term infant or dead fetus.
• Necrosis – localized tissue death that occurs ingroups of cells in response to disease or injury.
• Pus – a creamy, viscous, pale yellow, or yellowgreen fluid exudate that is the result of fluid remains
of liquefactive necrosis of tissues. Bacterial
infection is its most common cause.
• Purulent – producing or containing pus.
• Regeneration – new growth
• Sanguineous – pertaining to blood or containing
blood.
• Serous – pertaining to, resembling, or producing
serum.
• Serosanguineous – thin and red; composed of
serum and blood.
• Ulceration – the process of ulcer formation
Review of A&P
• Skin is the body’s largest organ
• Functions
1. protective barrier
2. sensory organ for pain temperature and touch
3. synthesize vitamin D
• Two layers
– separated by membrane dermal-epidermal junction
1. epidermis
2. dermis
Stages of wound healing
1. Inflammatory Phase – begins within
minutes of injury and lasts about 3 days.
2. Destructive Phase (granulation) – begins
before inflammation ends and lasts for
about 2-5 days.
3. Proliferative Phase (granulation) – begins
and lasts from 3-24 days.
4. Maturation Phase – the final stage of
healing and may take more than a year
Inflammatory Phase
Stages of wound healing
• Reparative processes control bleeding
(hemostasis), deliver blood and cells to
the injured area, and form epithelial cells
at the injury site.
• During hemostasis, injured blood vessels
constrict and platelets gather to stop
bleeding.
• Clots form a fibrin matrix that later
provides a framework for cellular repair.
Inflammatory Phase
• Damaged tissue and mast cells
secrete histamine, resulting in
vasodilatation of surrounding
capillaries and exudation of
serum and WBC’s into damaged
tissues resulting in localized
redness, edema, warmth &
throbbing
Inflammatory Phase
• Leukocytes reach the wound within a
few hours. The primary WBC is the
neutrophil, which begins to ingest
bacteria and small debris.
• The second WBC is the monocyte,
which transforms into macrophages,
which clean a wound of bacteria,
dead cells, and debris by
phagocytosis.
Inflammatory Phase
• After macrophages clean the
wound and make it ready for
tissue repair, epithelial cells
gather under the wound space
for about 48 hours forming a
barrier against infectious
organisms and toxic materials.
Stages of wound healing
Destructive Phase (granulation)
• Begins before inflammation ends
• Lasts for about 2-5 days.
• Macrophages continue the process of cleaning the
wound, attracting more macrophages, and
stimulating formation of fibroblasts, the cells that
synthesize collagen.
• Collagen can be found as early as the second day
and is the main component of scar tissue, it provides
strength and structural integrity to a wound.
Stages of wound healing
Proliferative Phase (granulation)
• Lasts from 3-24 days.
• During this period the wound begins
to close with new tissue.
• As reconstruction progresses, the
tensile strength of the wound
increases, and the risk of wound
separation or rupture is less likely.
Stages of wound healing
Maturation Phase
• Final stage of healing
• May take more than a year, depending on the
depth and extent of the wound.
• Collagen scar continues to gain strength and
undergoes remodeling or organization before
assuming their normal appearance.
• A healed wound usually does not have the
strength of the tissue it replaces
Types of wound healing
Can be
• Primary
• Secondary
• Tertiary
Types of wound healing
Primary Intention – refers to
wounds where there is not tissue
loss and skin edges are well
approximated.
These wounds have a low risk of
infection and heal quickly, with
little scarring i.e). surgical
incision
Types of wound healing
Secondary Intention – refers to
wounds where there is tissue loss
and the skin edges are not
approximated, such as in a pressure
ulcer
These wounds tend to heal slowly
and have a higher rate of infection.
Types of wound healing
Tertiary Intention – can be
called delayed primary intention
or third-intention healing, refers
to surgical incisions that are left
open because of edema or
infection or to allow drainage,
and are then closed to heal.
Handout: Factors affecting wound healing
1.
