Way to administration of hot and cold to patient

2. SUPERFICIAL HEAT AND
COLD
 Primarily increase or decrease
temperature of skin, superficial
subcutaneous tissues

3. TRANSFER OF ENERGY: HEAT,
OR THE LOSS OF HEAT,
OCCURS IN ANY OF THE
FOLLOWING WAYS:
 Conduction: Contact
 Convection: movement
 Evaporation: through liquid-gas transfer
 Radiation: electromagnetic waves
 Conversion: transfer from one energy
type to another

4. THERAPEUTIC APPLICATION
 Heating Agents
◦ Transfer heat to patient’s body,
between various tissue / fluids
 Cooling Agents
◦ Transfer heat away from patient’s
body

5. HOT APPLICATION
Hot application is the application of a hot
agent, warmer than skin either in a moist
or dry from on the surface of the body;
 To relive pain and congestion,
 To provide warmth,
 To promote suppuration,
 To promote healing,
 To decrease muscle tone and
 To soften the exudates.

6. Cold application
Cold application is the application of a cold
agent cooler than skin either in a moist or
dry form, on the surface of the skin;
 To reduce pain and body temperature,
 To anaesthetize an area,
 To control hemorrhage,
 To control the growth of bacteria,
 To prevent gangrene,
 To prevent edema and
 To reduce inflammation.

7. Dry heat Moist heat
•Hot water
bottles
•Chemical
heating bottles
•Infrared rays
•Ultraviolet rays
•Short wave
diathermy
•Heating lamps
•Electric cradles
•Electric heating
pads
•Warm soaks
(Local baths)
•Hot
fomentations
(Compresses)
•Poultices
(cataplasm)
•Stupes (medical
fomentations)
•Paraffin baths
•Sitz bath
•Aquathermia
pad
•Sun bath
•Electric
cradles
•Blanket
bed
Dry heat Moist heat
•Steam
baths
•Hot packs
•Whirlpool
bath (Full
immersion
bath)

8. Dry cold Moist cold
•Ice bag
•Ice collar
•Ice pack
(poultice)
•Ice cradle
•Chemical
cold packs
•Ice to suck
•Cold
compress
•Evaporating
lotion
•Hypothermia
Dry cold Moist cold
•Cold
sponging
•Cold bath
•Cold packs

9. Local Application of heat and cold
to the body can be therapeutic, but
before using these therapies, the
nurse must understand normal
body responses to application of
heat and cold and how and when
to use.

10. CLASSIFICATION OF
TEMPERATURES: FOR
TREATMENT PURPOSES, ARE
CLASSIFIED AS FOLLOWS:
Very Cold 32 to 55 F
Cold 55 to 65 F
Cool 65 to 80 F
Neutral 80 to 92 F
Warm 92 to 98 F
Hot 98 to 104 F
Very Hot 104 F 
Hot

11. Temperature for hot and cold
applications
Description Temperature Application
Very cold Below 15C Ice bag
Cold 15-18 C Cold packs
Cool 18 – 27 C Cold compresses
Tepid 27 – 37 C Alcohol sponge bath
Warm 37 – 40 C Warm bath
Hot 40 – 46 C Hot soak, hot
compresses
Very Hot Above 46 C Hot water bag for adult

13. PRIMARY / PHYSIOLOGICAL
EFFECTS
HOT APPLICATION COLD APPLICATION
Peripheral Vasodilatation Peripheral Vasoconstriction
Increased capillary permeability Decreased capillary permeability
Increased oxygen consumption Decreased oxygen consumption
Increased local metabolism Decreased local metabolism
Decreased blood viscosity Increased blood viscosity
Decreased muscle tone Decreased muscle tone
Increased blood flow Decreased blood flow
Increased lymph flow Decreased lymph flow
Increased motility of leucocytes Decreased motility of leucocytes

14. SECONDARY EFFECT OF HOT AND
COLD APPLICATION
 With the local heat application, the maximal
increase in the of circulation & temperature
occurs after 20 to 40 min exposure. After this
time, the heat application must be discontinued
& a recovery time of 1 hour allowed otherwise
secondary effect (vasoconstriction) will take
place.
 With the cold application, the primary effects
may last only for 30 min to 1 hour. After this
time, a recovery time of one hour must be
allowed or secondary effects (vasodilatation)

15. SYSTEMATIC RESPONSE
Heat-loss via sweating and vasodilation
Heat conservation via
vasoconstriction, curl-up
Heat production via
shivering, movement

16. SYSTEMATIC RESPONSE
What happens if heat is
applied to a large body
area?

17. ANSWER

18. EXCESSIVE PERIPHERAL
VASODILATION
Diverts large supplies
of blood from the
internal organs
Drop in the Blood Pressure
Which could lead to a safety issue

19. LOCAL BODY RESPONSE
 Occurs through stimulation of temperature-
sensitive sensory nerve endings/ thermal
receptors in the skin.
 Sent up the spinal cord to the hypothalamus
in the brain where impulses are recognized
as hot or cold
 Protective adaptive responses are triggered:
cold= vasoconstriction; hot= vasodilation

20. ADAPTATION OF THERMAL
RESPONSE
Nerve receptors strongly stimulated
initially
Declines rapidly during first few
seconds
Declines slowly over the next half hour
Receptors adapt to the new

21. Exceeding normal temperature
ranges can damage tissues

22. REBOUND Phenomenon: Heat
 Occurs at the time that maximum
therapeutic effect of hot or cold
application is achieved
 Heat produces maximum vasodilatation
in 20-30 minutes.
 Continuation beyond 30-45 minutes
causes tissue congestion, the blood
vessels constrict

23. REBOUND Phenomenon: Heat
 Now the opposite effect is occurring
because of reflex vascular
constriction.
 Recovery time of one hour is advised
before reapplication

24. REBOUND Phenomenon: Cold
 Maximum vasoconstriction occurs when
the skin temperature reaches 150 or in
about 30 minutes to one hour.
 Vasodilation begins as a protective device
to prevent the body tissue from freezing
 Recovery time of one hour is best before
reapplication.

