RLE109MCP REVIEWER
c) Remove the gown and assist the client to
TEPID SPONGE BATH
 The application of cold water to the surface of
the skin by means of a wet sponge.
ASSESSMENT
1. Assess the client for other signs of fever: skin
warmth, flushing complaints of heat or chilling,
diaphoresis, irritability, restlessness, general
malaise or delirium.
2. Determine patient’s ability to tolerate cold
sponge bath.
3. Assess baseline vital signs and any hazards to
the patient’s vital function with the application of
cold.
4. Observe fluid and electrolyte status, especially in
patients with elevated temperature.
5. Assess condition of skin before and after
application to determine, if alteration occur.
OBJECTIVES
 To reduce body temperature by conduction and
evaporation
 To relieve restlessness, thereby providing
comfort and relaxation
GENERAL CONSIDERATIONS
1. Tap water can be used instead of cold.
2. Measure the client’s temperature, pulse and
respiration to provide comparative baseline data.
3. Face, neck, arms, and legs will be sponged
(back is optional).
4. Chest and abdomen need not be sponged for
there are no large superficial blood vessels in
that area that aid the transfer of heat.
EQUIPMENT
o Water source of coolant (tap or cold)
o Basin for sponge bath
o Wash cloth (preferably 2)
o Bath towel
o Large sheet to be utilized as bath blanket
o Table protector
o Small basin filled with ice chips
PROCEDURE
Prepare the water to a temperature of about
29.5°C (85°F), but add ice chips to bring the
1.
temperature down while bathing the patient until
the water temperature reaches about 18°C
(64.4°F)
2. Prepare the client.
[To gain cooperation]
a) Explain that the face, neck, arms, legs and
back (optional) will be sponged and that
the procedure takes about 25 - 30
minutes.
b) Protect the patient’s bed with moisture
proof material.
[To protect the linens from getting wet]
a comfortable supine position.
[Removing the gown provides access to
all skin surfaces.]
d) Cover the patient properly to prevent
shivering as various parts of the body are
exposed for bathing.
[For prevention of chilling, minimal
exposure and provision of privacy]
e) Place bath towel under the head.
[Protects the bed sheet from getting wet]
f) Prepare several ice bags.
 One ice bag is placed on the
patient’s head to promote comfort;
 other are placed in the axillary areas
and in the groin, where the blood
vessels are close to the skin surface.
[The ice bags help to cool the patient further.
The axillae and groins contain large superficial
blood vessels that aid the transfer of heat.
The application of ice bag promotes cooler
temperature of the body’s core by conduction.]
g) If washcloth is to be used in the axillary
areas or groin:
 Wet four (4) washcloths and fold into
four parts. Wring them out so that they
are very damp but not dripping.
[Washcloths need to be as moist as
possible to be effective]
 Place washcloths in the axillae and
groins.
[Washcloths warm up relatively
quickly in such vascular areas.]
 Leave washcloths in place for about
five (5) minutes or until they feel
warm. Re-wet and replace them as
required during the bath.
3. Immerse folded washcloths or material for
sponging in basin with water.
Sponge the client’s face with plain water. Pat to
4. dry. Then, sponge the neck. Sponging of the
face and neck should be within 3 to 5 minutes.
[Friction of rubbing may raise body temp.]
5. Sponge the arms and legs.
 Place a bath towel under one arm and
sponge the arm slowly and gently for
about 3 to 5 minutes or as tolerated by the
client. (The farther arm should be the first
to be sponged.)
[Slow, gentle motions are indicated
because firm, rubbing motions increase
tissue metabolism and heat production.
Cool sponges given rapidly or for a short
period of time tend to increase the body’s
heat production mechanisms by causing
shivering.]
  Cover, but do not dry, each part as it is
sponged.

 Do the same thing in the lower

extremities. Sponge for about 3 to 5
minutes doing it slowly and gently.
[Evaporation of moisture on the skin helps
to reduce body temperature. An
excessively heavy covering may increase
body temperature.]

 When sponging the extremities, hold the

washcloth briefly over the wrist and
ankles.
[The blood circulation is close to the skin
surface in the wrist and ankles.]

 Change water as needed.

 If the back portion of the patient’s body is

to be sponged, do this for 10 minutes
(optional).
[Water temperature rises as a result of
exposure to the patient’s warm body
surface.]

 The anterior chest and abdomen are

usually not sponged.
[No presence of large superficial blood
vessels in this area.]

