SUFFOLK COUNTY COMMUNITY COLLEGE
SCHOOL OF NURSING
Michael J. Grant Campus
NUR101 Lab#5
Wound Care / Application of Heat & Cold
INSTRUCTIONS TO STUDENTS:
 Please complete lab handout, assigned readings, and review appropriate ATI DVD in advance of lab classes.
 Students who are unprepared for lab are negatively affecting their grades and more importantly, their ability
to make the most from the learning opportunities in the lab.
Healthy intact skin and mucus membranes are effective barriers to micro organisms. Open skin and wounds
must be protected against micro organisms entering. Open wounds such as surgical incision, pressure ulcer and
burns require care that will promote healing and prevent injury or contamination. Selecting appropriate
dressings and disposing of soiled dressings correctly breaks the chain of infection at the mode of transmission.
The purpose of a dressing is to protect a wound from micro contamination, promote healing, and provide moist
environment and support. Traditionally there are 3 layers to a wound dressing: contact layers, absorption layer
and outer protection layer. Some principles to keep in mind:
1.
2.
3.
4.
5.
Dressings over open wounds must be sterile.
Choose the most appropriate dressing available and apply it securely and comfortably, without
compromising the periwound skin.
Dispose of soiled dressings correctly.
Observe and describe the wound accurately (Documentation).
Moisture enhances cell growth
Review:
Medical asepsis = clean, reduce the number of organisms, reduce transmission.
Surgical asepsis = sterility
Type of Dressing Materials:
1.
Gauze pads: 4” x 3”, 4” x 4” or 2” x 2” size folded gauze pads. Available as sterile 2 pack, or
non- sterile.
2.
Split Sponges: aka trach dressing or drain sponge. Used for drains and tracheostomy tubes.
3.
Super absorbency gauze AKA Fluffs, Kerlix: loosely folded, help to absorb drainage; used to pack
wounds. Comes in packages or rolls. Rolls are used to secure dressings around feet or elbows.
4.
ABD pads AKA 5 x 9, Combines or topper: larger pads used over smaller dressing material, most are
moisture resistant on one side.
5.
Transparent film dressing: (AKA moisture vapor permeable transparent film) clear dressing with
1 adhesive side that adheres to dry, intact skin, or small non draining wounds. These dressings allow
moisture and oxygen to move through but not bacteria. Protects the site, allows for close observation
such as IV site or suture line. Examples: Tegaderm, Opsite.
6.
Non-adherents: special sterile dressings that will not stick to wound surface and maybe
impregnated with petroleum or antimicrobials. Ex: Telfa, Adaptic, Vaseline gauze, and Xeroform.
7.
Hydrocolloid dressings (Duoderm): soft wafer cut to 1" larger than pressure ulcer and is usually used for
clean decubiti. Allows for padding, protection and moist environment while epithelialization and
healing take place. Usually kept in place for up to 5 days. Must be changed more frequently if bacteria
(such as feces) get underneath.
NUR101 LAB #5
8.
Rolls: Kling/Kerlix or gauze: comes in varying widths, used for packing and securing dressings.
9.
Tape: Adhesive, non-allergic, paper tape: comes in varying widths.
10.
Elastic Net: Stretch net dressing available in varying widths. Used to secure dressings in place of tape.
11.
Ace bandages
12.
Montgomery Ties: Adhesive backing with straps to secure over dressing instead of tape.
13.
Drains: used to enhance the flow of drainage from a wound, thus promoting wound healing; and keeps
operative incisions dry. Ex: penrose; hemovac, jackson pratt.
14.
Other Equipment: Sterile Q-tips, Sterile Field, Sterile Suture Set, C&S (Culture) Tubes, Sterile Saline.
Wound terminology: Define the following terms:
Healing by Primary (First) Intention Healing by Secondary Intention Serosanquinous drainage –
Serous drainage –
Purulent drainage –
Sanquinous drainage –
Granulation –
Periwound -
CRITICAL THINKING:
1.
Using the picture from Potter & Perry Fundamentals of Nursing textbook on pg. 1325 as an example,
write a sample nurse’s note describing a closed surgical incision that is healing by primary intention.
2.
What further assessments should be made for the client with the wound pictured on pg. 1325?
3.
Describe methods to cleanse incision. (Note – wound irrigation is discussed in NUR133 Lab).
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NUR101 LAB #5
4.
A physician order reads: “Apply warm soaks to R leg bid” for 20 minutes. Discuss how to implement
this order. Your patient is a 65-year old mildly confused man admitted with cellulitis of the R lower
extremity. The R leg is reddened, however the skin is intact. Can this procedure be delegated to a
nursing assistant? Why or why not?
Heat and Cold Applications:
Patients vary in their ability to tolerate heat & cold (amt of body fat, condition of skin, level of consciousness,
neurological & circulatory deficit). Maximum effects are reached in 20 to 30 minutes. Longer application may
result in “rebound phenomenon”.
Complete the following table:
Local effects of heat –
Local effects of cold -
Indications for heat –
Indications for cold -
Contraindications for use of heat –
Contraindications for use of cold-
Precautions –
Precautions -
Methods for applying heat –
Methods for applying cold -
Demonstration / Practice:
Sterile dressing change
Apply Wet – to – Moist dressing
Demonstrate various dressing changes to wound on: Foot, heel, abdomen.
Practice application of elastic bandages.
Discuss “clean” dressing changes and “sterile” dressing changes.
Review ATI DVD: surgical asepsis, dressing to sterile sutured wound, application of transparent
dressing, wet to moist dressing.
Note: performing would irrigation, negative pressure wound therapy and most wound drainage devices
are discussed in NUR133 lab.
Rev: rmk 6/10
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