Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

Name: ______________________________________ Grade: _________

Year & Section: _______________________________ Date: __________
Group No: ___________________________________

PROCEDURE CHECKLIST
HOT AND COLD APPLICATION
Instruction: Below is the grading scale which will be used in rating your performance.
5 Excellent 95 - 100
4 Very Satisfactory 88 - 94
3 Satisfactory 82 – 87
2 Fair 76 – 81
1 Needs Practice 70 – 75

A. PURPOSE
 Heat and cold are applied to a part or all of the patient’s body to bring
about a local or systematic change in body’s temperature for various
therapeutic purposes.

B. ASSESSMENT
 Determine the client’s ability to tolerate the therapy.
 Identify conditions that might contraindicate treatment (e.g., bleeding,
circulatory impairment).

C. EQUIPMENT:
 Water Bag/ Compress/ Packs/Collar
 Water
 Towel
 Basin
 Bath Thermometer
 Waterproof pad

D. PREPARATION
1. Determine the client’s ability to tolerate the therapy.
2. Identify conditions that might contraindicate treatment (e.g., bleeding,
circulatory impairment).
PROCEDURES 5 4 3 2 1
1. Review the physician’s order for the application of
cold therapy, including frequency, type of therapy,
body area to be treated, and length of time for the
application.
2. Gather the necessary equipment
3. Identify the patient and explain the procedure.
4. Assess the condition of the skin where it will be
applied
5. Perform hand hygiene
6. Close the room door or curtains. Place the bed at
a comfortable working height.
7. Assist the patient to a comfortable position that
provides easy access to the area to be treated.
Expose the area and drape the patient with a bath
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

blanket if needed. Put a waterproof pad under the

area to protect the bed if necessary.
8. Fill the equipment above 2/3 or ¾ full with water.
Remove excess air from the device. Securely
fasten the end of the bag or collar; tie the glove
closed.
9. Cover the device with the towel or washcloth. If the
device has a cloth exterior, this is not necessary.
10. Put on gloves or packs or compress. Remove and
dispose of any dressings at the site, if present.
11. Place the device lightly against the area. Remove
the device and assess the site for redness after 30
seconds. Ask the patient about presence of
burning sensation.
12. Replace the device snugly against the site if no
problems are evident. Secure in place with gauze
wrap or tape.
13. Reassess the treatment area every 5-15 minutes
or according to facility policy.
14. After 20 minutes or the prescribed amount of time,
remove the device and dry the skin.
15. Apply a new dressing to site, if necessary.
16. Remove the equipment at the designated time,
and dispose of it appropriately.
17. Document the procedure, the patient’s response,
and your assessment of the area before and after
application

EVALUATION:

Document in patient's record:

a. Condition of skin.
b. Patient’s response to the treatment
Report any change in patient's condition to physician.

REMARKS:____________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________

Date & Time: __________________________

Clinical Instructor: __________________________