2.
3.
4.
5.
6.
7.
8.
9.
Age
Malnutrition
Obesity
Impaired oxygenation
Smoking
Drugs
Diabetes
Radiation
Wound stress
Complications of Wound Healing
 Hemorrhage
 Infection
 Dehiscence
 Evisceration:
 Fistula
 Delayed Wound Healing
Hemorrhage
• Bleeding from wound site is normal during &
immediately after the initial trauma.
• Hemostasis occurs within several minutes
unless large vessels are involved or the pt has
impaired clotting function
• Bleeding after hemostasis could indicate:
slipped suture
dislodged clot
infection
erosion of a blood vessel by a foreign object (ie a
drain).
Hemorrhage
• Can occur internally or externally.
– Internal can be detected by observing for
distention, swelling, change in the type or
amount of drainage or signs of hypovolemic
shock Hematoma – a localized collection
of blood under the tissues.
– External – more obvious, all wounds
monitored, esp surgical wounds for the 1st
24 – 48hrs post-op
Infection
• Wound infection is 2nd most common nosocomial
infection
• Chances of wound infection are greater
– when the wound contains dead or necrotic tissue,
– when there are foreign bodies in or near the wound,
– and when blood supply & local tissue defenses are
reduced
• A contaminated or traumatic wound may show
signs of infection early (within 2-3days)
• A surgical wound infection does not develop until
the 4th or 5th day
Dehiscence
• Partial or total separation of wound layers
• When a wound fails to heal properly, the layers of skin &
tissue may separate
• Most commonly occurs during the 3rd to 11th day (before
collagen formed)
• Those at risk:
– Obese (stain placed on wounds & fatty tissue heals poorly)
• Often occurs with straining (coughing, vomiting, sitting up,
walking)
• Pt will report feeling of “something's given way”
• Increase in serosanguineous drainage from a wound, think
Dehiscence (may lead to evisceration…)
Evisceration
• Is the protrusion of visceral organs through a wound
opening
• May occur with total separation of wound layers (ie.
Total dehiscence)
• A MEDICAL EMERGENCY, will require surgical
repair
• If it occurs, STERILE towels soaked in sterile saline
are place over the extruding organs to reduce chances of
bacterial invasion & drying
• If organs protrude thru the wound, blood supply to the
tissues is compromised
Fistula
• An abnormal passage between 2 organs or
between an organ & the outside of the body
• May be created for therapeutic reasons (as in
gastrostomy tube for feedings) but MOST form as
a result of poor wound healing where tissue layers
are prevented from closing properly
• Fistulas increase the risk of infection and loss of
fluid or electrolytes
• Chronic fluid drainage can also predispose the
person to skin breakdown
Delayed Wound Healing
• Sometimes referred to as third intention wound
healing
• Delayed wound closure is a deliberate attempt by
a surgeon to allow effective drainage of a cleancontaminated or contaminated wound
• Wound not closed until all evidence of edema &
debris removed (may be weeks).
• Wound covered by occlusive dressing to prevent
bacterial contamination
• Wound then closed to heal by first intention
Factors affecting Wound Healing
1. Age:
2. Nutrition:
3. Obesity:
4. Impaired Oxygenation:
5. Smoking:
6. Drugs:
7. Diabetes:
8. Radiation:
9. Wound stress:
Types of dressings
• Generally most drsg have 3 layers:
a)Contact layer. Fibrin, and debris adhere to this layer. If
the drsg sticks, moisten it to remove carefully
– If the objective is debridement, then the
adherence is OK such that removing the dressing
pulls away the necrotic tissue and debris
b)Absorbent layer is a reservoir for secretions. The
wicking action pulls the extra moisture away from the
wound.
c)Outer layer is a barrier to keep bacteria and other
contaminants away.
