Chapter 48 Skin Integrity and Wound Care: Implement and Take Action; Evaluate

when to avoid heat therapy

Bleeding (exacerbates the bleeding) Cardiovascular conditions/disease (interrupts blood flow) Local abscess (could cause rupture) Unknown pain in abdomen, especially if suspected appendicitis (could cause rupture)

moist compress

Can be used for either heat or cold therapy. A sterile gauze or linen is soaked in a sterile solution, which is then placed over the wound. The area is covered with towels or a waterproof pad to maintain warmth or cold for the time prescribed.

disadvantages of using transparent dressings

Cannot be used for wounds with more than minimal drainage; cannot be used with infected wounds

disadvantages of using alginates

Cannot be used in dry wounds

interventions for wound drains

Clean drain in a circular motion. Note that each movement requires a new cleansing gauze. Clean from close to the drain, outward. Place specially prepared 4" × 4" dressing around drain. Apply abdominal (ABD) pads and tape.

interventions for incontinence

Clean the contaminated skin immediately with a cleanser for perineal care. Do not use antibacterial soap and avoid hot water because they cause drying. Use warm water and a mild pH-neutral soap. Apply a moister-barrier ointment to skin at risk for exposure to urine or stool.

interventions for wound drainage

Clean wound drainage off the skin immediately. Clean pressure injuries with wound cleaners or through irrigation, depending on the type of wound. Assess wounds for excessive exudates and infection. Dress and pack wounds correctly to prevent complications.

interventions for wound cleaning

Clean wound regularly or as prescribed. Clean wound before and after removal of sutures and staples. Assess the wound for color, type of tissue, periwound tissue, wound measurements, drainage characteristics if present, and presence of infection. After cleaning, leave wound open to air or cover with a dressing. Obtain a new cleaning gauze for each cleaning stroke (see image). Clean from the least contaminated to the most contaminated area. Document date, time of procedure, wound assessments, name of procedure (cleansing wound), and patient response to wound cleansing.

interventions for perspiration

Cleanse the patient's skin, especially under skinfolds, ensuring the patient remains dry in high-risk areas. Change linens. Apply deodorant as needed. Pat dry, instead of rubbing it, to prevent skin and tissue damage

evaluation of Impaired Skin Integrity, Impaired Tissue Integrity, and Pressure Ulcer/Injury: unchanged

Continues to experience the same signs and symptoms as before treatment; wound keeps the same dimensions, skin remains intact, or infection is not present, depending upon patient's hypothesis (if the wound or pressure injury stays the same, the nurse must consider that if this continues, the patient may be declining; the wound or pressure injury should be diminishing in size)

evaluation of primary sources of contamination: unchanged

Continues to have intact skin Continues to exhibit the same skin characteristics as before treatment

evaluation of Malignant Wound, Surgical Wound, or Traumatic Wound: unchanged

Continues to have the same wound characteristics and cues before dressing change or irrigation, if prescribed (the nurse has to remember that if this continues, the findings may move into the declining category)

evaluation of heat therapy: unchanged

Continues with same signs and symptoms before heat therapy was applied (the nurse has to remember that if this continues, the findings may move into the declining category)

evaluation of cold therapy: unchanged

Continues with the same signs and symptoms before cold therapy was applied (the nurse has to remember that if this continues, the findings may move into the declining category)

NPWT is primarily used on wounds, such as:

Dehiscence Fasciotomies Pressure injuries Venous stasis ulcers Skin flaps Partial-thickness burns

evaluation of primary sources of contamination: declining

Develops skin infection (notify health care provider, monitor temperature and white blood cell count, obtain culture) Develops any type of break in skin (try other skin protection techniques, especially diligence about keeping skin dry, turning patient, and positioning patient)

support surfaces

Diminish pressure by redistributing the body's weight over a greater surface area made of foam, gels, fluids, or air Include overlays, replacement mattresses, and specialty beds; made for chairs, operating room tables, and stretchers Accommodate all types of patients: children, adults, and the obese does not eliminate the need for regular and frequent position changes, skin assessments, and modifications of risk factors

precautions for heat therapy

Do not allow patient to lie on heating device because pressure amplifies the heat, increasing burn risk. Ensure patient knows to report pain or changes in sensation during therapy; check more frequently if the patient is unable to report pain or changes. Monitor length of time of therapy to prevent injury and/or complications.

