Learning Objectives
1. State the purposes for applying heat to the body; for applying cold to the body.
2. Describe the rationale for maintaining normothermia in the client.
3. Explain specific precautions when applying heat; when applying cold.
4. Demonstrate the administration of a leg soak, a sitz bath, and the aquathermia pad.
5. Demonstrate the use of the cooling blanket and the application of an ice collar or ice bag.
|
IMPORTANT TERMINOLOGY |
|
|
aquathermia pad |
sitz bath |
|
hypothermia |
tepid sponge bath |
|
normothermia |
|
|
Acronyms |
|
|
Aqua-K Pad |
US |
|
IR |
UV |
|
SSI |
WA |
Some conditions benefit from the application of heat and/or cold. Because complications can occur due to extreme heat or cold, the nurse must be aware of safety precautions and use these therapies carefully.
NORMOTHERMIA
Body temperature must be maintained within a fairly narrow range—normothermia or normal body temperature. This is particularly important during and after invasive procedures. It has been proved, for example, that normother-mia during surgery helps prevent surgical site infections (SSI) and other complications. Surgical clients are particularly vulnerable to hypothermia (abnormally low body temperature). A number of special gowns and blankets are available to help maintain total body normothermia, using dry heat. Warmed IV fluids may also be given. You may be required to manage this equipment postoperatively or in an emergency situation.
HEAT
Heat is often applied in general client care. Heat causes vasodilation (enlargement of blood vessels), increasing blood flow to a specific area. This increases the oxygen, nutrients, and various blood cells delivered to body tissues. Vasodilation also aids in removal of wastes from injured tissues, such as debris from phagocytosis.
Rationale for Heat Application
Heat application serves to:
• Relieve local pain, stiffness, or aching, particularly of muscles and joints
• Assist in wound healing
• Reduce inflammation and infection
• Make the chilly client more comfortable
• Raise body temperature to help maintain normothermia
• Promote drainage (draw infected material out of wounds)
Because heat must be fairly intense to be effective, burns may result if heat is applied improperly or for too long. The application must be sufficiently hot to accomplish its purpose, but within a safe temperature range. Box 54-1 provides temperature ranges for hot and cold applications. Heat applied over a large area affords more warmth; however, the potential for injury is greater than that of heat applied over a small area. Protect the client from possible burn injury by observing safety precautions. In Practice: Nursing Care Guidelines 54-1 outlines steps for applying heat therapy.
Both dry heat and moist heat have local effects. Apply dry heat with a heating blanket, warm-water bag, waterproof, water-filled heating pad (aquathermia pad), heat lamp, electric heat cradle, or electric heating pad. Moist heat warms the skin more quickly and is more penetrating than dry heat, because water is a better heat conductor than air. Apply moist heat with compresses, packs, or soaks, including the sitz bath. Sometimes wet compresses are used in combination with the aquathermia pad to provide longer-lasting moist heat. Skin maceration (abnormal softening) may develop when moisture is applied directly to the skin for long periods. The client’s skin may be protected by first applying a thin layer of petroleum jelly, if ordered. The provider’s order typically specifies the length of time for heat applications to be administered. For example, the order may be: “Moist compresses for 15 minutes every hour WA (while awake).”
BOX 54-1. Approximate Range of Temperatures for Hot and Cold Applications
|
Hot |
37.7°C-40.5°C |
I00°F-I05°F |
|
Warm |
35°C-37.7°C |
95°F-!00°F |
|
Tepid |
26.6°C-35°C |
80°F-95°F |
|
Cool |
!8.3°C-26.6°C |
65°F-80°F |
|
Cold |
!0°C-!8.3°C |
50°F-65°F |
|
To convert Fahrenheit to Celsius: C |
= (F – 32) X 5/9 |
|
|
To convert Celsius to Fahrenheit: F |
= (C X 9/5) + 32 |
|
Nursing Alert Applying heat to localized areas of infection, such as an abscess or infected topic, may cause rupture. Heat application is contraindicated (should be avoided) in this case. Systemic spread of infection (generalized septicemia) may occur and can be life threatening.
NCLEX Alert Heat therapies are commonly used in clinical settings, thus, are likely to be integrated into an NCLEX clinical option. You must understand and be able to differentiate the effects of heat therapy vs. cold therapy for the given situation. It is very important that you understand why a particular heat therapy is chosen (i.e. the rationale for use), what are the expectations of this therapy (e.g. assist muscle relaxation, improve circulation, encourage wound drainage, promote nor-mothermia, et al) and how to prevent complications of the chosen version of therapy Safety and client teaching issues regarding the type of equipment and monitoring for complications are also common NCLEX concerns.
Specific Localized Heat Therapies Dry Heat
Aquathermia Pad. An aquathermia (Aqua-K) pad, which produces dry heat, is used to treat muscle sprains and mild inflammations and for pain relief. Temperature-controlled, distilled water flows through the waterproof pad. Apply the pad following specific orders. Check to make sure the pad is heating properly and not overheating and stop treatment and report malfunctions if overheating occurs. In Practice: Nursing Procedure 54-1 describes the use of an aquathermia pad.
