Hot and cold packs
Applying a heating pad to an arthritic joint or an ice pack to a sprained ankle is a fairly simple approach to reducing pain or inflammation. But even the simplest therapies require an understanding of why you do what you do, and how to do so safely.
Consider the basics of hot and cold therapy. Both relieve pain; they just use different pathways. For each method, the end result is the same: they both block pain impulses and stimulate the release of endorphins.1,2,3
It's the same for inflammation: different methods, same result.1,2,3 Cold causes local vasoconstriction and increased blood viscosity. The decreased blood flow and slower metabolism blunt the inflammatory response, limit swelling, reduce oxygen consumption, and control bleeding.1,2,3
Heat, on the other hand, controls inflammation by causing local vasodilatation and decreased blood viscosity. The increased blood flow quickly brings immune responders to the site and clears away debris. It also increases swelling and oxygen consumption and promotes bleeding.1,2,3
While these effects are beneficial, there's a downside to both, depending on the size of the area being treated:4,5 Cold can cause shivering, raise blood pressure, and decrease the respiratory rate. Prolonged exposure may cause blistering or necrosis. Heat can lower blood pressure and increase the respiratory rate. Prolonged exposure can lead to burns and necrosis. Proper management of either therapy is a must.
Things about cold you must know
Cold therapy can be delivered in a variety of ways. Among the most common are disposable ice bags or collars, cold packs, gels, water-filled electric cooling devices, and moist compresses, soaks, or sitz baths.4,6 In a pinch, you can even use a disposable glove. Fill it with ice and tie up the open end.
Cold works best when applied within the first 24 hours of injury or condition.6,7 Treatment is usually applied for 15 – 20 minutes followed by at least a 30-minute rest period.6,7 Because moisture intensifies cooling, cold compresses, soaks, or sitz baths should be used in shorter intervals (10-minute).8 Intermittent applications are generally continued for the first 24 – 48 hours.6,7
What's important to keep in mind is that while some disposable cold packs can be applied directly to the skin, many cannot.4 You'll need to wrap cold packs that can't be applied to the skin in a pillowcase, thin towel, or washcloth. The same applies to electric cooling devices that don't have a protective cloth cover. Never place a cooling device on an open wound.5
Before you apply cold therapy, always check the order for the type, duration, and number of repeated applications. Assess the patient for adequate circulation and sensation. Gather gloves, waterproof pads, and the cold therapy. Depending upon what's ordered, you may need to bring a clean basin, ice, towels, and tape.
Explain the procedure to the patient, and teach him that some numbness and tingling is to be expected.4 But instruct him to immediately report any burning, increase in pain, or severe numbness. These are signs of ischemia, and you should stop the treatment.4,6
Place a waterproof pad under the area being treated. Don gloves and mold the pack—or wrap the pad—to the injury.
To make it easier to mold the pack to the injury, it's best to fill ice bags, gloves, or collars with small chips, and no more than two-thirds full. Always squeeze the excess air out of the bag, because air interferes with cold conduction.
To make a cold compress, fill a basin with ice and add a little bit of water. Submerge a few hand towels into the basin, so you'll have them ready for subsequent applications. Take out a towel, wring out the excess water, and gently mold the towel around or to the injury. Wrap it in a waterproof pad and tape it down to seal in the cold.
Regardless of the type of cold therapy, check the patient's skin every five minutes or so for signs of cold intolerance, such as pallor, blanching, and mottling.4 Keep in mind that edema decreases sensation, so a patient who already has some swelling may not feel any burning or numbness.
When the time is up, remove the device and pat the skin dry. Document the skin's condition at the site, the level of edema, and the patient's response to therapy.
When your patient requires heat therapy
Like cold, there are a variety of devices used to administer heat, including commercial hot packs, gels, wraps, and water-filled heating devices, such as an aquathermia pad (K-pad). In home care, you may also see an electric heating pad or a hot water bottle.4,6
Never apply a heating device directly to the patient's skin unless the device has a protective cover.4,5,6 Wrap those that don't have a cover in a thick towel to prevent burning. Heat is transferred more quickly than cold. Never place a heating device under a patient's limb or body part, because compression will promote burning.4,6
Warm compresses can be placed on open wounds, as long as you use sterile technique.4,6 While warm sterile compresses are commercially available, you can make one from sterile gauze or towels.
