Bachelor of Nursing with Honours in General Health Care

Bachelor of Nursing with Honours in Mental Health Care

NURSN103F Fundamental Nursing Practice (2019/2020)

Hot and Cold therapy

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Learning Outcomes
Upon completion of this class, students should be able to:
• Understand physiological responses to hot and cold application
• Identify therapeutic use of hot and cold therapy
• Describe different types of hot and cold therapy
 Dry and moist methods
• Explain the contraindications for applying hot and cold therapy
• Illustrate the special precautions for applying hot and cold therapy
• Describe the roles and responsibilities of a nurse in applying heat and cold therapy

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Body temperature
• Normothermia : normal body temperature
• Hypothermia : abnormal low body temperature
• Hyperthermia : abnormal high body temperature
• The body can tolerate a wide range of temperature from 15℃to 45℃.
• Normal skin temperature is ~ 34℃

Physiologic Response to Heat & Cold

• Local response
Occurs through stimulation of temperature-sensitive sensory nerve endings/
thermal receptors in the skin
 Send up through the spinal cord to the hypothalamus in the brain where
impulses are recognized as hot or cold
 Protective adaptive responses are triggered by vasoconstriction and
vasodilation

• Systematic Response
 Heat loss through sweating and vasodilation
 Heat conservation through curl-up and vasoconstriction
 Heat production through shivering and movement

• Adaptation of Thermal Response

Nerve receptors strongly stimulate initially
 Decline rapidly during first few seconds
 Decline slowly over the next half hour
Receptors adapt to the new temperature

Choice for Heat or Cold Therapy

• Heat and cold stimuli create different physiologic response
• The choice of heat or cold therapy depends on desired local responses.

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Physiologic effect of Hot Therapy
Physiological Response Therapeutic Benefit

Vasodilation • Improve blood flow promote delivery of

nutrients and removal of waste
• Lessen venous congestion in injured tissues

blood viscosity • Improve delivery of leukocytes and antibiotics

muscle tension • Promote muscle relaxation

• Reduce pain from spasm or stiffness

tissue • Increase blood flow

metabolism

capillary • Improves delivery of leukocytes

permeability • Promotes movement of waste products and
nutrients
• Prolong clotting time accelerate the
inflammatory process and promote healing
(Potter & Perry, 2015; Taylor et al, 2015)

Therapeutic use of heat application

• Relieve local pain, stiffness or aching
• Assist in wound healing
• Reduce infection
• Raise body temperature
• Promote drainage

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Physiologic effect of Cold Therapy
Physiological Response Therapeutic Benefit

Vasoconstriction • Reduce blood flow to injured area slow

down the local release of pain-producing
substances such as histamine
• Prevent edema formation
• Slow bacterial growth & reduce inflammation

Local anesthesia • Alter tissue sensitivity (produce numbness) 

promote comfort by slowing the transmission
of pain stimuli  reduce localized pain
cell metabolism • Reduce oxygen need of tissues

capillary permeability • Promote blood coagulation at injury site

& • Facilitate the control of bleeding
blood viscosity • Reduce edema formation

muscle tension • Relieve pain

(Berman et al, 2015; Potter & Perry, 2015; Taylor et al, 2015)

Therapeutic use of cold application

• Slow or stop bleeding
• Slow bacterial activity in client with an infection
• Relieve pain
• Reduce swelling in injured tissues
• Control pain and fluid loss in the initial treatment of burns
• Diminish muscle contraction and muscle spasms

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Factors affecting Heat/ Cold Tolerance
• Length of exposure
• Body parts
• Age
• Intactness of skin
• Surface area/ size of the exposed body part

REBOUND Phenomenon: Heat

• Occurs at the time that maximum therapeutic effect of hot or cold application is
achieved
• Heat produces maximum vasodilation in 20-30 mins
• Continue beyond 30-45 mins  tissue congestion  blood vessels constrict
• Now the opposite effect occurs ∵reflex vasoconstriction
• Recovery time before reapplication: 1 hour

REBOUND Phenomenon: Cold

• Maximum vasoconstriction occurs when the skin temperature reaches 15℃
• Reflex vasodilation begins as a protective device to prevent the body tissue from
freezing when below 15℃.
• Recovery time before reapplication: 1 hour