Types of Dressings
1)
2)
3)
4)
5)
6)
7)
Transparent adhesive films (opsite,
Tegaderm) p. 1545
Impregnated nonadherent dressing
(Vaseline gauze)
Hydrocolloids (Duoderm) p. 1545
Hydrogel (intrasite gel) 1546
Polyurethane foams (lyofoam)
Exudate absorbers (debrisan)
Gauze dressings (dry to dry, wet to dry, wet
to damp or wet) 1541-1545
Telfa (Box of
100) 2" x 3"
Ouchless
Non-Adherent
Dressing
How are dressings attached?
1.Tape
– How do you put it on?
– How do you remove it?
2.Ties
3.Bandages
4.Anchoring material (netting)
5.Binders
• 6.
Measures to minimize discomfort
a.
Careful removal of tape, gentle cleansing of
wound edges, and careful manipulation of
dressings and drains minimize stress on sensitive
tissues
b.
Careful turning and positioning also reduce
strain on a wound
• Administration of analgesic medications 30-60
minutes before dressing changes
How do you assess a wound?
• Who changes dressings?
• What does the nurse note for charting?
– Are the wound edges closed?
• Is there inflammation?
• Discoloration?
– What is the nature of the wound drainage?
•
•
•
•
•
Amount?
Color and consistency?
Odor?
Response to palpation?
Pain?
WOUND CULTURES
•Do not collect wound
culture from old
drainage.
•Cleanse the wound with
NS to remove skin flora
Procedure
1. use a microbiology requisition
2. cleanse the site with saline
3. make certain you note the following
information:
–
–
–
–
specimen location
request: C&S. gram stain (gm stain)
history (usually disease)
antibiotics (WHY?)
4. CHART what you have done.
CHANGING A DRESSING
• To prepare:
– the nurse must know: type of dressing, the presence of
underlying drains, and the type of supplies needed.
How do you find that out?
1. physician’s order should indicate dressing type,
frequency of changing, and any solutions or ung.
2. chart for operative reports
3. nurses notes
4. other staff
5. the patient
General Recommendations
1) hand wash before and after
2) an open or fresh wound should be
touched only with sterile gloves
3) a sealed wound dressings may be
handled with clean gloves.
4) dressings should be changed when they
become wet, or if the client has S&S of
infection.
Common cleaning solutions
• Soap & water for minor abrasions, lacerations, small
puncture wounds
• Povidone-Iodine solution = for staphylococcus aureus
• Dakin’s solution= diluted & is a bacteriocidal for
staphylococcal and streptococcal organisms. Very
irritating to skin around the wound.
• Acetic acid solution= effective against gram-positive and
gram-negative bacteria
• Hydrogen peroxide is a debriding agent. It should not be
applied to granulation tissue.
• Saline is most often used to debride wounds. It maintains
the moist surface needed to promote epithelial tissue
growth.
Principles
• Clean from least contaminated to more
contaminated (*ie clean to dirty)
• Never use the same piece of gauze to cleanse
twice
– Wound is considered LESS contaminated than
the surrounding skin
– Drain site is considered MORE contaminated
than an incisional site. Cleansing moves from
the incisional site to the drain.
– Isolated drain site the site is LESS
contaminated than the skin near it.
