kjan Korean Journal of Adult Nursing Korean J Adult Nurs 1225-4886 2288-338X Korean Society of Adult Nursing 10.7475/kjan.2018.30.3.325 kjan-30-325 Original Article Development of Evidence-based Nursing Practice Guidelines for Cold Application in Adult Care Shin Yong Soon 1 Kim Hyun Jung 2 An Ji Won 3 Lee Yoon Young 4 School of Nursing, Hanyang University, Seoul, Korea Department of Nursing, Asan Medical Center, Seoul, Korea Department of Nursing, East-Far University, Eumseong, Korea Department of Nursing, Sunchon National University, Suncheon, Korea Corresponding author: Lee, Yoon Young https://orcid.org/0000-0003-3068-9876 Department of Nursing, Sunchon National University, 255 Jungang-ro, Suncheon 57922, Korea. Tel: +82-61-750-3884, Fax: +82-61-750-3880, E-mail: yoonyoung1@hanmail.net 62018 2162018 303 325345 06042018 21052018 08062018 Copyright © 2018 Korean Society of Adult Nursing 2018 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose

The aim of this study was to develop evidence-based nursing practice guidelines for cold application in adult care.

 Methods

The study procedure was based on the Scottish Intercollegiate Guidelines Network and Korean Hospital Nurses Association's guideline development methods. The evidence review procedures included targeted searches from databases including the Cochrane Library, PubMed, CINAHL, Embase, KoreaMed, KERIS and NDSL. The initial search yielded 6,426 articles published from 2006 to 2016. Based on the screening process, 147 articles were selected and systematically reviewed. From evidence summaries of 20 clinical questions, recommendations were formulated and graded. Draft recommendation were evaluated through external review.

 Results

The guidelines consisted of 10 domains and 27 recommendations. The content validity index of the recommendations was above .80. Major recommendations include 1) applying external cooling to reduce acute pain, edema, and hemorrhage, 2) selecting cooling instruments based on the purpose, patient's condition, and preference, 3) preparing and maintaining cooling instruments at an adequate temperature, and 4) intermittent cold application for appropriate durations with sufficient recovery time.

 Conclusion

These guidelines can be utilized in both clinical and community settings to help narrow the gaps between nursing practices.