evaluation of Malignant Wound, Surgical Wound, or Traumatic Wound: troubleshooting

Dressing is sticking to wound: Use normal saline to moisten stuck gauze and remove. Patient reports pain with irrigation: Medicate and then wait 30-45 minutes before proceeding. Nurse does not have enough irrigation solution to complete procedure: Remove angiocatheter from syringe, refill syringe, and reattach (if contaminated angiocatheter, obtain another), and continue.

precautions for cold therapy

Ensure the patient knows to report pain or changes in sensation during therapy; check more frequently if the patient is unable to report pain or changes. Monitor the length of time of therapy to prevent injury and/or complications.

evaluation of primary sources of contamination: improving

Experiences no skin breakdown Wound healed Progresses to warm, dry, and intact skin

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing?

Fish Fish is a high-protein food; zinc is found in high-protein foods.

types of dressings

Gauze Transparent Hydrocolloids Foams Alginates Gels

gel dressings

Gelatinous material supplied in tubes and sheets hydrophilic polymer composition 80-96% water cooling effect provide autolytic debridement may accelerate wound healing hydrating good for painful wounds

evaluation of Impaired Skin Integrity, Impaired Tissue Integrity, and Pressure Ulcer/Injury: declining

Has a 2 cm by 2 cm break in skin (apply skin barrier) Is eating 25% of meals (consult dietitian/nutritionist) Needs a two-person assist for transfers (provide enough staff to transfer and to use mechanical lifts) Has developed redness, induration, swelling, and drainage from skin; experiences fever and chills (notify the health care provider for a wound culture and antibiotics) Has an increase in wound diameter from 3 to 4 cm and has an increase in length from 4 to 5 cm (notify health care provider, consult with WOCN) Reports that pain is 6/10 after taking pain medication (try nonpharmacologic pain measures; notify health care provider for new pain medicine prescription) Has a decrease in Braden Scale score from a 10/10 to an 8/10 (obtain a special bed) Has an increase in pressure injury from 3 to 4 cm and has an increase in length from 4 to 5 cm (notify health care provider, consult with WOCN)

evaluation of Impaired Skin Integrity, Impaired Tissue Integrity, and Pressure Ulcer/Injury: improving

Has intact, dry, warm skin Consumes a high-protein diet Helps transfer from bed to chair Has no redness, induration, swelling, or drainage from skin; no fever or chills Has a decrease in wound diameter from 3 to 2 cm and has a decrease in length from 4 to 3 cm Reports that pain is a 2/10 after taking pain medication Has an increased Braden Scale score from 10 to 12 Has a decrease in pressure injury from 3 to 2 cm and a decrease in length from 4 to 3 cm

evaluation of Malignant Wound, Surgical Wound, or Traumatic Wound: improving

Has no increased redness, swelling, induration, or drainage Has wound healing progression and granulation tissue

evaluation of Malignant Wound, Surgical Wound, or Traumatic Wound: declining

Has signs of infection: increased redness, swelling, induration, and drainage (Notify primary health care provider for a wound culture and consult with WOCN; monitor vital signs, especially temperature and white blood cell count) Is showing no signs of wound healing progression (obtain wound measurements and notify primary health care provider)

advantages of using alginate dressings

Highly absorbent (up to 20 times their weight); appropriate for a variety of wounds can be combined with foam or other dressings to increase absorbency and decrease number of dressing changes can be used to stop bleeding from wounds

when to avoid cold therapy

Impaired circulation (cool extremities, weak pulse, cyanosis); notify health care provider before applying Presence of edema/swelling (slows absorption of fluid from the vasoconstriction, causing edema/swelling to last longer; ice is applied before the edema occurs) Circulatory conditions/disease (exacerbates reduction of circulation to area) Shivering (increases patient discomfort)

disadvantages of using hydrocolloids

Inappropriate for wounds infected or suspected of being infected because of occlusive properties and long wear time

disadvantages of using gauze

Ineffective barrier to microorganisms can cause painful removal may damage healing wound bed when removed may have possible sloughing of fibers into wound can allow drying of wound, which can impede healing

actions for wrapping the wound/injury

Keep limb elevated for 15 to 30 minutes before wrapping. Begin at the distal end of the limb. Perform two circular wraps to secure bandage. Wrap from distal to proximal. Wrap according to injured limb: a) Extremities: spiral or reverse spiral b) Joints: figure 8 c) Head or amputation: recurrent For each wrap, cover half of previous wrap. Check circulation. Keep extremity elevated.