Wound Cleaning
Figure 35.08a
Wound Cleaning
Figure 35.08b
Drains
• Inserted into or close to a surgical
wound
if large amounts of drainage is
expected
if keeping wound layers closed is
especially important
• If fluid is allowed to accumulate
under tissues, the inner wound edges
wound never close
Drains
• Nurses’ responsibility is to:
1)Assess drain placement,
patency
2)Assess character of drainage
3)Observe condition of collecting
apparatus (must be measured
as ‘output’ when emptied)
TYPES OF DRAINS
• Penrose
– No suction
– Usually secured by a pin
• Hemovac & Jackson-Pratt
– Low-suction
– Containers need to be emptied
• T-Tube
– T shaped tube gravity drainage
• SOMETIMES use colostomy bags
Hemovac
Jackson-Pratt
Hemovac
Wound Cleaning
with drain in place
Figure 35.08c
Critical Elements for Wound Care
•
•
•
•
Maintains sterile technique
Removes soiled dressings appropriately
Cleanses “clean to dirty”
Maintains wound integrity (correct solution, uses each
sponge only once)
• Assesses wound drainage and selects appropriate cover
(for the amount of exudate)
• Applies dressing, if needed, in appropriate fashion
• Reports and records as per facility policy (includes:
color and amount of drainage, incision line, type of
dressing, client response)
Critical Elements
Collection of Specimens
• Gathers appropriate equipment
• Provides appropriate asepsis: medical or
surgical
• Follows procedures
• Charts date, time type of collection
definitions
• AKA – above the knee amputation
• BKA – below the knee amputation
• Blanching – to become white or pale, as
from vasoconstriction Capillary return
• Cyanosis – bluish discoloration of the
skin and mucous membranes caused by
an excess of deoxygenated hemoglobin
in the blood
• CWCM – colour, warmth, circulation, and
movement
• Dependent edema – a fluid accumulation in
the tissues & influenced by gravity. It is
usually greater in the lower part of the body
than in tissues above the level of the heart.
• Distal – away from or being the farthest from
the midline or central point
• Proximal – nearer to a point of reference,
usually the truck of the body, than other parts
of the body.
Indications for applying binders & bandages
Binders and bandages applied over or around
dressings can provide extra protection and
therapeutic benefits by:
Creating pressure
Immobilizing a body part Supporting a wound
(abdominal binder applied over a large
abdominal incision and dressing).
Reducing or preventing edema
Securing a splint
Securing dressings
Types of bandages and binders
• Available in rolls of varying widths and materials e.g.
gauze, elasticized knit, elastic webbing, flannel, muslin
– Gauze bandages are lightweight, inexpensive and mould
easily around a limb, and permit air to circulate
– Elastic conforms to body parts, but as well can be used to
exert pressure over a body part
– Flannel and muslin are thicker than gauze and thus are
stronger. A flannel bandage also insulates to provide
warmth
– Binders and bandages that are made of large pieces of
material to fit a specific body part
– Binders are usually made of elastic, cotton, muslin or
flannel
Principles for applying bandages & binders
Position
body part to be bandage in
comfortable position of normal
anatomical alignment
Prevent friction between and against skin
surfaces by applying gauze or cotton
padding
Apply bandages securely to prevent
slippage during movement
Principles for applying bandages & binders
When
bandaging extremities apply
bandage first at distal end and progress
toward trunk
Apply bandages firmly with equal
tension exerted over each turn or layer.
Avoid excess overlapping of bandage
layers
Position pins, knots, or ties away from
wound or sensitive skin
Before a bandage or binder is applied, the
nurse’s responsibilities include the following:
• Inspecting the skin for abrasions,
edema, discoloration, or exposed
wound edges
• Covering exposed wounds or open
abrasions with a sterile dressing
• Assessing the condition of
underlying dressings and changing
them if soiled
The nurse’s responsibilities include the following:
• Assessing the skin of underlying body
parts and parts that will be distal to the
bandage for signs of circulatory
impairment (coolness, pallor or
cyanosis, diminished or absent pulses,
swelling, numbness, and tingling) to
provide a means for comparing changes
in circulation after bandage application
• After a bandage is applied,
nurse assesses, documents, &
immediately reports
changes in circulation, skin
integrity, comfort level, and
body function such as
ventilation and movement.
CHARTING
The nurse must chart:
• The type of bandage
• Area of the body involved
• Comfort level
• CWCM
• Skin integrity
• Body function
• Bandage may be loosened or tightened but it
must be monitored
Slings
•Slings support arms with
sprains or fractures
•Usually a large
triangular piece of cloth
Slings
• Client may sit or lie
• Bend afflicted arm, bringing arm
across chest
• Open part of sling fits under the
afflicted arm and across the chest
• Base of triangle under the wrist and
the triangle's point at the client's
elbow
Slings
• One end fits around the back of client's
neck
• Loose end is brought up and over
afflicted arm and tied in back of neck
• Knots are tied at side of neck so it does
not press,
• Fingers must be supported
• Hand higher than wrist
Scultetus (many-tailed) binder
• a rectangular piece of cotton with 6 to
12 tails attached to each side
• used to provide support to the
abdomen or to retain dressings.