26. The nurse should assess
WHY thermal therapy is
being utilized

27. FACTORS AFFECTING HEAT AND
COLD TOLERANCE
 Body part: Certain areas of the skin have a
sensitivity to temperature variations. The
inner aspect of the wrist and forearm, the
neck, and the perineal area are
temperature-sensitive, while the back of the
hand and the foot are not as sensitive.
 Duration of application: Therapeutic
benefits of heat and cold applications are
achieved with short periods of exposure to
temperature variations. Tolerance increases
as the length of exposure increases.

28.  Area of body exposed: The larger the
area exposed to heat and cold, the
lower the tolerance to temperature
changes.
 Damage to body surface area: Injured
skin areas are more sensitive than intact
areas to temperature variations.

29.  Individual tolerance: Tolerance to
temperature variations is affected by age
and physical condition. The young and
the aged are especially susceptible to
heat and cold. Neurosensory impairments
may interfere with the reception and
perception of stimuli, increasing the risk
of injury.
 Age: Thinner skin layers in children and
elderly people increase the risk for burns
from the heat and cold applications. Older
adults have a decreased sensitivity to

30. Scientific principles involved in
hot and cold applications
 Water is a good conductor of heat
 Air is a poor conductor of heat
 The flow of heat is from the hotter are to
the less hot area
 Prolonged exposure to moisture
increases the skin’s susceptibility to
maceration and skin breakdown,
reducing the protection of the intact skin.

31.  Moisture left on the skin causes rapid
cooling due to evaporation of the moisture
 Presence of steam increases the
temperature of the hot application
 Oil acts as insulator and delays the
transmission of heat
 Woolen absorb moisture slowly, but hold
moisture longer and cool off less quickly
than the cotton materials.
 The temperature tolerance varies with
individuals and according to the site and
area covered
 Friction produce heat.

32. HEAT
APPLICATION

33. INDICATIONS

34. THERAPEUTIC USES OF LOCAL
HOT APPLICATIONS
 Decreases pain
 Decreases muscle tone
 Promote healing
 Promotes suppuration
 Relives deep congestion
 Softens the exudates
 Provide warmth
 Stimulates peristalsis

35. Contraindications

36. CONTRAINDICATIONS OF HOT
APPLICATIONS
 Malignancies
 Impaired kidney, heart & lung functions
 Acutely inflammed areas
 On clients with paralysis
 Open wounds
 Edema associated with venous or lymphatic
diseases
 Headache
 Client with metabolic disorders
 Very young & very old client
 Client with very high temperature

37. COMPLICATIONS

38. COMPLICATIONS OF HOT
APPLICATIONS
 Pain
 Burns
 Maceration (with moist heat)
 Redness of the skin
 Edema
 Pallor (secondary effect)
 Hyperthermia

39. THERAPEUTIC
EFFECTS OF HEAT

40. Hemodynamic

41.  Increase circulation 1.5-2x normal
 Increased metabolism
(contraindicated in 2-3 days post
injury)
 Increased inflammation,
phagocytosis, & wound healing
 Decreased pain (analgesia); not as
effective as cryotherapy for acute
pain
 Decreased muscle spasm
 Decreased tissue stiffness (fluids
less viscous and collagen releases

42.  Depth of effects are not as great as
with cold
 Vascular changes are confined to skin
(1cm)
BUT

43. Neuromuscular

44.  Increase sensory nerve conduction
 Analgesic effects both distal and
proximal to area treated
 This is why non-acute back patients use
heat instead of ice
 Reducing muscle spasm
 Inhibits muscle contraction

45. GENERAL INSTRUCTION
 Assess the condition of the client prior to,
during & after the application of the heat
& cold application.
 Check vital signs.
 Maintain correct temp. for the entire
duration of the application.
 Never use any equipment unless
understand its operation completely.
 There must be a recovery period
between the application.

46.  Expose the client only to a safe temp.
 Don’t allow the client to adjust temp.
control
 Never ignore the complaints of a client
 Make sure that the client is in a position
to remove the application if it is causing
him discomfort.
 Client must have a calling signal with in
reach
 Never leave client even for short period
 Squeeze off water from moist heat
applications to prevent scalding.

47.  Apply thin layer of petroleum jelly or oil to
skin prior to the application of moist heat
application. It will reduces soaking of the
skin & therefore maceration.
 Don’t use electrical appliances close to
the open oxygen.
 Don’t use electrical appliances near
water or other fluid.
 If any sign of complication recognized
stop procedure immediately.
 After procedure, dry the body area gently
by patting not by rubbing to remove the
moisture.