Heat Lamp Treatments and Ultrasound. Specially trained personnel give heat lamp and ultrasound treatments, because the client’s exposure to light rays must be carefully regulated to prevent injury. The nurse must have specific inservice education to administer infrared (IR), ultraviolet (UV), or ultrasound (US) treatments.
Nursing Alert When disassembling the aquathermia pad after use:
• First, clamp all tubing until over the sink.
• Unplug the unit.
• Empty the water out of the pump unit, the pad, and all tubes over a sink to prevent leakage.
• Discard the pad (it is contaminated).
• Return only the heater/pump to the appropriate department.
• Carefully wash hands.
IN PRACTICE: NURSING CARE GUIDELINES 54-1
APPLYING HEAT THERAPY
• Heat is applied only when specifically ordered by a primary provider and applied with the utmost caution. Rationale: Nerves in the skin are numbed easily. The client may not feel the pain of a burn, especially if heat has been applied often.
• Specific body parts, such as the eyelids, neck, and inside an arm, are especially sensitive to heat.
• Each person has his or her own sensitivity to heat. Apply the heat source slowly and ask the client for feedback. Rationale: This helps determine how much heat is safe and for how long.
• Infants, older people, and those with fair, thin skin have less heat resistance. Lowered body resistance because of illness also makes body tissues less resistant to heat. Rationale: It is important to consider each client individually.
• Clients who are unresponsive or anesthetized and those with neurologic or psychological disorders or dementia are at increased risk for injury from heat applications. Rationale: These clients are often unable to report when heat is too intense.
• Impaired circulation and some metabolic diseases make people more susceptible to burns (e.g., clients who are in shock or have any type of peripheral vascular disorder, or clients who have diabetes). Rationale: Changes in body systems interfere with skin integrity and healing and may impair the client’s ability to identify discomfort.
• Clients receiving radiation therapy or chemotherapy and those with any degree of paralysis are particularly susceptible to burns. Rationale: Such clients have compromised immune systems or skin integrity.
• Client complaints are very important. Listen to the client; if he or she complains of pain or discomfort, stop the treatment and consult the primary provider Rationale: Each client is different. Only the client can state how the treatment feels.
Infrared (IR) rays relax muscles, stimulate circulation, and relieve pain, as do other forms of dry heat. Ultraviolet (UV) rays are not as penetrating as infrared rays. Sunlight provides mild UV radiation; prolonged exposure will, however, burn sensitive skin. UV rays are used to treat skin infections and wounds. Ultrasound (US) is a method of applying deep, penetrating heat to muscles and other tissues. Lubricating gel is applied to the client’s skin, and the US paddle or wand is kept moving at all times during the treatment to prevent burns.
Nursing Alert The US machine’s timer must be in good working order and must be set correctly to ensure the appropriate treatment time and to prevent client injury
Key Concept Ultrasound is also used to visualize and examine internal tissues.
The Heat Cradle. In rare instances, a lamp or special heater is mounted inside a bed cradle to provide dry heat.The primary provider must clearly specify the time limits and these orders must be followed exactly (e.g. “Heat cradle 20 min Q hr, WA”). As with any heat application, monitoring the client closely is vital, to prevent burns. Some heat cradles have an automatic timer that turns the lamp on and off at preset intervals.
Nursing Alert Do not perform any type of heat treatment without a specific order and special training in the use of the equipment.
Electric Heating Pad. An electric heating pad is a covered network of wires that emits heat when electricity passes through it. Pads with a waterproof cover are the safest. The client who is paralyzed, has very sensitive or friable (fragile) skin, or has a neurologic impairment is particularly vulnerable to a burn from the electric pad. These heating pads are also unsafe to use with children; confused, irrational, or unresponsive persons; clients who are suicidal; or clients who have spinal cord injuries. Acute care facilities rarely use this heating pad because of its danger. Extended-care facilities occasionally use them and they are commonly used in the home. In Practice: Educating the Client 54-1 describes the safest use of electric heating pads.
Nursing Alert Never use pins with any heating pad. They may puncture the Aqua-K pad, causing leaks or may cause a shock if the pin touches a wire. If wires are bent or crushed, the pad can overheat, causing a fire.
Moist Heat
Warm, Moist Compresses and Packs. Warm, moist compresses and packs apply moist heat to an area to stimulate circulation, ease pain, and promote wound drainage. They are also used to apply medications. The primary provider prescribes the type of application, where it is to be applied, and the schedule of applications. The order also includes the solution to use, most often plain water, a mild antiseptic solution (e.g., 2% boric acid), or normal saline.