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Episiotomy discomforts relief using cold gel pads in primiparaus Iranian women (a comparative study) Research Journal of Medical Sciences 2011 5 3 1504 https://doi.org/10.3923/rjmsci.2011.150.154 Shin YS Lim NY Yun SC Park KO A randomised controlled trial of the effects of cryotherapy on pain, eyelid oedema and facial ecchymosis after craniotomy Journal of Clinical Nursing 2009 18 21 302936 https://doi.org/10.1111/j.1365-2702.2008.02652.x Shirvani MA Ganji Z The influence of cold pack on labour pain relief and birth outcomes: a randomised controlled trial Journal of Clinical Nursing 2014 23 17-18 24739 https://doi.org/10.1111/jocn.12413 Shi-yang Y Shuai C He-de Y Cun-yi F Effect of cryotherapy after elbow arthrolysis: a prospective, single-blinded, randomized controlled study Archives of Physical Medicine & Rehabilitation 2015 96 1 16 https://doi.org/10.1016/j.apmr.2014.08.011 Skiveren J Kjaerby E Nordahl Larsen H Cooling by frozen gel pack as pain relief during treatment of axillary hyperhidrosis with botulinum toxin a injections Acta DermatoVenereologica 2008 88 4 3669 Song M Sun X Tian X Zhang X Shi T Sun R Com-pressive cryotherapy versus cryotherapy alone in patients undergoing knee surgery: a metaanalysis SpringerPlus 2016 5 1 1074 https://doi.org/10.1186/s40064-016-2690-7 Sprouse-Blum AS Gabriel AK Brown JP Yee MH Randomized controlled trial: targeted neck cooling in the treatment of the migraine patient Hawai'i Journal of Medicine & Public Health 2013 72 7 23741 Sriram S Prembabu KR Madeshwaran M Ramesh R Bala-meena S Saravanan M Comparison of pulsed ultrasound versus cryotherapy with transcutaneous electrical nerve stimulation in the management of enthesitis associated with spondyloarthritis International Journal of Rheumatic Diseases 2015 18 1 20 Steen M Marchant P Ice packs and cooling gel pads versus no localised treatment for relief of perineal pain: a randomised controlled trial Evidence Based Midwifery 2007 5 1 1622 Stöckle U Hoffmann R Schütz M Fournier C Südkamp N Haas N Fastest reduction of posttraumatic edema: continuous cryotherapy or intermittent impulse compression? 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Clinical Ortho-paedics and Related Research 2014 472 11 341723 https://doi.org/10.1007/s11999-014-3810-8 van den Bekerom MPJ Struijs PAA Blankevoort L Welling L van Dijk CN Kerkhoffs GMMJ What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training 2012 47 4 43543 https://doi.org/10.4085/1062-6050-47.4.14 van Grinsven S van Cingel REH Holla CJM van Loon CJM Evidence-based rehabilitation following anterior cruciate ligament reconstruction Knee Surgery, Sports Traumatology, Arthroscopy 2010 18 8 112844 https://doi.org/10.1007/s00167-009-1027-2 Waterman B Walker JJ Swaims C Shortt M Todd MS Ma-chen SM The efficacy of combined cryotherapy and compression compared with cryotherapy alone following anterior cruciate ligament reconstruction The Journal of Knee Surgery 2012 25 2 15560 https://doi.org/10.1055/s-0031-1299650 Watkins AA Ice packs reduce postoperative midline incision pain and narcotic use: a randomized controlled trial Journal of the American College of Surgeons 2014 219 3 5117 https://doi.org/10.1016/j.jamcollsurg.2014.03.057 Watkins AA Johnson TV Shrewsberry AB Nourparvar P Madni T Watkins CJ Ice packs reduce postoperative midline incision pain and narcotic use: a randomized controlled trial Journal of the American College of Surgeons 2014 219 3 5117 https://doi.org/10.1016/j.jamcollsurg.2014.03.057 Woolf SK Barfield WR Merrill KD McBryde Jr AM Comparison of a continuous temperature-controlled cryotherapy device to a simple icing regimen following outpatient knee arthroscopy The Journal of Knee Surgery 2008 21 1 159 https://doi.org/10.1055/s-0030-1247786 Yarlagadda SD Rao MS Compare the effectiveness of massage versus cryotherapy in treating delayed onset muscle soreness Indian Journal of Physiotherapy & Occupational Therapy 2014 8 4 1126 https://doi.org/10.5958/0973-5674.2014.00022.7 Yava A Koyuncu A Tosun N Kili? S Effectiveness of local cold application on skin burns and pain after transthoracic cardioversion Emergency Medicine Journal 2012 29 7 5449 https://doi.org/10.1136/emj.2010.098053 Yu H Randhawa K Cote P Optima C The effectiveness of physical agents for lower-limb soft tissue injuries: a systematic review The Journal of Orthopaedic and Sports Physical Therapy 2016 46 7 52354 https://doi.org/10.2519/jospt.2016.6521 Yu YM Moon SM Kim JY Bae HJ Ha HR Comparison of the degree of pain according to nursing intervention method during arteriovenous fistula needle insertion for patients on hemodialysis Journal of Korean Clinical Nursing Research 2011 17 2 28696 Yuksel E Unver B Karatosun V Comparison between kinesi-otaping and cold therapy on muscle strength functional performance outcomes after total knee arthroplasty: preliminary results of a randomized controlled trial Annals of the Rheumatic Diseases 2016 75 1307 https://doi.org/10.1136/annrheumdis-2016-eular.6073 Yusamran C Titapant V Kongjeera A Relief perineal pain after perineorrhaphy by cold gel pack pad: a randomized controlled trial Thai Journal of Nursing Research 2007 11 2 8795 Zandi M Amini P Keshavarz A Effectiveness of cold therapy in reducing pain, trismus, and oedema after impacted mandibular third molar surgery: a randomized, self-controlled, observer-blind, split-mouth clinical trial International Journal of Oral and Maxillofacial Surgery 2016 45 1 11823 https://doi.org/10.1016/j.ijom.2015.10.021 Zencir G Eser I Effects of cold therapy on pain and breathing exercises among median sternotomy patients Pain Management Nursing 2016 17 6 40110 https://doi.org/10.1016/j.pmn.2016.05.006 Zeng Y Li Y Gao JH Application of a cold patch for relieving pain after transepithelial photorefractive keratectomy Pain Research and Management 2015 20 4 1958 https://doi.org/10.1155/2015/850245 Zhang W Moskowitz RW Nuki G Abramson S Altman RD Arden N OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence Osteoarthritis and Cartilage 2007 15 9 9811000 https://doi.org/10.1016/j.joca.2007.06.014 Zhang W Moskowitz RW Nuki G Abramson S Altman RD Arden N OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines Osteoarthritis and Cartilage 2008 16 2 13762 https://doi.org/10.1016/j.joca.2007.12.013 Figures and Tables