49. Hot water bag
 Fill two-thirds to half full with warm water
and remove air at the top so the bag is
easier to mold over the body part.
 Dry the outside of the bag & test for
leakage by holding the bag upside down.
 Cover bag with a towel or pillowcase
(never apply directly on the skin surface)
 Keep bag in place for 20–30 minutes and
then remove.
 Do not allow the client to lie on the hot
water bag

51. HOT PACKS / CHEMICAL
HEATING PACKS
 Commercially prepared, disposable hot
packs supply warm dry heat to an injured
area.
 Striking or squeezing the pack will
release chemicals that create the heat.
 These packs are designed to maintain a
constant temperature between 40.6º C &

53. AQUATHERMIA PADS
 Are useful in treating muscle sprains and for
areas with mild inflammation or edema.
 Unit consists of a waterproof plastic or
rubber pad connected by two hoses to an
electrical control unit that has a heating
element and a motor. The reservoir of the
unit is filled two-thirds full with distilled water.
 The desired temperature is usually set with
a key at 45°C for adults.
 Cover the pad with a thin cloth or pillowcase
prior to application.
 Treatment usually continues for 20–30
minutes.
 Do not have client lie on pad.

55. ELECTRICAL HEATING PADS
 Provide constant, even heat, are lightweight,
and can easily be molded to a body part.
 Unit composed of electrical coil enclosed
within a waterproof pad covered with cotton
or flannel cloth to absorb the perspiration &
to insulate the pad.
 Instruct the client to avoid using high setting,
to prevent burns.
 No wet dressing should be applied with
pads.
 Do not allow the client to lie directly on the
pad, because heat will not dissipate and the
client may be burned.

58. INFRARED LAMP
 Radiant energy
 2 types luminous (infrared)
and nonlumious (far
infrared)
 Luminous produces some
visible light (as opposed to
nonluminous), nonlumious
is less penetrating than
luminous

59. ULTRAVIOLET RAYS / LAMPS
 Transmit ultraviolet rays, which are
invisible heat rays.
 Observe the skin carefully during
and after the treatment.
 Client & therapist must use
protective goggles to shut out
reflected harmful rays.
 Duration of treatment is usually 20-
30 min

60. DIATHERMY
High-frequency wave achieves
deep heat penetration
 Ultrasound
 Shortwave
 Microwave

61. ELECTRIC CRADLES / HEAT
CRADLES
 It is used when large body part is to be
treated & covering of skin with gown or
sheets is not possible.
 Sheet or blankets can be added over the
cradle to maintain the heat at the desire
levels.
 Duration of treatment is usually 20-30
min, after unit is warmed up, or can be
used continuously to provide low temp.

62. HEATING LAMPS
 Used to supply heat to the body parts.
 The distance between the exposed part
& the lamps depend upon the wattage of
the light bulb & heat tolerance.
 Duration of treatment is usually 20-30
min
 Recommended distances are as follows:
WATT BULB DISTANCE FROM THE BODY PART
25 35 cm
40 45 cm
60 60 to 75 cm

65. FOMENTATION
 Moist application of heat over an area by
means of double thickness of flannel or
other soft material wring out from hot
water, protected by a waterproof
covering, wool and bandage.
Types:-
 Simple
 Medical
 Surgical (applied over an open wound)

66. Purpose
 To relieve pain & congestion
 To relieve inflammations
 To relieve retention of urine
 To promote suppuration
 To stimulate peristalsis & relieve tympanites
 To relieve intestinal & renal colic
 To soften the crust & for the easy removal of
the crust
 To help in the absorption of the exudates
 To relieve muscular spasm
 To relieve congestion in the internal organs

67. TREATMENT PROCEDURE
 Have all equipment assembled at bedside
before beginning treatment
 Have the person remove clothing and
drape with a sheet.
 Explain the procedure, tell them to tell you
when it is too hot & when it isn’t hot
enough
 The duration and frequency in changing
the fomentations depend upon the desired
effect.
 Take care not to burn the person with too

68.  Be sure person’s feet are warm (if cold, cover with
blanket).
 Cover part to be treated with a bath towel.
 Apply fomentation. To relieve congestion, have the
fomentation cover a large area. For local effect,
make the fomentation the area size.
 Add another towel if the fomentation is too hot.
 Remove fomentation every 3-5 minutes and use cold
mitten friction or rub with cold wash cloth for 30
seconds and then dry the area.
 Reapply fomentation (3-6x in total – always finish
with cold).
 Hot fomentation - cold mitten friction and dry area -
 hot fomentation - cold mitten friction and dry
area - hot fomentation - cold mitten friction and
dry area.
 If general perspiration was produced – neutral to cool
shower or a sponge bath.
 Have person rest 30 minutes.

69. Contraindications
 1. Unconsciousness.
 2. Careful not to burn patient
 3. Paralyzed parts of the body.
 4. Do not use on the legs or feet of a
diabetic.
 5. Edema and varicose veins and advanced
vascular disease of the legs and feet.
 6. Malignancy.
 7. Tendency to bleed.
 8. Stomach and bowel ulcers.

70. Important Considerations
 Always ask if fomentations are burning the
patient. If they are too hot, put a towel
between skin and hot fomentation.
 Have extra dry towels handy to layer in
case fomentation is too hot.
 Have the room warm before you begin
treatment; make sure there are no drafts.
 Caution with the thin or aged persons and
children.
 Parts where bone is close to skin surface
are especially apt to burn.