Check the patient’s color and pulse rate during

the bath. If the patient becomes pale or
6. cyanotic or if the pulse rate increases or
becomes irregular, discontinue the bath.
[This indicates that the temperature of the
patient may have dropped to subnormal level]

Do after care of equipment

7.
and change bed linens, if soiled.
[To avoid transmission of infection]

Check the patient’s body temperature

8. about 30 minutes after the bath
[To evaluate the effectiveness
of the sponge bath]

Document assessment, including the

temperature rechecks. (Drop temperature is
9.
recorded. Graph using broken red lines.)
[Recording communicates the care provided in
an accurate and firmly fashion.]
WARM MOIST COMPRESS
 It is a warm moist local compress application to a
body area.
ASSESSMENT
1. Assess skin condition for possible complications
such as redness, burns, and blisters related to
previous applications of moist heat.
2. Determine if sterile technique is required.
3. Check for length of time heat treatment is
ordered.
4. Assess vital signs, especially respirations on
debilitated patients before applying heat.
5. Refer to medical record to identify any systemic
contraindications to heat application.
Rationale: Heat causes vasodilatation, which
aggravates active bleeding. Heat applied to
localized area of acute inflammation or tumor may
cause rupture or activate cell growth.
OBJECTIVES
1. To conduct heat through moist application
2. To produce local vasodilatation
3. To improve tissue metabolism in an infected area
4. To increase circulation to the affected area
5. To promote comfort for an injured area
6. To hasten suppuration and soften exudates from
a wound (Carbuncle, Infiltration, Boils or Abscess)
EQUIPMENT
FOR CLEAN PROCEDURE
 Gauze (OS) or its substitute (clean cloth)
 Ordered solution
 Container for warming solution
 Plastic drape or absorbent pad for moisture
barrier
FOR STERILE PROCEDURE
 Sterile forceps (2)
 Sterile OS
 Sterile bowl
 Gloves (optional)
GENERAL CONSIDERATIONS
1. Do not apply warm compress when there is
tendency to bleed because of vasodilatation
effect on the blood vessels.
2. Very thin or damaged skin is more susceptible
to injury from heat. Non-intact skin and
drainage from wounds are indications to wear
gloves.
3. Diabetic clients, victims of stroke, and clients
with peripheral neuropathy are particularly at
risk for thermal injury.
4. Warm moist compress may either be sterile or
clean depending on the area for which they
are ordered.
5. For sterile solution, use sterile forceps to wring
out gauze so sterile precautions are indicated
when the compress is applied to an open
wound or to the organ such as the eye.
6. Consider age of patient, body part involved,
and type of treatment. Determine safe
temperature of application to prevent burning.
PROCEDURE
Explain procedure and purpose to client.
1.
[Minimizes client’s anxiety and promotes
cooperation during the procedure]
Assemble equipment and supplies.
2.
[Prevents unnecessary delays in the
procedure]
3. Wash hands.
[Reduces transmission of microorganisms]
Check temperature of water or solution.
[Dip your finger to check the desired temp
4.
(do this for clean moist compress but for
sterile procedure, test without contaminating
the water or solution)]
Bring equipment to bedside.
5.
[Organization of equipment to bedside
prevents delay in procedures]
6. Close door or bedside curtains.
[Provides client’s privacy]
Assist client in assuming comfortable position
in proper body alignment and place
waterproof pad under area to be treated.
7.
[Compress remains in place for several
minutes. Limited mobility in uncomfortable
position causes muscular stress.
Pad prevents soiling of bed linen]
Prepare compress.
 Soak the gauze or its substitute in
warm water or solution.
 Wring out compress with forceps.
a) Grasp forceps by handles, keeping tips
down.
[The solution or water is hot usually
110°F or 43.3°C]
b) Using forceps, pick up gauze dressing
8.
by edges.
c) Keeping one forceps stable, wind the
gauze dressing around the tip of the
forceps.
d) When the dressing is dry, unwind and
place over the affected area to be
treated.
[The compress should not be so moist,
so that solution may not drip from it.]
9.
Place compress on skin surface for
a few seconds and then lift up to
inspect skin for redness.
[Increased redness indicates burn]
 Change compress frequently
10. to ensure warmth.
[Prevents cooling and maintains
therapeutic benefit of compress]

11. Keep the water or solution warm at all times

during the treatment.

Maintain treatment for 15 – 20 minutes

12. or as ordered by the doctor.
[Continued exposure to moisture
will macerate skin]

Remove the compress when the prescribed

time is reached and inspect the patient’s skin
13.
and compressed area and dry.
[Check the effect of the
warm moist compress in the area]

Assist client to preferred comfortable position.

14.
Determine any side effects from treatment.
[Maintain client’s comfort]

15.
Do after care of equipment and return to CSR.

16. Wash hands.

[Reduces transmission of microorganisms]

EVALUATION
1. Increased circulation occurs to the affected area.
2. Increased warmth occurs to area of application.
3. Suppuration progresses.
4. Pain is decreased with heat application.

RECORDING AND REPORTING

 Record type, location and duration of application.
Note solution and temperature.
 Describe condition of wound and skin before and
after treatment, as well as client’s response to
therapy.
 Report unusual findings to nurse in charge or
physician.
COLD MOIST COMPRESS