Flow of review process.

Clinical Questions

Domains Clinical questions
Assessment 1. What should nurses assess before cold application?
Indication and contraindication 2. Does cold application help lower fever?
3. Does cold application help to reduce hemorrhage?
4. Does cold application help to reduce edema?
5. Does cold application help pain control?
6. What should cold not be applied for?
Instruments 7. What is a validate instrument for cold application?
8. What instrument is for continuous cold application?
Application site 9. Where are cold applied on?
Preparation 10. What are adequate temperature of cold application?
11. How are cold application prepared?
12. What are appropriate fixation methods of cold application?
Application and recovery time 13. How long is a adequate time for intermittent cold application?
14. How long is a recovery time of intermittent cold application?
Remove the cold 15. When should cold application be removed or stopped?
Assessment and management of side effects 16. What are side effects of cold application?
17. What should nurses act when side effects occur?
Patient education 18. What is the appropriate education for patient to management and maintain cold application?
Documentation 19. What should nurses document on cold application?
20. What should be reported when unplanned event related to cold application occur?

Evidence Summary

Clinical questions Number of evidence
SR Guideline RCT Non-RCT
1. What should nurses assess before cold application? - - - 2
2. Does cold application help lower fever? 2 - 1 1
3. Does cold application help to reduce hemorrhage? 4 - 10 6
4. Does cold application help to reduce edema? 4 - 10 6
5. Does cold application help pain control? 21 - 65 21
6. What should cold not be applied for? 2 - 2 -
7. What is a validate instrument for cold application? - - 68 -
8. What instrument is for continuous cold application? - - 15 -
9. Where are cold applied on? - - 68 -
10. What are adequate temperature of cold application? - - 68 -
11. How are cold application prepared? - - 1 3
12. What are appropriate fixation methods of cold application? - - 8 3
13. How long is an adequate time for intermittent cold application? - - 49 -
14. How long is a recovery time of intermittent cold application? - - 49 -
15. When should cold application be removed or stopped? - - 2 1
16. What are side effects of cold application? 5 - - 1
17. What should nurses act when side effects occur? - - 2 5
18. What is the appropriate education for patient to management and maintain cold application? - - 1 -
19. What should nurses document on cold application? - 1 - -
20. What should be reported when unplanned event related to cold application occur? - 1 - -

RCT=randomized controlled trial; Non-RCT=non-randomized controlled trial; SR=systematic review.

Level of Evidence, Strength and Content Validity of Recommendations for Cold Application