72. STUPES (MEDICAL FOMENTATIONS)
 Medicine (e.g. turpentine) is applied
locally to augment the effects of the
hot compresses used.
 Commonly used to relieve
tympanites by increasing the
peristalsis & relaxing the muscle
spasm.
 Drugs used are: turpentine (1 part)
with olive oil (3 parts) for adults. For
children, turpentine (1 part) with

73. POULTICES (CATAPLASM)
 Application of moist heat in the
form of a soft spongy mass that
retains its heat for a varying length
of time, according to the ingredient
used.
 Starch poultices: starch and sodium
bicarbonate in the proportion of 8:1
 Duration of application is 30 to 60
min

75. MOIST HEAT PACKS
 Canvas Pouch with Silica Gel
 Pack is kept in a water-filled heating
unit maintained between 160º F -170
º F
 Pack maintain temperature for 30-45
minutes
 Packs transfer heat by conduction
 Main benefit is superficial heat to
1cm

76. MOIST HEAT PACKS
 Set-up
◦ Cover pack with terry cloth or towel
covering
◦ Place pack on patient in comfortable
manner (patient on pack is
contraindicated)
◦ Check patient within 5 to 6 minutes for
comfort
◦ Allow 3-4 hr minimum between
treatments on the same day

78. MOIST HEAT PACK
 Precaution:
◦ infected areas
must be covered
with gauze
 Contraindications:
◦ Acute conditions
◦ Peripheral
vascular disease
◦ Impaired
circulation
◦ Poor thermal
 Indications:
◦ Subacute or chronic
inflammatory conditions
◦ Reduction of subacute
or chronic pain
◦ Subacute or chronic
muscle spasm
◦ Decreased ROM
◦ Hematoma resolution
◦ Reduction of joint
contractures
◦ Infection (discuss)

79. WARM COMPRESSES (GAUZE
DRESSING MOISTENED IN A
PRESCRIBED WARMED SOLUTION)
 Applied to improve circulation, relieve
edema, and fasten the suppurative process
and healing.
 For an open wound, use sterile technique.
 Solution to moisten the gauze can be
heated first to 40.5°C (105°F) or procedure
is similar to application of a wet to dry
dressing and the use of a hot water bag or a
heating pad to cover the dressing.
 Remove compress after 20–30 minutes
and redress wound.

81. WARM SOAKS
(LOCAL BATHS)
 Immersion of body part in warmed solution
promotes circulation, decreases edema,
increases muscle relaxation, and provides a
means to debride wounds and apply medicated
solution.
 Can also be accomplished by wrapping body
part in dressings and saturating them with
warmed solution.
 Sterile technique is generally indicated for open
wounds, such as a burn. Check agency
protocol regarding the temperature of the
solution.

82.  Temp. of warm water is at 105 to
110 F (40.5 to 43 C)
 Duration of treatment is usually 20
min
 Temp. of solution should be checked
frequently & additional solution is
added or the solution is replaced in
order to maintain the appropriate

84. PARAFFIN BATH
 A mixture of 15 to 30 ml of mineral oil to 1
pound of paraffin wax
 Temperature of 118º F to 126 ºF for upper
extremity tx.
 Temperatures of 113 º F to 121 º F for lower
extremity (circulation is less efficient)
 Paraffin can provide approx. 6x the amount of
heat as water due to low specific heat.

85. PARAFFIN BATH
 Used to deliver heat in uniform
amounts to small irregularly shaped
areas (hands, fingers, wrist and foot)
especially for rheumatoid arthritis.
 Wax moistens skin, water tends to dry
skin

86. PARAFFIN BATH SET UP
 Immersion Bath
◦ Clean body part
◦ Dip part quickly; allow
10 sec. to dry (turns
milky)
◦ Dip the extremity 6-12
more times
◦ Then cover with
cellophane or towel for
duration of tx (10-15
min)
◦ DO NOT touch sides or
bottom of bath (burns)
◦ After tx scrape off and
 Pack (Glove) Method
Clean extremity
◦ Immerse extremity in
bath and allow wax to dry
- repeat 7-12 more times
◦ After final withdrawal
from wax, cover
extremity with plastic
bag, or wax paper. Then
wrap in towel
◦ If indicated elevate body
part
◦ Following tx remove wax
and return to bath

87. PARAFFIN BATH
 Precautions
◦ Sensation is
different from
specific heat and
thermal capacity -
may cause burns
 Contraindications
◦ Open wounds (options?)
◦ Skin infections
◦ Sensory loss
◦ Peripheral vascular
disease
 Indications
◦ Subacute and chronic
inflammation
◦ limitation on ROM after
immobilization

88. WHIRLPOOLS / FULL
IMMERSION BATHS
 Tx temperature is between 105º-112º F
for extremities and 100-108º F for whole
body
 Tx times usually last 10-20 minutes;
watch for lethargy with WWP

89. WARM WHIRLPOOL
 Precautions
◦ Must be connected to ground-fault
indicator
◦ Instruct patient not to turn whirlpool motor on
or off while in whirlpool
◦ Patient should be continually monitored
◦ Do not run while turbine is dry
◦ Clean tank pre and post infectious wound tx
◦ Keep clothing and bandages out of whirlpool

90. WARM WHIRLPOOL
 INDICATIONS
◦ Decreased ROM
◦ Subacute or
chronic
inflammatory
conditions
◦ Stiffness or
soreness
◦ Irregular shaped
areas
 CONTRAINDICATIONS
◦ Acute conditions where
water turbulence would
further irritate injured area
◦ Fever above 101º F
◦ Comprimised circulation

