NURSING
PRACTICE &
SKILL
Authors
Nathalie Smith, RN, MSN, CNP
Cinahl Information Systems, Glendale, CA
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Reviewers
Kathleen Walsh, RN, MSN, CCRN
Cinahl Information Systems, Glendale, CA
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
August 14, 2015
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2016, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Heat and Cold Therapy: Administering Warm Soaks
What is Involved in Administering Warm Soaks?
A warm soak is a type of moist heat therapy in which a part of the body is immersed or
soaked in warmed fluid that may or may not contain medication. Warm soaks are used for
a variety of purposes, including pain relief, drainage of wound sites, and removal of skin
crusts and secretions
What: Most warm soaks are provided using clean, warmed tap water, although
sometimes sterile water or sterile saline solution is used. The procedure can be
performed by having the patient submerge the affected body part in a tub or basin or by
wrapping the affected body part in a gauze dressing that has been moistened with water
or a prescribed solution
How: To administer a warm soak, the clinician either applies a warm, wet dressing
to the affected body part or assists the patient in appropriate use of a basin or tub for
partial immersion of the body. Standard precautions are usually sufficient during the
procedure; however, if sterility must be maintained (e.g., if the soak is being applied to
an open wound) adjustments to the procedure must be made for more stringent infection
prevention
Where: Warm soaks are administered in inpatient and outpatient settings, and in the
home
Who: Warm soaks can be administered by any appropriately trained healthcare provider,
but should not be delegated to assistive healthcare staff members because of the risk
for skin burns if the temperature of the soaking solution is too high and/or if the soak
is left in place too long. If the patient will be cared for in the home, warm soaks can be
administered by family members or by the patients themselves following appropriate
training. If acceptable to the patient, it is appropriate for family members and other home
caretakers to be present during the procedure
What is the Desired Outcome of Administering Warm Soaks?
Warm soaks are used for various purposes. Depending on the indication, the desired
outcome of administering warm soaks is to avoid heat-related skin injury while
relieving pain, soothing skin lesions, and reducing skin irritation, such as itching
speeding healing after skin infection
dissolving skin secretions and loosening crusts and/or eschar so the material can be
removed from the skin or wound surface
rehydrating the wound surface
enhancing the absorption of topical medication or promoting drainage of wound sites
Why is the Administration of Warm Soaks Important?
Warm soaks are important because they
provide nonpharmacologic pain relief
enhance wound healing by increasing blood circulation to the affected area
provide an alternative method of applying topical medication
offer a minimally invasive method of wound debridement
Facts and Figures
Chronic and nonhealing wounds are linked to considerable morbidity and increased healthcare costs. Investigators have
reported that warm water soaks provided as whirlpool therapy have not proven beneficial in the treatment of these persistent
wounds (Hess et al., 2003)
Short-term exposure to water experienced during warm soaks can, in some cases, significantly decrease the amount of
natural moisturizing factors (NMF) within the skin. Researchers in one study found that concentrations of NMF in the
stratum corneum layer of the skin remained significantly below normal levels for at least 4 hours after completion of the
warm water soaks. These findings suggest that warm soaks caused significant dehydration of the stratum corneum, which
increases the risk for alterations in skin integrity (Robinson et al., 2010)
Warm water soaks offer an alternative to the use of oscillating saws in the removal of orthopedic plaster casts because warm
water is able to dissolve the plaster of Paris used in orthopedic casts. This intervention can be particularly valuable when
working with young children who can be frightened by the noise of the saw. Investigators in one study reported that parents
of young children found this technique easy and effective to use when removing orthopedic casts at home. The average time
required to dissolve and remove a childs cast was 25 minutes (Sadruddin et al., 2007)
While warm soaks are effective in raising localized skin temperature, they have limited use in promoting deep tissue
heating. In a study examining the effects of different modes of tissue heating on passive range of motion (PROM) of the
hip, investigators found that neither warm whirlpool therapy nor application of moist hot packs were comparable to active
exercise via stationary bike in improving PROM. Exercise increases blood flow to the muscles, heating the body tissues from
within (Hansen et al., 2012)