Recommendations LOE SOR CVI
Assessment 1. Assessment before cold application III C 0.97
 ⦁ Cold allergy
 ⦁ Peripheral circulation
 ⦁ Blood pressure (Cold application may increase blood pressure and decrease heart rates in patients with hypertension.)
Indication and contraindication 2. Cold can be applied to reduce acute pain. I A 1.00
3. Cold can be applied to reduce edema. I A 0.93
4. Cold can be applied to reduce hemorrhage. I A 0.83
5. Cold application is not recommended for fever control because there are insufficient evidence on fever control effects of cold application. I A 0.90
6. Cold should not be applied following: III C 0.93
 ⦁ Sever hypoxia  ⦁ Peripheral vessel disease
 ⦁ Malignant hyperthermia  ⦁ Radiation injury
 ⦁ Heatstroke  ⦁ Connective tissue disease
 ⦁ Traumatic brain injury  ⦁ Raynaud's disease
 ⦁ Aspirin, anticoagulant, NSAID, vitamin E, vasoactive agent  ⦁ Diabetic neuropathy
 ⦁ Unconsciousness
Selection of instruments 7. In selecting instruments for cold application, nurses should consider purpose of cooling and the patient's condition and his or her preference. III C 1.0
8. Following instruments can be used for acute pain control. I A 1.0
 ⦁ Ice pack
 ⦁ Cold gel pack
 ⦁ Cold water circulating system
 ⦁ Ice cube (Gargling for cancer patients or migraine patents)
9. Following instruments can be used for reducing edema. I A 0.97
 ⦁ Cold gel pack
 ⦁ Cold water circulating system
 ⦁ Ice pack
10. Following instruments can be used for reducing hemorrhage. I A 0.87
 ⦁ Cold water circulating system
 ⦁ Cold gel pack
 ⦁ Ice pack
Application sites 11. Cold can be applied on following sites with consideration of purpose and the patient's condition and his or her preference. III C 0.80
 ⦁ Surgical wound  ⦁ Acute tissue injury
Preparation 12. Cold should be prepared with following temperature. I A 0.86
 ⦁ Ice pack: surface temperature of -4℃~4℃
 ⦁ Cold gel pack: surface temperature of 0℃~10℃
 ⦁ Cold water circulating system: water temperature of 10℃~15℃
13. Cold gel pack, ice pack or ice bag should be wrapped with thin linen. III C 0.93
14. Cold gel pack, ice pack or ice bag should be closely fixed using following methods. If contact area is narrow, cooling is ineffective. III C 0.87
 ⦁ Elastic bandage
 ⦁ Velcro tape
 ⦁ Linen belt
Application and recovery time 15. Cold application time should be decided according to purpose of cooling, instrument, patient's responses. III C 1.00
16. For minimally invasive sites, intermittent cold application should be applied from 1~5 minutes at a time. I A 0.86
 ⦁ Arterial puncture
 ⦁ Amniocentesis
 ⦁ Heparin injection
 ⦁ Arteriovenous fistula puncture
 ⦁ Botulinum injection
Application and recovery time 17. For moderately invasive sites, intermittent cold application should be applied from 10~20 minutes at a time. I A 0.93
 ⦁ Chest tube
 ⦁ Episiotomy or normal birth
 ⦁ Keratectomy or rhinoplasty
 ⦁ Arthroscopy
 ⦁ Percutaneous coronary artery intervention
 ⦁ Other non-surgical conditions (musculoskelectal health problems, breast engorgement, migraine etc.)
18. For highly invasive sites, intermittent cold application should be applied from 20~30 minutes at a time. I A 0.90
 ⦁ Cardiac surgery
 ⦁ Craniotomy
 ⦁ Total hip arthroplasty
 ⦁ Maxillary surgery
 ⦁ Anterior cruciate ligament reconstruction
19. Intermittent cold application should have recovery time more than 40 minutes. II B 1.00
20. Cold water circulating system can be used for continuous cold application I A 1.00
Remove the cold 21. Cold application should be removed or stopped in following: III C 1.00
 ⦁ Newly developed pain
 ⦁ Sensory impairment such as numbness
 ⦁ Redness or pale of cold application site
 ⦁ Shivering
 ⦁ Discomfort due to cold
 ⦁ Skin temperature ≤13℃
Assessment and management of side effects 22. Following unexpected effects of cold application should be assessed. III C 1.00
 ⦁ Pain  ⦁ Sensory impairment such as numbness or tingling sense
 ⦁ Frosbite  ⦁ Skin color change such as redness
 ⦁ Stress  ⦁ Muscle pain
 ⦁ Vomiting  ⦁ Infection
 ⦁ Restlessness  ⦁ Discomfort due to cold application within 3 hours etc.
 ⦁ Headache
 ⦁ Shivering
 ⦁ Hunting response
23. If skin color change or tissue damage are observed, cold application should be stopped and tissue damage should be monitored continuously. III C 1.00
Patient education 24. Education methods should be selected based on assessment patient's age, level of development and cognition, health literacy, cultural background and language. III C 1.00
25. Educational contents include following: III C 1.00
 ⦁ Appropriate management of cold application instruments.
 ⦁ Prevention of unexpected effects such as tissue damage.
 ⦁ Sign and symptoms should be reported.
Documentation 26. Nurses should record information on purpose and instrument of cold application and unexpected effects. Nursing record includes following contents. III C 1.00
 ⦁ Purpose
 ⦁ Instrument
 ⦁ Applied site
 ⦁ Application time and recovery time
 ⦁ Unexpected effects
 ⦁ Results of the intervention (patient's response)
27. Events due to cold application are recorded and reported according to institutional policy, procedure and nursing practice guideline. The events include harmful, critical and preventable side effects for the patient III C 1.00

CVI=content validity index; LOE=level of evidence; NSAID=non-steroid anti-inflammatory drug; SOR=strength of recommendation.