– apply while patient is supine
– line bottom up with pubic bone
– apply tails upward alternately
– assess breathing when patient sits up
– pins last flap
Heat and cold application
Bodily responses to heat and cold
• Exposure to heat and cold can result in both a
systemic and a local response
• SYSTEMIC responses occur through heatloss mechanisms (sweating and
vasodilatation) or through mechanisms that
conserve heat (vasoconstriction and
piloerection)
• LOCAL responses occur through stimulation
of temperature sensitive nerve endings within
the skin
• The body can tolerate wide variations
• Normal skin temperature is 34° C, but
the receptors will adapt to
temperatures between 45° and 15°C
• Pain develops when temperatures
outside this range
–Too much heat = burning sensation
–Too cold = numbing sensation
Therapeutic effects
•Heat
vasodilation
reduced blood viscosity
reduced muscle tension
increased tissue metabolism
increased capillary
permeability
Therapeutic effects
• Cold
vasoconstriction
local anesthetic
reduced cell metabolism
increased blood viscosity
decreased muscle tension
Uses for heat
•
•
•
•
•
•
•
•
•
Inflamed or edematous body parts
New wounds with swelling (e.g. perineal)
Infected wounds
Arthritis
Back and joint pain
Muscle strain
Menstrual pain
Henmorroidal, perianal, vaginal inflammation
Inflammation
Uses for cold
• Direct injury or trauma (strains
sprains, fractures, muscle spasms)
• Superficial lacerations or puncture
wounds
• Minor burns
• Arthritis and joint pain
• Injections
Safety issues
• If heat is used too long
–reflex vasoconstriction
–damage to epithelial cells
• If cold is used too long
–reflex vasodilation
Factors affecting heat and cold
tolerance
•
•
•
•
•
•
duration of application
body part.
damage to body surface
prior skin temperature
body surface area
age and physical conditions
Conditions that increase risk of
injury
1. age
2. open wounds or broken skin
3. areas of edema or scar formation
4. peripheral vascular disease.
5. confused or unconsciousness
6. spinal cord injury
7.abscessed tooth or appendix
Assessment
• assess the client to determine risk
factors for tolerance to heat and cold.
• observe the area to be treated
• establish a baseline.
• are there any conditions that would
directly contraindicate the use of heat
and cold?
• check the equipment to be used
CONTRAINDICATIONS
• To Heat
– Bleeding
– Appendix
– CV problems
• To Cold
– Site of injury is edematous
– Impaired circulation
• Both
– Confusion or unconsciousness
– Unsafe equipment -
Applying heat and cold
• in institution doctor's order required
– the body site to be treated type, frequency and
duration of application
• follow the agency's policies
• teaching:
– purpose of the therapy,
– symptoms for temperature exposure
– precautions to prevent injury
SAFETY
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–
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Explain the sensations to be felt
Instruct patient to report sensation changes or pain
Provide patient with a timer or clock
Keep the call light with in reach
Know the agency's policies
Do not allow the patient to adjust temperature
Do not allow the patient to move application
Do not position patient so they cannot move away
Do not leave unattended a client who cannot sense
temperature changes
Choice of moist or dry applications
• Both heat and cold can be applied in a
moist or a dry form
• Choice is made according to:
– Type of wound or injury
– Location of body part
– Presence of drainage
– Presence of inflammation
Advantages
• MOIST
–
–
–
–
–
Reduces drying of skin
Softens exudate
Fit to body area being treated
Penetrate deeply into tissue layers
Does not promote sweating
• DRY
– Less risk of burns to skin
– Does not cause skin maceration
– Retains temperature longer
Disadvantages
• MOIST
– Prolonged exposure may cause maceration
– Cools rapidly because of evaporation
– Creates greater risk for burns
• DRY
– Increases body fluid loss through sweating
– Does not penetrate deeply into tissues
– Causes increased drying of the skin
Hot moist compresses
• May be used for open wounds
– They improve circulation
– Relieve edema
– Promote consolidation of pus and drainage
• Heat from hot compresses dissipates quickly
• Nurse must change the compress often or apply an
aquathermic pad over top OR a waterproof-heating
pad.
