Heat applications

Therapeutic Heat Applications

1. Heat Applications Dr. Binu Babu Ph.D , M.Sc. (N), MBA Mrs. Jincy Ealias M.Sc. (N)

2. Application of heat 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

3. Indications of Heat Indication Effect of Heat Muscle spasm Relaxes muscles and increases their contractility Inflammation Increases blood flow, softens exudates. Pain Relieves pain, possibly by promoting muscle relaxation, Increasing circulation, and promoting psychological Relaxation and a feeling of comfort; acts as a counterirritant Contracture Reduces contracture and increases joint range of motion by allowing greater distention of muscles and connective tissue. Joint stiffness Reduces joint stiffness by decreasing viscosity of synovial fluid and increasing tissue distensibility .

4. Heat application Heat application is the application of a heat 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.

5. Temperature for heat and cold applications Description Temperature Application Very Cold 32 to 55 F Ice bag Cold 55 to 65 F Cold packs Cool 65 to 80 F Cold compress Neutral 80 to 92 F Alcohol sponge bath Warm 92 to 98 F Warm bath Hot 98 to 104 F Hot soak Very Hot more than 104 F Hot water bag

6. Physiological effects heat application Peripheral Vasodilatation Increased capillary permeability Increased oxygen consumption Increased local metabolism Decreased blood viscosity Increased muscle tone Increased blood flow Increased lymph flow Increased motility of leucocytes

7. Local Effects of Heat Heat has been a long-standing remedy for aches and pains, and people often equate heat with comfort and relief. Heat causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients , antibodies, and leukocytes. Application of heat promotes soft tissue healing and increases suppuration . The major disadvantage of heat is that it increases capillary permeability , hence it permits the extracellular fluid and substances like plasma proteins to pass through the capillary walls and may result in edema or an increase in preexisting edema. Heat is also used for clients with musculoskeletal problems such as joint stiffness from arthritis, contractures, and low back pain.

8. Systemic Effects of Heat Heat applied to a localized body area, particularly a large body area, may cause excessive peripheral vasodilation, which produces a drop in blood pressure. A significant drop in blood pressure can cause fainting .

9. Heat can be applied to the body in two forms. Dry heat is applied locally by means of a hot water bottle, aquathermia pad, disposable heat pack, or electric pad. Moist heat can be provided by compress, hot pack, soak, or sitz bath.

10. Classifications of Hot Applications Local General Dry heat Moist heat 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)

11. 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. Area of body exposed: The larger the area exposed to heat and cold, the lower the tolerance to temperature changes.

12. Damage to body surface area: Injured skin areas are more sensitive than intact areas to temperature variations. 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. Age: Thinner skin layers in children and elderly people increase the risk for burns from the heat and cold applications.

13. Variables Affecting Physiological Tolerance to Heat and Cold Body part. The back of the hand and foot are not very temperature sensitive . In contrast, the inner aspect of the wrist and forearm, the neck, and the perineal area are temperature sensitive . Size of the exposed body part. The larger the area exposed to heat and cold, the lower the tolerance. Individual tolerance. The very young and the very old generally have the lowest tolerance. Individuals who have neurosensory impairments may have a high tolerance, but the risk of injury is greater. Length of exposure. People feel hot and cold applications most while the temperature is changing. After a period of time, tolerance increases. Intactness of skin. Injured skin areas are more sensitive to temperature variations .

14. Therapeutic uses of local heat applications Decreases pain Decreases muscle tone Promote healing Promotes suppuration Relives deep congestion Softens the exudates Provide warmth Stimulates peristalsis

15. Contraindications of heat applications Malignancies Impaired kidney, heart & lung functions Acutely inflamed 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

16. Complications of Heat Applications Pain Burns Maceration (with moist heat) Redness of the skin Edema Pallor (secondary effect ) Hyperthermia

17. Neuromuscular 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

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

19. 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. 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. Never leave client even for short period Squeeze off water from moist heat applications to prevent scalding.

20. 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.

21. Dry heat

22. 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

23. Hot Water Bag

24. Hot 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  46º C for 30 min to 1 hour.

25. Hot Packs

26. 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 40°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.

27. Aquathermia Pads

28. 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.

29. Electrical Heating Pads

30. 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

31. 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

32. Diathermy Diathermy is the controlled production of "deep heating" beneath the skin in the subcutaneous tissues, deep muscles and joints for therapeutic purposes . High-frequency wave achieves deep heat penetration Ultrasound Shortwave Microwave

33. 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.

34. 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: 25 Watt Bulb 35 cm distance 40 Watt Bulb 45 cm distance 60 Watt Bulb 60 to 75 cm distance

35. Moist heat

36. 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)

37. 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

38. 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 hot a fomentation.

39. 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 ). If general perspiration was produced – neutral to cool shower or a sponge bath. Have person rest 30 minutes.

40. Contraindications Unconsciousness . Careful not to burn patient Paralyzed parts of the body. Do not use on the legs or feet of a diabetic. Edema and varicose veins and advanced vascular disease of the legs and feet. Malignancy . Tendency to bleed. Stomach and bowel ulcers.

41. 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 starting the 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.

42. 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 olive oil (3 parts)

43. Stupes

44. 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

45. 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. Preparation 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 Precaution : Infected areas must be covered with gauze

46. Contraindications : Acute conditions Peripheral vascular disease Impaired circulation Poor thermal Regulations 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

47. 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.

48. 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 .

49. 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

50. 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 treatment. Temperatures of 113ºF to 121ºF for lower extremity (circulation is less efficient) Paraffin can provide approx. 6x the amount of heat as water due to low specific heat.

51. 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 It is classified in to two Immersion Bath Pack (Glove) Method Clean extremity

52. Procedure 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 treatment (10-15 min) DO NOT touch sides or bottom of bath (burns) After treatment scrape off 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 treatment remove wax and return to bath

53. 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

54. Whirlpools/Full Immersion Bath Temperature is between 105º-112º F for extremities and 100-108º F for whole body Usually last 10-20 minutes; watch for lethargy with Warm whirlpool 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 treatment Keep clothing and bandages out of whirlpool

55. 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 Compromised circulation

56. 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

57. 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

58. 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 .

59. 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

60. Guidelines in application Determine the client’s ability to tolerate the therapy. Identify conditions that might contraindicate treatment (e.g ., bleeding , circulatory impairment). Explain the application to the client. Assess the skin area to which the heat or cold will be applied. Ask the client to report any discomfort. Return to the client 15 minutes after starting the heat or cold therapy, and observe the local skin area for any untoward signs (e.g ., redness ). Stop the application if any problems occur. Remove the equipment at the designated time, and dispose of it appropriately . Examine the area to which the heat or cold was applied, and record the client’s response.

61. 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

62. 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 patient who is unable to move or paralyzed

63. References Taylor , C., Lynn, P., & Bartlett, J. L. (2019).  Fundamentals of nursing : the art and science of person-centered nursing care  (9th ed.). Wolters Kluwer . Kozier , B. (2018).  Fundamentals of Canadian nursing : concepts, process, and practice . Pearson Lehmann, J. F. (1990).  Therapeutic heat and cold . Williams & Wilkins.

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