Evidence-based Nursing Practice Guidelines for Cold Application in Adult Care

Recommendations
Assessment Assessment before cold application
 ․ Cold allergy
 ․ Peripheral circulation
 ․ Blood pressure (Cold application may increase blood pressure and decrease heart rates in patients with hypertension)
Indication and contraindication  ․ Indication: Cold can be applied to reduce acute pain, edema and hemorrhage.
 ∗ Cold application is not recommended for fever control because there are insufficient evidence on fever control effects of cold application.
 ․ Contraindication: Cold should not be applied following: Sever hypoxia, Malignant hyperthermia, Heatstroke, Traumatic brain injury, Administration of Aspirin, anticoagulant, NSAID, vitamin E and vasoactive agent, Peripheral vessel disease, Radiation injury, Connective tissue disease, Raynaud's disease, Diabetic neuropathy and Unconsciousness
Application sites Cold can be applied on following sites with consideration of purpose and the patient's condition and his or her preference.
 ․ Surgical wound & Acute tissue injury
 ․ Episiotomy or normal birth
 ․ Arterial puncture, Amniocentesis, Heparin injection, Arteriovenous fistula puncture, Botulinum injection
 ․ Chest tube removal
 ․ Breast engorgement
 ․ Migraine etc.
Selection of instruments In selecting instruments for cold application, nurses should consider purpose of cooling and the patient's condition and his or her preference.
 ․ Ice pack
 ․ Cold gel pack
 ․ Cold water circulating system
 ․ Ice cube (Gargling for cancer patients or migraine patents)
Preparation Cold should be prepared with following temperature.
 ․ Ice pack: surface temperature of -4℃~4℃
 ․ Cold gel pack: surface temperature of 0℃~10℃
 ․ Cold water circulating system: water temperature of 10℃~15℃
Cold gel pack, ice pack or ice bag should be wrapped with thin linen.
Cold gel pack, ice pack or ice bag should be closely fixed using following methods (Elastic bandage, Velcro tape and Linen belt).
If contact area is narrow, cooling is ineffective.
Application time Cold application time should be decided according to purpose of cooling, instrument, patient's responses.
 ․ For minimally invasive sites (Arterial puncture, Amniocentesis, Heparin injection, Arteriovenous fistula puncture and Botulinum injection), intermittent cold application should be applied from 1~5 minutes at a time.
 ․ For moderately invasive sites (Chest tube removal, Episiotomy or normal birth, Keratectomy or rhinoplasty, Arthroscopy, Percutaneous coronary artery intervention and Other non-surgical conditions-musculoskelectal health problems, breast engorgement, migraine etc.), intermittent cold application should be applied from 10~20 minutes at a time.
 ․ For highly invasive sites (Cardiac surgery, Craniotomy, Total hip arthroplasty, Maxillary surgery and Anterior cruciate ligament reconstruction), intermittent cold application should be applied from 20~30 minutes at a time.
Remove the cold Cold application should be removed or stopped in following:
 ․ Newly developed pain
 ․ Sensory impairment such as numbness
 ․ Redness or pale of cold application site
 ․ Shivering
 ․ Discomfort due to cold
 ․ Skin temperature≤13℃
Assessment and management of side effects  ․ Assessment of side effects: Pain, Frosbite, Stress, Vomiting, Restlessness, Headache, Shivering, Hunting response, Sensory impairment such as numbness or tingling sense, Skin color change such as redness, Muscle pain, Infection and Discomfort due to cold application within 3 hours etc.
 ․ Management of side effects: If skin color change or tissue damage are observed, cold application should be stopped and tissue damage should be monitored continuously.
Patient education Education methods should be selected based on assessment patient's age, level of development and cognition, health literacy, cultural background and language.
Documentation Nurses should record information on purpose and instrument of cold application and unexpected effects.