8 assess clients heart rate and ensure that client is

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8.Assess client’s heart rate and ensure that client is notlightheaded. Place the call button/ call light switch is withinreach.9.After 20minutes, or as ordered, wear clean gloves, removeclient from the soak. Dry client, as necessary, and assist clientback to bed on position of comfort.10.Drain the used sitz water and clean the equipment properly.Place in the appropriate storage area. Dispose of soiled blanketor towel and gloves and perform hand hygiene.STOP the application immediately if any untoward incident orproblem(s) occur.Evaluation:1.Inspect the body part or wound condition for evidence ofeffectiveness of therapy and sensitivity to touch.2.Ask client to describe level of comfort and burning sensationfollowing the treatment.3.Obtain vital signs and compare with baseline.4.Identify any unexpected outcome.Recording and Reporting: Record, document, and report allpertinent information of the procedure performed.Application of ColdFIRST: Introduce self and identify the client by asking for at least2 identifiers (e.g. name,birthday, age, etc.)Assessment:1.Verify order for type of moist heat application, location andduration, and desired temperature.2.Review client’s medical history and contraindications that mayprohibit the use of cold therapy3.Assess client’s vital signs and mobility.4.Assess client’s skin around the area to be treated and client’stemperature and pain sensitivity.5.Inspect wound, if any, for size, color, odor, tenderness,drainage.6.Assess client and family’s awareness, understanding of theprocedure, and related safety factors.Planning:1.Identify expected outcomes2.Assemble and prepare the equipment and supplies needed.Implementation:Provide privacy at all times.a)Applying a cold compress: Materials needed: Coldcompress may be commercially prepared, a towel, orgauze pads or roll (size and number depend on the bodypart of client to be treated); Ice, Container/basin,Waterproof pad or clean dry towel, 1 pair clean gloves1.Explain the procedure and purpose to the client, sensations theclient would feel and precautions to prevent complications.2.Perform hand hygiene and put on a pair of clean gloves3.Keep client’s body part in proper alignment, drape client asneed, exposing only the body part to be treated.4.Place a waterproof pad or towel under the client’s body part, ifappropriate.5.Place ice water into a basin and check the temperature.6.Submerge gauze pad or towel into the water and wring outexcess moisture.7.Apply compress to affected area, molded over the site.8.Remove, remoisten, and reapply to maintain the coldtemperature as needed.9.Check skin condition at appropriate and regular intervals.10.After Remove gloves, dispose of properly, and perform handhygiene.

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