91. SITZ BATH / HIP BATH
 Used for clients who have had rectal surgeries, an
episiotomy during childbirth, painful hemorrhoids, or
vaginal inflammation.
 Only the client’s pelvic area is immersed in warm fluid;
the client sits in a special tub or chair or in a basin
placed on the toilet seat so that the legs and feet remain
out of the water (immersing the entire body causes
widespread vasodilation, negating the effect of local
heat to the perineum or pelvic area).
 Water temperature should be from 43° to 46°C (110° to
115°F) & Duration of the bath is usually 15–30 minutes.
 Prevent overexposure and chilling by draping a bath
blanket over the client’s shoulders and thighs, and
prevent drafts.
 Assess the client during the bath for extensive

92.  Solutions used:-
◦ Potassium permanganate solution 1:5000
◦ Boric acid 1 dram to 1pint
◦ Eusol solution
 Contraindications
◦ Pregnancy
◦ Menstruation
◦ Renal inflammation
◦ Increased irritability of the genital organs

95. COUNTERIRRITANTS
 Drugs used to augment the desired
effects of the heat application to induce
vasodilatation in the superficial tissues to
affect the circulation or muscle tone in an
underlying area or distant part by reflex
action.
 Counterirritants include mustard,
turpentine, capsicum and liniments such
as camphor, and methyl Salicylates.

96. RUBEFACIENTS
 Simple form of counterirritant which
merely reddens the skin by
vasodilatation.
 Its effect is immediate and lasts only for
a short period.
 E.g. mustard plaster, Tr. iodine,
turpentine

98. INDICATIONS

99.  Relieves pain
 Prevent gangrene
 Prevent edema & reduce
inflammation
 Control hemorrhage
 Control the growth of bacteria
 Reduces the body temperature
 Anaesthetize an area
THERAPEUTIC USES OF
LOCAL COLD APPLICATIONS

100. Contraindications

101.  Client in the state of shock &
collapse
 Edema
 Diseases associated with impaired
circulation
 Muscle spasm
 Decreased sensation
 Client have shivering or having very
CONTRAINDICATIONS OF COLD
APPLICATIONS

102. CONTRAINDICATIONS FOR
COLD
 Cold hypersensitivity or intolerance
 Cryoglobulinemia
◦ Uncommon disorder
◦ Aggregation of serum proteins in distal
circulation when distal extremities cooled
◦ Proteins form a “gel” that can impair
circulation,
◦ Causes local ischemia, gangrene
 Paroxysmal Cold Hemoglobinuria
◦ Release of hemoglobin into urine from lysed
red blood cells,
◦ In response to local or general exposure to
cold

103. CONTRAINDICATIONS FOR
COLD
 Raynaud’s Disease
◦ Paroxysmal digital cyanosis
◦ Sudden pallor followed by redness of skin of digits,
◦ Precipitated by cold or emotional upset
◦ Relieved by warmth
◦ Bilateral and symmetric (women)
 Raynaud’s Phenomenon
◦ Generally only in one extremity
◦ May be associated with thoracic outlet, carpal tunnel
syndrome or trauma

104. CONTRAINDICATIONS FOR
COLD
 Regenerating Nerves
◦ Local vasoconstriction or decreased nerve
conduction may delay regeneration
 Circulatory compromise or peripheral
vascular disease
◦ Chronic peripheral vascular disease may have
edema
◦ Cold may increase this edema
 Indicators for swelling due to Peripheral vascular
disease
 Pallor and coolness

105. COMPLICATIONS

106.  Pain
 Blisters and skin breakdown
 Maceration (with moist cold)
 Grey or bluish discoloration
 Thrombus formation
 Redness (secondary effect)
 Hypothermia
COMPLICATIONS OF COLD
APPLICATIONS

107. PENETRATION DEPENDS ON
MANY FACTORS:
 Cold has a longer wavelength than heat
 Local temperature gradient
 Treatment surface area covered
 Thickness and characteristics of tissue
treated (fat is an insulator, tissues with
high water content have better heat
transfer)

108. THERAPEUTIC EFFECTS
OF COLD

109. Hemodynamic Effects

110. Hemodynamic Effects
 Immediate vasoconstriction
◦ Less than 15 minutes
◦ Stimulates smooth muscles of vessels to
contract
◦ Decreases release of histamine,
prostaglandins (vasodilators)
◦ Increases blood viscosity (increases
resistance to flow)
◦ Decreases blood flow to maintain core
temperature

111. Hemodynamic Effects
 After 15 minutes, vasodilatation occurs
◦ Mostly distal extremities
◦ Temperatures < 10 C (350 F) >15 minutes
◦ Cold induced vasodilatation (COVD)
◦ Amount of vasodilatation usually small
◦ Skin redness NOT due to vasodilatation
 Due to increase in oxyhemoglobin concentration
of blood
 Cold decreases oxyhemoglobin dissociation
 Makes less oxygen available to tissues
 Hunting Response
◦ Response to pain associated with extreme
cold

112. Raynaud's Phenomenon
 A vascular reaction to cold application or
stress that results in a white, red, or blue
discoloration of the extremities. The fingers
and toes are the first to be affected
◦ Raynaud's phenomenon is a condition resulting
from poor circulation in the extremities (i.e., fingers
and toes). In a person with Raynaud's
phenomenon, when his or her skin is exposed to
cold or the person becomes emotionally upset, the
blood vessels under the skin tighten and the blood
flow slows
◦ This happens because the blood vessels under
the skin tighten. When blood does not reach parts
of the body, these areas may turn blue and feel
cold.