Warm, moist compresses, such as 4 X 4 gauze or Telfa pads, are used to apply heat to a small area. Large warm, moist packs of cotton or terry cloth are used to apply heat over a larger area. Commercially prepared warm packs are also available and may be used to apply either dry or moist heat (Fig. 54-1). Covering any warm pack with heavy, dry material helps it retain heat longer. Application of an Aqua-K pad over a pack enables the pack to remain heated almost indefinitely. Compresses and warm packs are usually not sterile. However, if there is a break in the client’s skin, sterile dressings are used.
IN PRACTICE :EDUCATING THE CLIENT 54-1
USING ELECTRIC HEATING PADS AT HOME
• Before applying the pad, connect it to an electric outlet and turn the heating switch to high to see whether the pad heats promptly Then turn it off and disconnect it.
• Check to make sure the cord is intact and there are no frayed wires. If there is any question, do not use the pad.
• Never use safety pins or water near a heating pad.
• Make sure the pad is covered.
• After plugging it in, adjust the pad to low temperature and apply it over the body part; do not allow the client to lie on it.
• Inspect the skin frequently to prevent burning.
• Leave the setting on low at all times.
• Use the pad only for the length of time specified by the primary provider
• Make sure there is nobody in the home who might become entangled in the cord. (This includes children, confused persons, or those who are suicidal.)
The pack should be as warm as the client can comfortably tolerate. Apply it slowly so the client can tell you how the pack feels. The client is the best judge of his or her own comfort. During the procedure, the client may feel chilly, so take precautions to keep the person warm and protected from drafts.
You may need to apply a warm compress to a client’s eye. The eyelid and the skin around the eye are thin and delicate structures, easily susceptible to injury. For an eye compress, use tepid water only (see Box 54-1). Use extreme caution to prevent injury. Wash your hands carefully and wear clean gloves for this procedure; the eye is highly susceptible to infection.
FIGURE 54-1 · A commercial warm pack can be used to apply dry heat, but is most often used as a moist heat application. Some of these packs can also be used as cold packs.
If the eye is draining, discard each compress on removal. All reusable equipment is sterilized after the treatment. If applying compresses to both eyes, use separate equipment and wear new gloves for each eye to prevent spreading infection from one eye to the other.
To apply warm, moist compresses and packs to all body parts, follow the general rules as outlined in In Practice: Nursing Procedure 54-2.
Warm Soaks. Another method for applying moist heat consists of immersing the client’s affected body part in warm water or medicated solution for a prescribed time. This procedure is called a soak.A warm soak:
• Improves circulation
• Increases blood supply to an infected area
• Assists in breaking down infected tissue
• Applies medications
• Cleans draining wounds
• Loosens scabs and crusts from encrusted wounds.
Soaks may be done in a basin if the area is small or in a tub if the area is large. Often, a soak may be combined with a whirlpool bath by the physical therapy staff. Although the tub is usually not sterilized between clients, it must be cleaned thoroughly with soap, disinfectant, and water, per agency protocol. Rationale: Persons receiving soaks often have open wounds. Therefore, thorough cleaning of the tub helps prevent the spread of infection between clients.
Use tap water for soaks unless otherwise specified. A mild detergent (e.g., Dreft) or other substance (e.g., colloidal oatmeal) may be added to the water. The water temperature for a small area must not exceed 40.5oC (105oF). For a larger soak, the water is usually warm, not hot (see Box 54-1) . The order may prescribe the temperature. Test the water’s temperature frequently, add hot water slowly, and stir to distribute the heat evenly. This is important to prevent burns. Usually a soak lasts 15 to 20 minutes. Follow the steps in In Practice: Nursing Procedure 54-3 for giving an arm or leg soak.
Sitz Bath. The purpose of a sitz bath (sitting in a tub of warm water) is to provide moist heat to the pelvic, perineal, and/or perianal area. They are most often used following infant delivery or rectal/perineal surgery. Disposable sitz basins are used. The basin fits inside the commode and is equipped with a bag, tubing, and nozzle, to allow water to flow freely to the affected area (Fig. 54-2). In the client’s home, a regular bathtub containing enough water to cover the client’s hips and perineum is often used. In Practice: Nursing Procedure 54-4 describes the use of the disposable sitz tub.
Nursing Alert Vasodilation from heat application over a large area of the body may cause hypotension (low blood pressure). All clients should be monitored closely and assisted when rising. Rationale: This helps prevent injuries.
Heat applications may be contraindicated in clients with known cardiac conditions or those taking certain cardiac medications or antihypertensives. Rationale: These people may be more susceptible to changes in blood pressure and blood flow.
The application of heat is usually contraindicated if a client is actively bleeding. Rationale: Heat application can increase blood flow and thus increase bleeding.
FIGURE 54-2 · A disposable sitz bath fits inside a commode.
Nursing Alert Moist heat is not used if there is inadequate arterial blood flow to a wound area. Rationale: In this case, eschar will protect the wound and must be kept dry.