• With moist heat there is evaporation and the client
may feel chilly.
Applying a hot moist compress
•
•
•
•
•
•
•
•
•
inspect condition of exposed skin and wound
assess client to sensitivity to temperature
check physician’s order
prepare equipment
explain procedure
make client comfortable
wash hands
procedure is sterile
after procedure
– inspect affected area
– chart
Methods
• Hot water bottle
– Filled to approximately 2/3 full
– Remaining air is expelled and top secured
– Bag is dried and held upside down to test for
leakage
– Wrapped in a cover
– Usually stays hot for 45 minutes
• TEMPERATURES
– Normal adult 52°
– Debilitated or unconscious 40-46°
– Child 40- 45°
Aquathermia (water flow) pad
• Device through which warm distilled water
circulates
• Distilled water circulates through hollowed channels
in the pad to the control unit where the temperature
is set to either heat or cool
• Water reservoir must be kept 2/3 full
• Temperature is set with a key
• Cover is placed between pad and skin
• Secured with tape NEVER pins
• Application is 20-30 minutes
• patient is never allowed to lie on the pad,
Heating pads
– C/o an electric coil enclosed in a waterproof
pad covered with cotton
– Pad connected to an electric cord with a
temperature control
• CAUTION
– Never use the high setting
– Never lie on the pad
– Safety pins and/or water may result in
electrical shock
Commercial hot or cold packs
• Hot packs
– Apply warm dry heat to an area
– Instructions tell how to initiate the heating
(knead, hit or snap the bag)
– These list the time for which they are effective
– They are considered disposable
• COLD PACKS
– Same as for heat packs
Ice collar/ bags
• Ice bag is a rubber or plastic bag with a removable
cap
• Ice collar is similar but is long and narrow
• Ice glove rubber or plastic glove filled with ice chips
and tied at the end
• PROCEDURE
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–
–
–
–
Crushed ice is placed in container until 2/3 full
Air is expelled
Top secured and cover tightened
Put onto body part so it moulds
Apply for 30 minutes. Reapply in 1 hour
Sitz Baths
– Used for rectal surgery, episiotomies,
hemorrhoids, vaginal inflammation
– only the perineal area is immersed
– Patient uses a special tub or a plastic basin
– Disposable sitz baths have a bag into which hot
water is placed to run in slowly
– Treatment usually 20 minutes
– Client must be kept warm
– Feet flat on the floor
– No pressure on the sacrum
Warm soaks
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•
•
•
•
•
Promotes circulation
Lessens edema
Increases muscle relaxation
May assist debridement
Allows the application of medication
PROCEDURE
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Position the patient comfortably
Put waterproofing on the bed
Heats solution to 40-43°
Immerse the body part
Cover container and person to prevent heat loss
Change solution q 10 min
• There are also cold soaks
Treating Injuries effectively
• When do you use ice?
– immediately after injury and up to 72 hours if
the S&S of inflammation are no longer
present
– Use for 20 minutes with an hour off.
• When do you use heat?
– AVOID immediately after an injury and for
up to 72 hours
– Apply for 20 minutes. Repeat several times a
day
Critical Elements
Checks for the physician's order
Follows the agency's policies
Assesses the patient and the wound before
the application and after
Knows the risks and benefits of heat and cold
applications
Knows how to correctly apply the various types of
heat and cold applications
Knows the time limits for application
Provides teaching: for the patient