Heat is primarily used to treat the chronic phase of an injury or condition, a time when blood flow is required to speed up healing. (usually 48 hours after an acute injury).5,6,7 Heat is also used to localize and clear up superficial infections. Therapy is typically applied for 15 – 30 minutes.6,7
Thermal wraps are an exception. They deliver low heat—104°F (40°C)—and can effectively relieve pain when left in place for up to eight hours.1,2,9 Thermal wraps restore function in patients who suffer from acute or sub-acute lower back, neck, or wrist pain.1,2
As with cold therapy, when it's time to apply heat, check the order and gather the necessary supplies. Assess the patient's circulation, sensation, and vital signs. Heat can drop blood pressure faster than cold can raise it, depending on how big the area being treated is.4
Explain the procedure, and teach the patient to report any pain or burning sensation. He should also let you know if he feels lightheaded or short of breath. Place a waterproof pad under the area being treated. Don gloves and gently apply the hot pack, compress, wrap, or K-pad to intact skin.
If you need to make a warm compress for an open wound, heat a bag or container of sterile water or saline in a basin of hot water. When it's sufficiently warmed, pour the sterile solution into a sterile basin. Drop sterile gauze or towels into the sterile solution. Don sterile gloves, pick up the gauze, and squeeze out any excess liquid. Check the temperature of the compress by squeezing a few drops onto the inner aspect of your wrist before putting it on the patient. It should feel warm, but not hot.
Pack the compress gently within the wound bed, avoiding the surrounding tissue. Wait a few seconds, assess the patient for pain, then lift up the dressing and check for excess redness, which may indicate a burn. If all is well, cover the compress with dry sterile gauze to prevent infection, and then a towel to seal in the heat.4
Warm compresses applied like this need to be changed every five to 10 minutes to maintain the heat unless you apply an aqua K-pad to it.4
Assess the skin during all types of heat therapies. The skin should be pink with no increase in edema.4 If intense redness or edema occurs, stop therapy and notify the physician of the heat intolerance.
When the time is up, remove the device and pat the skin dry. Note the skin color, wound bed, level of edema, and the patient's response to therapy.
Whether you are applying hot or cold therapy to a patient, vigilant monitoring and documentation are essential. That, combined with your expert application of the therapy itself, will ensure that your patient derives the maximum benefit from what is a very simple therapy.
REFERENCES
1. McCarberg, B., & O'Connor, A. "A new look at heat treatment for pain disorders, part 1." 2004. http://www.ampainsoc.org/pub/bulletin/nov04/inno1.htm (28 Nov. 2006).
2. O'Connor, A., & McCarberg, B. A new look at heat treatment for pain disorders, part 2." 2005. http://www.ampainsoc.org/pub/bulletin/win04/inno1.htm (28 Nov. 2006).
3. Berry, P. H., Covington, E. C., et al. "Pain: Current understanding of assessment, management, and treatments." 2006. http://www.ampainsoc.org/ce/downloads/npc/npc.pdf (24 Nov. 2006).
4. Perry, A. G., & Potter, P. A. (2006). Warm and cold therapy. Clinical nursing skills and techniques (6th ed.), (pp. 1307 – 1328). Mosby: St. Louis.
5. Klein, M. J. "Superficial heat and cold." 2006. http://www.emedicine.com/pmr/topic201.htm (23 Nov. 2006).
6. Perret, D. M., Rim, J., & Cristian, A. (2006). A geriatrician's guide to the use of physical modalities in the treatment of pain and dysfunction. Clin Geriatr Med, 22(2), 331.
7. AHRQ: National Clearinghouse Guidelines. "Clinical practice guideline for the management of postoperative pain." 2006. http://www.guidelines.gov/summary/summary.aspx?doc_id=3284&nbr=002510&string=heat+AND+therap (5 Dec. 2006).
8. Wilson, J. J., & Best, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician, 72(5), 811.
9. French, D. D., Cameron, M. "Superficial heat or cold for low back pain." 2006. http://www.clinicalevidence.com/ceweb/conditions/msd/1103/1103_I14.jsp#REF12 (5 Dec. 2006).
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