disadvantages of using gel dressings

Not recommended for wounds with excessive moisture or drainage because of the high moisture content and inability to absorb drainage if used incorrectly, can cause maceration of skin surrounding wound

disadvantages of using foam dressings

Not suitable for wounds with minimal drainage do not relieve pressure even though sometimes used for padding (not recommended for this purpose) may not be reimbursed when used in the home

Five Ps of circulation after bandaging an extremity (check within 30 minutes of applying and then on a regular basis):

Pain Pulselessness Pallor Paresthesia Paralysis Remove wrap, if any of the five Ps are found, and rewrap

mechanical debridement

Physical removal of debris by irrigation, hydrotherapy or wet-to-dry dressing application Use of wet/damp-to-dry dressings or whirlpools Normal saline-moistened gauze allowed to dry and attach to the wound (when gauze is removed, surface layer of the wound bed comes off with the dried dressing) Is painful for patient, who may need pain medication before removal of dried dressing from the wound Can damage viable tissue (do not use normal saline to remove gauze stuck to tissue because that defeats the purpose of mechanical debridement) Can cause bleeding Takes time; is a rigorous regimen

Which technique would the nurse use to turn a patient?

Position patient's body laterally at 30 degrees. The nurse would position patient laterally 30 degrees when side-lying to avoid direct pressure on bony prominences.

interventions for wound irrigation

Use sterile technique and proper personal protective equipment (PPE). Use normal saline 0.9% because it is an effective irrigating solution and alternative to commercial wound cleansers. Warm irrigating solutions or have solutions at room temperature (cold solutions reduce leukocyte activity, which is needed for wound healing). Use enough force to sufficiently remove debris and surface contaminants, but do not use so much force that intervention damages delicate healing tissues. Use piston syringe (avoid bulb syringe as it is hard to regulate force and the pressure is too low) or syringe with 18-gauge catheter. Irrigate 1 inch above the wound from the least contaminated to the most contaminated area. Pat area dry (do not rub). Reapply wound dressing. Document date, time of procedure, wound assessment, name of procedure (irrigation), and patient response to irrigation.

advantages of using hydrocolloids

Versatile (available in multiple shapes, sizes, and thicknesses) form a gel as drainage is absorbed; absorb small to moderate amount of drainage over several (3 to 7) days provide moist wound environment, but absorptive properties prevent tissue bed and surrounding tissues from becoming too wet

safety when using closed drains

Wear gloves at all times. Avoid touching the port or plug. Clean port or plug with alcohol wipes. Obtain a graduated cylinder to measure the Hemovac drainage or obtain a measuring cup to measure the JP drainage. Measure and document amount and type of drainage at the end of each shift or every 4 hours, if needed. Recompress the Hemovac or JP after emptying. Keep the drainage unit below the level of the wound

safety when using open drains

Wear sterile gloves. Keep the safety pin in place to prevent tube from slipping back inside the body. Prevent tube from becoming dislodged or kinked. Document color, amount, and type (serous, serosanguineous, sanguineous) of drainage on dressing

sitz bath

a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain Soak perineum/pelvic area for 20 minutes. (The patient must be able to sit up to use this form of therapy.) Adjust temperature, following facility protocol. Use a chair, tub, or toilet attachment (usually has hose attached that sprays water on pelvic area and drains into basin; see image). Monitor the sensitive perineal area for any complications

negative-pressure wound therapy (NPWT)

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed reduction of bacteria in the wound removal of excess wound fluid offers a moist wound-healing environment promotes granulation tissue development decreases bacteria in wounds. Vascular perfusion is increased, which in turn increases supply of oxygen and nutrients to the wound. Also called vacuum-assisted closure (VAC)

examples of cold therapy

aquathermia pad, moist cold compresses, cold pack,, cold soaks

different directions of wrapping wounds

circular wrap spiral wrap reverse spiral a reverse spiral b figure eight recurrent wrap

what can the skin interventions can the nurse delegate to the UAP?