Complications of heat therapy

• Tissue damage
 Redness
 Localized tenderness
 Blistering
 Pain
• Excessive peripheral vasodilation
 Divert large blood supply from internal organs
 Drop in blood pressure  life threatening

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Complications of cold therapy
• Tissue ischemia
 Reddened appearance
 Bluish purple mottling
 Numbness
 Burning pain
• Signs of frostbite
 white, waxy, mottled blue skin
 Pulseless
 Skin hard to touch

Types of Hot Therapy

• Hot therapy is applied by both dry and moist methods
• Local dry heat examples:
– Hot water bags
– Electric heating pads
– Chemical hot packs
– Aquathermia pads
• Local moist heat examples:
– Hot compress
– Sitz bath
– Warm soak

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Types of Hot Therapy – Dry method
• Hot water bag
– Convenient
– Inexpensive
– Duration: ~30mins
– Safe water temperature in the bag

Adult/ child> 2 yr 46-52 ℃

Debilitated/ unconscious adult/ 40.5 - 46℃

child < 2 yr
(Berman et al, 2015)

– Preparing the hot water bag

• Fill the bag about 2/3 full
• Expel the remaining air and secure the top
– With the air removed, the bag can be molded to the body part
• Hold the bag upside down to test for leakage
• Wrap the bag in a towel or cover before place it on body part
• Do not allow patient to lie on the hot water bag

• Electric Heating Pads

– Easy to apply
– Lightweight
– Provide constant/even heat
– Recommendations for use:
• Avoid using safety pins or water due to danger of electric shock
• Place moisture proof cover over the pad to avoid short- circuiting
• Do not place the pad under body parts
• Assess skin condition at regular intervals

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• Chemical Hot Packs
– Commercially prepared and convenient
– Disposable
– By striking or squeezing the pack, chemical are mixed with heat release.
– Follow package direction for the recommended treatment time

• Aquathermia (water-flow) Pad

– Also referred as aquamatic pad
– Used to treat muscle spasm and area with mild inflammation and edema
– Desired temp.: 45℃
– Duration: ~30 mins
– Applying the aquathermia pad:
• Fill the reservoir of the unit about 2/3 full of distilled water
• Set the desired temperature
• Plug in the unit
• Cover the pad with towel or pillow case
• Apply the pad to the body part

Types of Hot Therapy – Moist method

• Hot Moist Compress
– Can be used for open wounds
• promote circulation
• relieve edema
• promote consolidation of pus and drainage
– A compress is a piece of gauze dressing moistened in a prescribed warmed
solution.
– Heat from warm compress dissipates quickly.

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• Sitz bath
– Also called hip bath
– For patients with rectal surgery, episiotomy during childbirth, painful
haemorrhoids or vaginal inflammation
– The patient sits in a special tub or a basin that fits on the toilet seat and pelvic
area is immersed in warm fluid.
– Desired temperature: around 40℃- 43℃
– Duration: 15-20mins
– Providing sitz bath:
• Position the patient
• Prevent overexpose the patient
• Monitor patient for signs of dizziness
• Help dry the patient after treatment
• Provide call bell

• Warm Soak
– The immersion of a body area into warm water or a medication solution is
called a soak
– Desired temperature: around 40.5℃- 43℃
– Duration: 15-20mins
– Purposes:
• Improve circulation and reduce edema
• Increase blood supply to a locally infected area
• Assist in breaking down infected tissues
• Apply medication
• Clean draining wound
• Loose slough, crusts from encrusted wound
– Providing warm soak:
• Sterile technique needed for large wound
• Position the patient so the body part can be immersed in the solution
• Maintain soak temperature by replacing the fluid

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Types of Cold Therapy
• Cold therapy can also be applied by both dry or moist methods
• Dry cold examples:
– Ice bags/ ice collars
– Cold packs
– Hypothermia blankets/ pad
• Moist cold examples:
– Cold compress
– Cooling sponge bath

