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

Yong Soon Shin; Hyun Jung Kim; Ji Won An; Yoon Young Lee

doi:10.7475/kjan.2018.30.3.325

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Shin, Kim, An, and Lee: Development of Evidence-based Nursing Practice Guidelines for Cold Application in Adult Care

Original Article

Korean J Adult Nurs 2018;30(3):325-345.

Published online: 21 June 2018

DOI: https://doi.org/10.7475/kjan.2018.30.3.325

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

Yong Soon Shin¹, Hyun Jung Kim², Ji Won An³, Yoon Young Lee^4,

¹School of Nursing, Hanyang University, Seoul, Korea

²Department of Nursing, Asan Medical Center, Seoul, Korea

³Department of Nursing, East-Far University, Eumseong, Korea

⁴Department 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

Received 6 April 201821 May 2018 Accepted 8 June 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.

Keywords: Cryotherapy, Evidence-based nursing, Practice guideline

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Figure 1.

Flow of review process.

Table 1.

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?
Instruments	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?
Application and recovery time	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?
Assessment and management of side effects	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?
Documentation	20. What should be reported when unplanned event related to cold application occur?

Table 2.

Evidence Summary

Clinical questions	Number of evidence
Clinical questions	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.

Table 3.

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
Application sites	⦁ 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.

Appendix 2.

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.
Assessment and management of side effects	․ 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.

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