113. Neuromuscular Effects

114. Muscle Activity
 Decreased muscle spasm by decreasing
muscle spindle activity.
 Intramuscular fibers (muscle spindle)
runs parallel to fibers of the muscle.
Muscle contraction causes spindle
contraction so it remains sensitive. The
lower the temperature, the lower the
spindle activity.

115. Decreased Nerve Conduction Velocity
 Proportional to degree and duration of
temperature change
◦ Application of cold > 5 minutes
◦ Reverses (normal) within 15 minutes
◦ After 20 minutes, may take 30 minutes or
more to recover.

116. Decreased Nerve Conduction Velocity
 Decreased NCV of sensory and motor nerves
occurs
◦ Greatest effect in myelinated, small fibers
 pain transmitters
◦ Least effect in unmyelinated, large fibers

117. Increased Pain Threshold
 Counter-irritation via Gate Theory
◦ Secondary to decrease in muscle spasm
◦ Secondary to decrease in sensory NCV
 Secondary to post-injury edema
reduction (decreased blood flow)
◦ Reduces pressure on nerves due to edema

118. Metabolic Effects

119. Decreases Metabolic Rate
 For inflammation
 For healing
◦ not recommended for patient with
delayed healing

120. Physiological Effects of Cold:
Metabolic
◦ Decreased secondary cell deaths by hypoxia
(swelling prevents oxygen from reaching
cells). The decrease in metabolism allows
them to live without as much oxygen.
◦ Normal body temperature is 37 ° C.
◦ Increase above 45° C (113° F) proteins
denature

121. Physiological Effects of Cold:
Metabolic
◦ Reduction of edema through decreased
capillary hydrostatic pressure and
decreased permeability and osmotic
pressure
◦ Increase blood viscosity (make it thicker
so it won’t flood the area as quickly)
◦ Decrease in chemical mediator
effectiveness (they cause vasodilatation)

122. Inflammation Control
 Decreases chemical reactions
secondary to acute inflammatory
response
 Decreased blood flow secondary to
vasoconstriction, increased viscosity
◦ Causes secondary decrease in bleeding,
edema
 (normally) Increased function during this stage of
healing

123. Inflammation Control
 Prophylactically after exercise to
decrease DOMS (Delayed Onset Muscle
Soreness)
◦ Due to muscle connective tissue damage
secondary to exercise

124. Edema Control
 Decreases intravascular fluid pressure
via decreasing blood flow, increased
viscosity
◦ Most effective if applied immediately, in
conjunction with elevation and compression
 Cryotherapy ineffective with edema
secondary to immobility and poor
circulation.

125. R-I-C-E-S: Rest, Ice, Compression,
Elevation, Stabilization
RICES serves to counteract the body’s
initial response to injury
◦ Rest limits scope of original injury by
preventing further trauma
◦ Ice can decrease cell’s metabolism, reducing
the amount of secondary hypoxic injury by
enabling tissues to live on limited oxygen and
secondarily reduce pain
 Crushed ice is the ideal form of cold application
during initial injury because it produces the most
rapid temp. decrease.

126.  Compression -
◦ decreases the pressure gradient between
blood vessels and tissue and discourages
further leakage from capillaries.
◦ Also Encourages Lymphatic drainage
◦ Compression Types
 Circumferential - provides even pressure
 Collateral - Pressure on 2 sides (aircast)
 Focal Compression - U-shaped horseshoe pads

127.  Elevation
◦ Decreases the hydrostatic pressure within the
capillary beds to encourage absorption of edema by
lymphatic system
◦ This has the greatest effect at 90° perpendicular to
the ground
 at 45 ° the effect of gravity is 71% comparatively
 Stabilization
◦ Limits muscle spasm & neural inhibition related to
guarding the injured area
◦ Early stabilization eases the pain-spasm-pain cycle
by letting the muscles relax

128. Pain Control
 10-15 minute application can control
pain for 1 or more hours.

129. Precautions

130. PRECAUTIONS
 Over superficial main branch of a nerve
 Over an open wound
◦ delays healing
 Hypertension
◦ can cause transient increases in systolic or diastolic BP
 Patients with poor sensation or mentation
 Very young or very old
◦ impaired temperature regulation,
◦ ability to communicate

131. Adverse Effects

132. Adverse Effects
 Tissue Death
 Frost Bite
 Nerve damage
◦ Unwanted vasodilation due to prolonged vasoconstriction,
ischemia, thromboses in smaller vessels.
 Freezing of tissues
◦ damage at 39 degrees F
 To avoid, duration limited to under 45 minutes and tissue
temperature above 39 degrees F
 When goal is vasoconstriction, treatment limited to 10-15
minutes

133. Application, General Rules

134. Application of Cold
 Assess patient and establish goals of
treatment
 Determine if cryotherapy most
appropriate treatment
 No Contraindications
 Select appropriate mode of application
based on body part and desired response
 Explain procedure, reasons for treatment,
and expected sensations

136.  Fill two-thirds full with crushed ice
so bag is easier to mold over body
part.
 Cover bag with towel or pillowcase
and apply to affected area for 30
minutes.
 Provides cold to localized area (e.g.,
muscle sprain, hematoma) to
Ice bag, ice collar

137. Application of Cold
 Ice Bags
◦ Crushed ice best
 conforms better
◦ Get all/most air out of bag.
◦ Colder than ice packs
 specific heat of ice higher than gels
◦ Either decrease time or provide slight insulation.