Types of Cold Therapy – Dry method

• Ice bags, Ice Collars
– For patients with muscle sprain, localized hemorrhage or hematoma
– For patients who have undergone dental surgery
• To prevent edema formation
• To control bleeding
• To anaesthetize the body part
– Ice collar is mostly applied for patients after tonsillectomy
– Filled with ice chips
– Providing ice bag:
• Fill the bag about 2/3 full with crushed ice
• Release any air from the bag by squeezing its side before securing the cap
• Wipe off excess moisture and invert to check for leakage
• Cover the bag with a towel or pillow case

• Cold packs
– Commercially prepared
– Sealed container filled with a chemical or a nontoxic substance
– Put in the freezer or being squeezed to activate the chemical substance to
produce cold
– Advantage : remain pliable and can be easily molded to fit the body part

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• Hypothermia blankets/ pads
– can be used as hypothermia/ hyperthermia blankets
– is mostly used in intensive care unit
– Indications:
• Hypothermia therapy eg. for patients after acute stroke, cardiac arrest,
traumatic brain injury by
¤ slowing of cellular metabolism resulting from a drop in body
temperature
¤ decreasing the body’s need for oxygen and thus reducing harmful
effect of ischemia

Types of Cold Therapy – Moist method

• Cold Moist Compress
– Used for reducing inflammation and swelling
– Method similar to warm moist compress
– Desired temperature: 15℃
– Duration : ~20 minutes
– It can be clean or sterile
– Alert adverse effects:
• Burning/ numbness
• Mottling of skin
• Redness
• Extreme paleness
• Bluish skin discolouration

• Cooling Sponge Bath

– Purpose : to reduce patient’s fever by promoting heat loss through conduction
and vapourization
– For patients with very high fever (> 40 ℃)
• Rapid temperature drop can cause chills and thus increase heat production
• Usually accompanied with antipyretic medication
• Desired temperature: 18-32 ℃
• Duration: ~30 mins
– Providing Cooling Sponge Bath:
• Sponge face, arms, legs, back and buttock slowly and gently

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 • Chest and abdomen are not usually sponged
• Leave the area wet and cover with damp towel
• Discontinue if patient become pale or cyanotic or shivering, or if pulse
becomes rapids and irregular
• Reassess vital signs

Choice for Moist or Dry

• Both hot and cold therapy can be administered in moist or dry form
• Consider the use according to:
– Type of wound or injury
– Location of the body part
– Presence of drainage
– Presence of inflammation

Advantages and disadvantages of Moist Application

Advantages Disadvantages

Reduces drying of skin and softens wound Prolong exposure can cause maceration
exudates of skin

Moist compresses conform well to body Moist heat will cool rapidly because of
area being treated moisture evaporation

Moist heat penetrates deeply into tissue Moist heat creates greater risk for
layers burns to skin because moisture
conducts heat

Warm moist heat does not promote

sweating and insensible fluid loss

(Potter & Perry, 2015)

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Advantages and disadvantages of Dry Application
Advantages Disadvantages

Dry heat has less risk of burns to skin Dry heat increases body fluid loss
than moist application through sweating

Dry application does not cause skin Dry applications do not penetrate
maceration deep into tissues

Dry heat retains temperature longer because Dry heat causes increased drying of
it is not influenced by evaporation skin

(Potter & Perry, 2015)

Contraindications to the use of Hot Therapy

The first 24 hours after traumatic Heat increases bleeding and swelling
injury

Active hemorrhage Heat causes vasodilation and increases

bleeding

Non-inflammatory edema Heat increases capillary permeability and thus

produces edema

Localized malignant tumor Heat accelerates cell metabolism and cell

growth. It increases circulation and
accelerates metastases (secondary tumors).

Skin disorder that causes redness Heat can burn or cause further damage to the
or blisters skin.

(Berman et al, 2015)

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 Contraindications to the use of Cold Therapy
Open wounds Cold can increase tissue damage by decreasing blood
flow to an open wound

Impaired circulation Cold can impair nourishment of tissues and cause

tissue damage

Allergy or hypersensitivity • Allergy to cold  inflammatory response, eg.

to cold erythema, hives, swelling, joint pain and
occasional muscle spasm
• A sudden increase in blood pressure

(Berman et al, 2015)

Special Precautions
• Conditions that warrant special precautions during hot or cold therapy:

Neurosensory Patients with sensory impairment are unable to perceive that

impairment perceive discomfort from heat and cold. They are at risks on
burn and tissue injury.