cleaning skin of urine, stool, wound drainage, and perspiration

foam dressings

composed from a hydrophilic polyurethane base hydrophilic at wound contact surface hydrophobic on the outer surface allows exudates to be absorbed into the foam through the hydrophilic layer most commonly available in sheets or pads with varying degrees of thickness Designed to fill cavities have variety of sizes and shapes, including sheets, rolls, and pillows.

open drain

drainage that passes through an open-ended tube into a receptacle or out onto the dressing

wrapping method for joints

figure 8

goal of all wound interventions

healing

primary sources of contamination that compromise skin integrity

incontinence, wound drainage, and perspiration

why should you never massage an injury?

it encourages circulation and can increase swelling during the body's initial response to injury -avoid for 72 hours

examples of heat therapy

moist warm compresses, warm soaks, sitz baths, aquathermia, and hot packs

examples for securing the bandage

montgomery straps abdominal binder

hot/cold packs

-provide heat/cold at desired time - directions on package for initiation of heat/cold -Effective tools for pain control -provides relief not only from the pain itself, but also from accompanying swelling or infection For commercial hot/cold packs, follow manufacturer's directions. For noncommercial ice bags, fill with water or only two-thirds full, if using crushed ice. Remove air before closing. Do not place heat or cold pack directly on skin; place a small washcloth between the skin and pack

what can wounds be closed with?

-suture -steri-strips -staples -special skin glue

safety when using NPWT

1. Avoid NPWT in the following situations: Wound tunnels into organs or body cavities. Wound has eschar and necrotic tissue. Wound causes osteomyelitis. Wound is malignant.Wound exposes arteries/veins. 2. Use cautiously for patient with bleeding problems or for patient taking anticoagulants. 3. Make sure the vacuum setting is in agreement with the health care provider's prescription (usually 25 to 200 mm Hg). 4. Do not disconnect longer than 2 h/day.

interventions for NPWT

1. Clean and pat dry wound and surrounding skin. 2. Apply skin barrier protectant. 3. Cut the foam to fit the wound and place in wound. 4. Apply a transparent occlusive dressing over foam and extend 2 inches out. 5. If there is not a precut center hole in the dressing, cut one. 6. Place suction tubing in the center hole without the tubing touching wound bed. 7. Apply another transparent dressing over both the tubing and the first dressing. 8. Apply the suction tubing to the canister. 9. Discard gloves and wash hands. 10. Turn on unit (should cause the dressing to shrink). 11. Document wound assessment, characteristics of drainage, type of dressing, pressure setting, and patient response to NPWT

troubleshooting NPWT

1. The alarm is sounding: Check canister. If angled more than 45 degrees, fix. Make sure it is not dislodged.If full of debris, change. Make sure all connections and tubing are not blocked. Determine if there is an air leak and fix with tape around dressing to make a tight seal. 2. Patient reports increase in pain: Change black foam to white soft foam. Consult with primary health care provider to decrease pressure setting and type of cycling (from continuous to intermittent).

purpose of bandages/wraps and binders

1. protecting the wound itself: Create pressure Immobilize injured body part Reduce or prevent edema Enhance venous return Reduce blood pooling 2. securing the wound dressing: Support wound Protect wound and periwound skin Sprains, strains, and muscle injury may also require the use of bandages/wraps.

hydrocolloids

Adhesive dressings consisting of carboxymethylcellulose and gelling substances.

transparent dressings

Adhesive-backed polyurethane dressing that adheres to the surrounding skin but not to the wound bed.

two main types of drains

open and closed

penrose drains

open drain Thin walled and soft, flexible tubing used to drain exudates from recovering wound sites Are commonly used for surgical patients for abdominal, after-incision, and drainage procedures Works by gravity Drains onto gauze pads or dressing May protrude above the skin Is not usually sutured in place Is made of flexible tubing Is generally removed a day or two before discharge

wound drains

prevent excess blood, pus, or serum from accumulating in the wound/incision area and reduce risk for infection -can, however, also be a source of infection because drains break the skin barrier. -Barrier products intended for incontinence, frequent dressing changes, and use of pouches (similar to those used for ostomy care) are effective interventions for preventing damage to the skin from drainage, if needed.