139. COLD PACKS
 Commercially prepared single-use ice
packs provide cold for designated period
of time.
 When the pack is squeezed or kneaded,
an alcohol-based solution is released,
creating the cold temperature.

140. COLD PACKS/ ICE PACKS
 Commercial
◦ Silica or mix of saline/gel
◦ Stored in freezer at 23º C
◦ Moldable to patient’s body
◦ Should be cooled at least 30 minutes
between treatments or 2 hrs. prior to initial
use.

141. COLD PACKS
 Ice Bags,
 Reusable Cold Pack
 Instant Cold Back
 Tx time for all are 15-30 minutes
◦ Because of lasting effects application should
be no less than 2 hours apart
◦ For controlled Cold Therapy Units - may be
applied continuously for 24 to 48 hours post
acute injury or surgery

142. COLD PACKS
 Indications
◦ Acute injury (may use
with wet wrap)
◦ Acute or Chronic Pain
◦ Postsurgical Pain and
Edema
◦ Shape of Body part
 Precautions
◦ AC joint and other areas may
not be suitable for wet wrap
◦ Tension of elastic wrap
should be enough to provide
adequate compression
without unwarranted
pressure
◦ Ensure Circulation w/wrap
◦ Frostbite - chance for
reoccurrence
◦ over large or superficial
nerves

143. Advantages and Disadvantages

144. Advantages of Ice Packs/Cold
Packs
 Easy to use
 Inexpensive
 Short use of clinician’s time
 Low skill level required
 Covers moderate to large areas
 Can elevate limb simultaneously

145. Disadvantages
 Must remove pack to inspect skin
 Patient may not tolerate weight
 Difficult to mold to contoured areas
 Longer treatment time (than ice cup)

147. ICE TOWEL
•Wet towel is used
•Ice towel need to be replaced
after 2-3 min. and total 20 min.
of treatment can be given.
•Useful in treating muscle and
allows movement to be
performed.

148. Ice Massage or Ice Cup

149. ICE CUBE MASSAGE
•Slow circular motion for 5-10
min. During
This time the patient will feel
cold, burning
And then aching sensation
before the part
Become numb.
•Short strokes should be given.

150. ICE MASSAGE
 Appropriate for
delivering cold tx to
small evenly shaped
areas.
 Most effective for
muscle spasm,
contusion and other
minor well-localized
areas
 Duration of tx
◦ 5-15 minutes or until
ice runs out
◦ if the purpose is
analgesic, then stop
when numb

151. ICE MASSAGE
 Indications
◦ Subacute inflammation or
injury
◦ Muscle strain
◦ Contusion
◦ Acute or chronic pain
 Contraindications
◦ All other ice
contraindications
◦ When pressure is not
warranted
◦ Suspected Fx
 Precautions
◦ Injuries where
pressure massage
may be
contraindicated

152. APPLICATION OF ICE MASSAGE
 Use towels in surrounding areas to
catch drips.
 Use small, overlapping circles
 Keep ice moving rapidly
 Continue for 5-10 minutes or until
analgesia achieved
 “Quick Icing” used as quick strokes
with ice cup to facilitate motor
response

153. ADVANTAGES OF ICE MASSAGE
 Treatment area can be observed during
treatment
 Excellent for small, irregular areas
 Short-duration of treatment
◦ Increases compliance
 Can elevate limb if desired

154. DISADVANTAGES OF ICE MASSAGE
 Requires clinician throughout treatment,
unless patient independent

155. Cold soaks
Procedure similar to that for
warm soaks.
Desired temperature for a 20-
minute soak is 15°C (59°F).
Take precautions (such as
preventing drafts and draping
shoulders) to prevent client from
chilling.

157. Intermittent Cold Compression and Cryocuff

158. COLD COMPRESSES
 Applied to either decrease or prevent
bleeding and to reduce inflammation.
 Procedure similar to that for warm
compresses except cold compresses
applied for 20 minutes at a temperature of
15°C (59°F).
 Technique may be clean or sterile.
 Observe for signs and symptoms of
burning or numbness, mottling of the skin,
redness, extreme paleness, or a bluish skin
discoloration.

159. CONTROLLED COLD
COMPRESSION
 Intermittent Compression/ Cold Pump
◦ Usually used in post-op patients
◦ Allows for intermittent cold and compression
 proven more effective than ice alone

160. COLD COMPRESSION UNIT
Cold water is circulated in a sleeve which
Is put over the limb and part of it is
inflamed
At intervals.

162. CRYOCUFF
 Relatively inexpensive
 Effective compression
with cold
 Patients often need
assistance in applying
device

163. COLD/ ICE SPRAYS
•Ethyl chloride was originally used
but it is highly inflammable an thus
posses some risks.
•Fluorimethane is now used
widely as it is non inflammable.
• The liquid is sprayed on to the
area to be cooled in series of
stroke of about 5s each with a few
seconds interval between each.
•The nozzle is held at the angle of
45 or right angle from the skin
surface.