Impaired Patients who are confused or have an altered level of

mental status consciousness need close monitoring and supervision during
applications to ensure safe therapy.

Impaired circulation Patients with peripheral vascular diseases, diabetes, or

congestive heart failure lack the normal ability to dissipate
heat via the blood circulation, which puts them at risk for
tissue damage with heat and cold applications.
Open wounds Tissues around an open wound are more sensitive to heat and
cold.
(Berman et al, 2015)

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Nursing Process for applying hot and cold therapy

1. Assessment
• Baseline assessment provides a guide for evaluating skin changes that might
occur during therapy
• Assess the patient for:
– Signs of potential intolerance to heat and cold
• Alteration in skin integrity
– Any contraindications for heat therapy, eg.
• Bleeding promote vasodilation
• Appendicitis  cause the appendix to rupture
• Cardiovascular problem cause massive vasodilation  shock
– Any contraindications for cold therapy, eg.
• Edematous injury site further retard circulation to the area and prevent
absorption of the interstitial fluid
• Presence of neuropathy  patient is unable to perceive the temperature
change and damage will be resulted from temperature extremes
– Assess the patient for their response to stimuli
• Sensation to light touch, pinprick, and mild temperature variation
– Assess circulation : colour, temperature, pulse, swelling, capillary refill
• Question the order if signs of circulatory insufficiency are present
• Assess the patient for:
– Level of consciousness
• It influences the ability to perceive heat, cold and pain
– Condition of equipment being used
• Leakage? Breaks?
• Is it functioning properly?

2. Planning
• Verify doctor’s prescription
• Introduce self and explain procedure
• Perform hand hygiene
• Inspect patient’s skin condition of treated area
• Check for sensitivity to temperature & pain
• Assemble equipment and supplies
• Prepare the therapy and check for desired temperature

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3. Implementation
• Verify doctor’s prescription again
• Recheck patient’s identity
• Provide privacy as appropriate
• Assist patient to a comfortable position
• Assist patient to expose treated area
• Drape patient
• Keep call bell within patient’s reach
• Inspect affected area every 5 to 10 minutes
– Ask patient’s tolerance
• Remove after prescribed time

4. Evaluation
• Determine whether the desired outcomes established during the planning phase
have been accomplished
• Expected outcomes include:
– Patient verbalizes increased comfort, increased ability to rest and sleep
– Demonstrate evidence of wound healing
– Demonstrate relief in symptoms (eg. muscle spasm, inflammation and edema)
• Collect data on :
– Skin status
– Signs of healing
• If outcomes are not achieved, explore the reasons and plan the implementation
again

Record and Report

• Document type, location and duration of application
– Record the temperature used if indicated
– Describe condition of treated area before and after treatment
• Describe patient’s response
– Include pain assessment
– Any analgesics used
• Report any education provided to patient/ family
• Report unusual findings

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 Safety Alert
• Explain to patient the expected sensation to be felt during the procedure
• Instruct patient to report changes in sensation or discomfort
• Time the application – do not overuse
• Keep call bell within patient’s reach
• Follow institution policy for safe temperature
• Do not allow patient to adjust the temperature settings
• Do not allow patient to move the application
• Do not place patient in a position that prevents movement away from the
temperature source
• Do not leave patient unattended, especially for those who are unable to sense
temperature changes or move away from the temperature source

Nursing checklist in heat & cold application

 Check doctor’s prescription on the site to be treated, type of therapy,
frequency and duration of application, as well as temperature to be used
 Assess patient’s general condition and skin area to be treated
 Check functioning of equipment
 Explain procedure and expected outcomes to patient
 Reassess patient’s status in 15 mins and after the treatment
 Document patient’s response

Reference/ Resource List

• Berman, A., Snyder, S.J., Kozier, B. & Erb, G. (2015). Kozier & Erb’s Fundamentals of
Nursing Concept, Process, and Practice. (10th ed.). New Jersey: Pearson Prentice Hall.
Chapter 33.
• Taylor, C.R., Lillis, C., LeMone, P. & Lynn, P. (2015). Fundamentals of Nursing. The
Art and Science of Person-centered Nursing Care. (8th ed). Philadelphia: Lippincott
Williams & Wilkins.

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