alginate dressings

produced from brown seaweed fibers nonadhesive and nonocclusive Used for moderate-severely secreting wounds of exudate due to its high absorbency and ability to fill up dead space Used for eschar and slough debridement Contraindicated for dry wounds (ex. full thickness burns--dry)

wrapping method for head or amputation

recurrent

debridement

removes necrotic tissue from wound

five different types of debridement

sharp mechanical enzymatic autolytic biologic

wrapping method for extremities

spiral or reverse spiral

fasciotomies

surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle

what is the purpose of wound closure?

to prevent infection, approximate the wound, and minimize scarring

Which parameters would the nurse include when charting about a patient's warm compress on the left leg?

type of therapy length of therapy type of drainage

montgomery straps

used for frequent dressing changes to protect the skin from irritation and skin tears adhesive straps are placed on either side of the wound, and straps/ties are untied when dressing needs to be changed

abdominal binder

used to help secure dressing and drains and provides support when patient is coughing or deep breathing or ambulating

what is the purpose of wound cleansing and irrigation?

used to prevent infection and promote healing by removing surface contamination and cellular debris

aquathermia

used to treat muscle sprains and areas of mild inflammation or edema. pad is waterproof and works by circulating distilled water through the internal channels of the pad via hoses connected to an electrical unit Obtain pad and control unit, which regulates temperature and water flow (can only use distilled water) through the pad channels. Place pad around extremity (some facilities may require a towel wrapped around the extremity before applying pad). Turn control unit on

evaluation of cold therapy: improving

Reports pain has decreased to a 3/10 Experiences decreased pain Exhibits no edema/swelling Experiences relief of muscle spasms

evaluation of heat therapy: improving

Reports pain has decreased to a 3/10 Has reduced edema/swelling Experiences muscle relaxation Experiences a decrease in stiffness Exhibits psychological relaxation

evaluation of cold therapy: declining

Reports pain has increased to a 6/10 (remove therapy) Has increased swelling (elevate injured extremity) Experiences a burn (remove therapy, assess burn, notify health care provider, complete incident/occurrence report)

evaluation of heat therapy: declining

Reports pain has increased to a 6/10 (remove therapy) Has increased swelling (remove therapy) Experiences a burn (remove therapy, assess burn, notify health care provider, complete incident/occurrence report

wound cleanser interventions

Use a cleaning agent that provides a balance between cleaning and trauma to the wound bed. Avoid Dakin's solution, povidone-iodine, acetic acid, and hydrogen peroxide because although they kill bacteria, they damage cells needed for healing and delay wound healing. Use normal saline 0.9% because it is readily available and adequate for wound cleaning.

sharp debridement

Use of a scalpel, curette, or scissors (sharp instrument) to remove the dead tissue Method of choice in the presence of infection or when large quantities of tissue need to be removed quickly Caution must be used when the patient has a bleeding disorder.

gauze

Most commonly used dressing; available in many forms, shapes, and sizes.

Jackson-Pratt (JP) and Hemovac drains

Are commonly used for surgical patients: orthopedic and abdominal Enhances healing because healing cells attach to the surgical site when the wound is not excessively moist Works by suction Drains into a collection pouch or container Decreases chance of infection because there are no openings for bacteria to enter (it is a closed system) Permits a more accurate drainage assessment Stops bacteria from tracking back up the drainage tube May be left in place after discharge May be sutured in place to prevent it from becoming dislodged

interventions related to Impaired Skin Integrity, Impaired Tissue Integrity, and Pressure Ulcer/Injury

Keep skin dry from urine, stool, wound drainage, and moisture (pat dry thoroughly). Apply skin barrier as needed. Turn patient every 2 hours. Position patient at 30 degrees laterally when side-lying. Keep head of bed 30 degrees or less. Transfer to chair (remember to have patient move, or if patient is unable, reposition patient as needed). Use pressure-reducing devices as needed: a) Chair pads b) Mattresses c) Special beds Offer healthy diet: a) Offer foods high in protein (all types of meat, milk, eggs, cheese, beans, nuts, seeds). b) Offer foods high in vitamins C and A. -Vitamin C: oranges, citrus fruit, strawberries, kiwi, broccoli, peppers, tomatoes -Vitamin A: carrots, apricots, sweet potatoes or dark yellow or orange vegetables; dark green leafy vegetables Offer food high in zinc and copper: a) Zinc: found in high-protein foods b) Copper: found in high-protein foods, molasses c) Offer fluids to increase intake. d) Ask patient for input on favorite foods and for completion of diet requests. Consult dietitian/nutritionist as needed.Monitor albumin and prealbumin levels.Use Braden Scale or Norton Scale for pressure injuries.Do not massage pressure injuries because this exacerbates the damage

moist soak

May be used for either heat or cold therapy. The extremity is completely submerged in solution, which may be medicated, if prescribed. Temperature of the solution container and extremity is maintained by covering them and the solution may be checked and changed as needed. The soaked extremity must be thoroughly dried to prevent tissue breakdown.