164. VAPOCOOLANT SPRAYS
 Ethyl chloride
 Fluorimethane sprays
 Work by rapid cooling
 Desired treatment of trigger points
 Applied in parallel strokes along skin of
muscle immediately prior to stretching

165. CRYOKINETICS
Combination of cold application
and active exercise

166. CRYOKINETICS
 Purpose:
◦ To apply cooling agent to point of numbness
shortly after injury,
◦ to decrease sensation of pain, allow patient
to exercise toward regaining ROM.
(Athletics)
 Cold for 20 minutes (numbness)
 Exercise for 3-5 minutes
 Re-cooling
 Repeat about 5 times

167. WHY CRYOKINETICS?
 Cold decreases pain, which
◦ Facilitates active exercise
 Exercise
◦ Reduces swelling (dramatically)
◦ Promotes healing and return to
function

168. INDICATIONS
 Sprains—dynamite treatment
◦ Ankle (especially)
◦ Fingers
• Strength training

169. DISADVANTAGES
 Pain during initial session
 Cold can be messy.

170. CONTRAINDICATIONS
 Any exercise or activity that causes pain
 Use of ice on a patient who is
hypersensitive to cold

171. PRECAUTIONS
 Use pain as a guideline.
◦ Warn patient not to gut out pain.
 Don’t allow patient to limp.
 May be an increase in pain 4–8 hr after
treatment

172. PRINCIPLES OF CRYOKINETICS EXERCISE
 All exercise should be active.
• Performed by the patient
 Exercise must be graded
• Begin with range of motion exercises.
• Progress through increasing levels
of difficulty.
• Full sport activity is final level.

173. Principles of Cryokinetics Exercise:
Example (cont.)
 Non-weight-bearing ROM
◦ Plantar flexion
◦ Dorsiflexion
◦ Inversion
◦ Eversion
◦ Circumduction

174.  Weight-bearing ROM
◦ Stand up.
◦ Shift weight
from foot to foot.
◦ Gradually increase
weight on injured limb.
Principles of Cryokinetics Exercise:
Example (cont.)

175. CRYOSTRETCH
 “Spray and Stretch” using vapocoolant
 Traditionally preformed with ethyl
chloride due to its ability to quickly
evaporate and cool superficial tissue
 This technique is used as a
counterirritant
◦ simply masks the symptoms to allow for a
stretch

176. CRYOSTRETCH
 Cooling prior to stretching
◦ Decreases spasm, secondary increase in ROM
◦ Spray n’ Stretch,
◦ Fluoro-methane Spray
 If patient condition not improving or worsening within
2-3 treatments,
◦ Approach should be re-evaluated and changed, or
◦ Refer to MD

177. CRYOSTRETCH
 Precautions
◦ Can Cause frostbite
◦ Ethyl Chloride is
extremely flammable
◦ Ethyl Chloride is a local
anesthetics but if
inhaled can become
general
◦ It’s use is based on
tradition rather than fact
 Contraindications
◦ Allergy
◦ Open wounds
◦ Post/surgical
◦ Eyes
◦ All other cold & passive
stretch
contraindications
 Indications
◦ Trigger points
◦ Muscle spasms
◦ Decreased ROM

178. COLD WHIRLPOOLS
 Duration of Tx
◦ 15-20 minutes
◦ Temp 50° - 60 ° F
 Indications
◦ Decrased ROM
◦ Cryokinetics
◦ Subacute to chronic
inflammation
◦ Peripheral nerve
injuries (avoid
extremes)
 Contraindications
◦ Acute conditions where
water turbulence would
further irritate area
◦ Gravity
◦ Postural
◦ Skin Conditions
◦ All other ice
contraindications

179. DOCUMENTATION OF
CRYOTHERAPY
 Area of body treated
 Type of cryotherapy used
 Treatment duration
 Patient position
 Response to treatment

180. Apply Your Knowledge
What is the main difference in the effect of
cryotherapy and thermotherapy that results in
the physiologic response of each?
ANSWER: Cryotherapy causes blood vessels
to constrict, resulting in its physiologic
effects, while thermotherapy causes blood
vessels to dilate.

181. 181
Apply Your Knowledge -
Answer
Remove the application immediately and
take the patient’s vital signs. Report the
results to the physician.
The physician has asked you to
perform a moist heat application to a
patient’s left leg. After about 10
minutes of treatment you check the
area and notice it is very red, and the
patient appears to be breathing fast.
What should you do?

183. GUIDELINES IN APPLICATION
 Check the order, check armband
 Assess general condition of the patient
 Assess the skin area where application going
 Check functioning of equipment
 Reassess patient and response in 15 minutes
 Stop treatment at designated time
 Examine the place where the treatment will occur.
 Record the patient’s response

184. Try This!
 After applying a heat treatment, the
patient puts on call light and says it is too
hot.
 What should the nurse do?

185. Safety Measures
“DO’s”
 Do explain to the patient sensations to be felt during the
procedure
 Do instruct the patient to report changes in sensation or
discomfort immediately
 Do provide a timer, clock, or watch so that the patient
can help the nurse time the application
 Do keep the call light within the patients reach
 Do refer to the agency’s policy and procedure manual
for safe temperatures

186. Safety Measures
Do “NOTS”
 Do not allow the patient to adjust the
temperature
 Do not allow the patient to move an
application
 Do not place the patient in a position that
prevents movement away from the
temperature source
 Do not leave unattended a patient who is

187. REVIEW
 Patient says that the heating pad must
be broken because it no longer feels
warm.
 What should the nurse do?

188. REVIEW
 The patient had an edematous ankle
and the nurse applied an ice pack as
ordered.
 Later when she assesses the ankle, it is
more edematous than earlier in the day.
 What should the nurse do now?

189. THANK YOU