advantages of using gauze

Preferable to allowing wound to dry can contain antibiotics, petrolatum, or other materials useful for packing wounds and absorbing exudate from heavily draining wounds

Numerous types of dressings, bandages, and binders are available for wound care. They are prescribed depending on the patient's wound/incision and health care provider's preferences. The purposes of dressings are to:

Prevent wound contamination Absorb drainage while preventing the wound bed from drying Protect the wound and surrounding tissue Treat infection Aid in wound debridement

cold therapy

Promotes vasoconstriction (decreases oxygen demands of the tissue and reduces blood flow) -increases blood viscosity -decreases metabolism of tissues, has local anesthetic effect -Decreases muscle tension -should not be applied for longer than 20 minutes or reflex vasodilation can occur

heat therapy

Promotes vasodilation (draws oxygen, nutrients, and leukocytes to area) -decreases blood viscosity -increases metabolism of tissues increases capillary permeability -should not be applied for longer than 20-30 minutes, or reflex vasoconstriction and tissue congestion can occur

advantages of using transparent dressings

Protects the wound from bacteria and fluids but lets oxygen and water vapor enter, imitating action of a blister, thus maintaining a moist environment for healing may be a primary or secondary dressing can be used for autolytic debridement (only if minimal drainage and no signs of infection)

advantages of using gel dressings

Provide wounds a moist environment; facilitate autolytic debridement and healing

advantages of using foam dressings

Pull fluid away from wound while maintaining moist environment ideal for wounds with moderate to heavy drainage and exudate can be placed over enzymatic debriding agents or gels

Which action would the nurse take for a patient with a hypothesis of Impaired Skin Integrity?

Suggest increasing fluid intake. The nurse would suggest increasing fluid intake for a patient with Impaired Skin Integrity to keep skin hydrated.

interventions related to turning, positioning, and using pressure-reducing devices

Turn patient at least every 2 hours. After that, skin begins to settle, and decomposition begins. A turning schedule can be used to ensure turning within this time frame. Elevate head of bed no more than 30 degrees to decrease shear effects. Position patient's head of bed at 30 degrees or less, not 90 degrees, to prevent shear. Position patient laterally 30 degrees when side-lying to avoid direct pressure on bony prominences. Place folded blankets or pillows or towels between knees to prevent pressure against knees when the patient is side-lying. Position legs with pillows so that heels "float" off the mattress (see image) to remove pressure. Heels are at an especially high risk for development of pressure injuries. Limit chair use to 2 hours or less. a) Frequent position changes also apply to seated patients. b) Patients who are unable to change positions independently or sense the need to change positions while seated in chairs need assistance changing positions to relieve pressure every hour; pressure-redistribution cushions can be beneficial. Provide adequate calories, protein, and vitamin C for healing of skin. Change wet/soiled gowns and sheets frequently.

procedure for wound VAC

The nurse places a foam sponge in the wound and covers it with a transparent adhesive drape. A controlled amount of suction is applied (using suction tubing and a negative-pressure setting device), which pulls or vacuums exudate from the wound. The nurse changes the dressing at least every 3 days, but it may be changed more frequently if needed.

closed drains

Tubes that terminate in a receptacle pull fluid by creating vacuum or negative pressure examples are Hemovac and Jackson-Pratt

Documentation for heat and cold therapy includes:

Type of heat or cold therapy Equipment used and assessments of patient Time of application, length, and frequency Any signs of infection at the site of application on the patient's skin Type of drainage Skin assessments throughout treatments Patient concerns or reports of pain Interventions, including patient teaching If any adverse effects occur and treatment provided, according to facility protocol Heat and cold therapies can be used at home. Patient education is necessary, and it is provided by the nurse, not the UAP. The nurse provides written directions, demonstrations, and videos (if needed). The patient and/or family member performs a return demonstration of the prescribed heat or cold therapy before discharge.