What You Need to Know Before Administering Warm Soaks

Prior to administering warm soaks, the clinician should understand the basic principles of moist heat therapy, including
the mechanisms by which warm soaks provide therapeutic benefit
In addition to their action on the skins surface (e.g., loosening and removing skin secretions through interaction with
warm water), warm soaks cause vasodilation, which improves circulation to the affected area. Heat provides localized
pain relief and stimulates the inflammatory response, aiding in healing
the relative benefits of moist heat over dry heat (e.g., heating pads)
Moist heat is less drying to the skin
Moist heat penetrates the superficial tissues more readily than dry heat
considerations that must be made to avoid patient discomfort and injury when applying warm soaks
Warm soaks should be withheld until the initial injury has stabilized (~ 1224 hours; some injuries may require 72 hours
to stabilize)
The duration of warm soak therapy is generally limited to 20 minutes to prevent rebound vasoconstriction (i.e.,
vasoconstriction that occurs after maximal vasodilation has occurred, as a response to prolonged heat therapy) and
thermal injury
Young children, older adults, and patients with thin/damaged skin and/or sensory impairment (e.g., as a result of stroke,
diabetic neuropathy, or spinal cord injury) are at increased risk for thermal injury
As a general rule, patients should be reassessed after 5 minutes of warm soak therapy to make sure they are free of
procedure-related discomfort and signs of thermal injury (e.g., skin redness, maceration), and to make sure the water is
still at the right temperature
Preliminary steps that should be performed before initiating warm soak therapy include the following:
Review the facility/unit specific protocol for warm soak therapy, if one is available
Review the treating clinicians order for warm soaks. Note
the area of the body for which the soak is intended
the duration and frequency of warm soak therapy sessions
the type of solution (e.g., tap or sterile water, saline) to be used
if medication is to be added to the warm soak
if the patient is to receive any premedication prior to the warm soak therapy sessions
Verify familiarity with the use of any equipment to be used during warm soak therapy (e.g., whirlpool, basin, bedside
commode, sitz bath supplies), and check that equipment is clean and in good working order
Verify completion of facility informed consent documents, if necessary
Typically, the general consent for treatment executed by patients at the outset of admission to a healthcare facility includes
standard provisions that encompass heat and cold therapy
 Review the patients history/medical record for any allergies (e.g., to latex, medication, or other substances); use alternative
materials, as appropriate
Request assistance from another staff member, as necessary, to support the patient in transferring to the basin or bath
Gather supplies, which typically include the following:
Sterile or nonsterile gloves (sterile gloves should be used if the procedure is to be performed under sterile conditions such
as for the provision of wound care, otherwise nonsterile gloves are appropriate); additional personal protective equipment
(PPE; e.g., gown, face mask, eye protection) may be necessary if exposure to body fluids is anticipated
Facility-approved pain assessment tool
Facility-approved skin/wound assessment tool, if indicated
Warmed tap water, sterile water, or saline, as ordered
The usual temperature range for warm soaks is 105110 F (40.643.3 C). Pediatric patients, older adults, and other
patients with fragile skin should be treated with temperatures at the lower end of this range; warmer temperatures may be
used, if ordered by the treating clinician
Medication to be added to the warmed water and/or analgesia, if prescribed
Submersible bath thermometer for measuring temperature of the water
If warm soaks will be provided using a basin or bathtub,
a basin large enough to allow total submersion of the affected body area
a bathtub or whirlpool may be used to provide warm soaks to the lower trunk (e.g., perineal and perirectal areas, and/or
lower extremities). Alternatively, warm soaks can be provided to the perineal and perirectal areas by using sitz baths. (For
more information on sitz baths, see Nursing Practice & Skill Heat and Cold Therapy: Sitz Baths -- Performing )
If warm soaks will be provided using warmed, wet dressings,
4 x 4 gauze pads of sufficient number to place two layers of gauze over the area to be treated
a container (such as a kidney basin or bath basin) in which to saturate the gauze with the warmed solution
waterproof pad
a waterproof heating pad or aquathermia pad
- For detailed information about the use of these items, which are often used in conjunction with warmed, wet compresses
to maintain the desired temperature, see Nursing Practice & Skill Heat and Cold Therapy: Aquathermia Pads and
Heating Pads --Using
Bath towels

How to Administer Warm Soaks

Perform hand hygiene and don PPE as appropriate
Identify the patient according to facility protocol
Establish privacy by closing the door to the patients room and/or drawing the curtain surrounding the patients bed
Introduce yourself to the patient and family member(s), if present; explain your clinical role; assess the coping ability of the
patient and the family and for knowledge deficits and anxiety regarding the use of warm soaks
Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language
barriers, or deafness); make arrangements to meet these needs if they are present
Use professional certified medical interpreters, either in person or via phone, when language barriers exist
Explain the procedure for administration of a warm soak and its purpose; answer any questions and provide emotional
support as needed
Assess the patients general health status, including his/her level of pain using a facility-approved pain assessment tool; if
ordered, premedicate the patient with the prescribed analgesia and allow for therapeutic level to be reached before initiating
warm soak therapy
Assess the patient to verify that the prescribed warm soak is appropriate to his/her current condition
Assess for conditions that may require alteration to the plan of treatment (e.g., circulation problems, decreased sensation,
age [skin of older adults is more vulnerable to heat and maceration, and skin of very young patients can be sensitive to
extreme temperatures])
Evaluate mobility status to determine if the patient will be able to participate in the treatment plan (e.g., is the patient able
to sit in the required position for the duration of the warm soak therapy?)
Assesses the affected body part to determine if the injured area should be exposed to moist heat therapy. Note: Increasing
redness or edema warrants reevaluation of the appropriateness of the procedure
If soaking a wound, use validated skin/wound assessment tool to assess the wound prior to the procedure
 Position and drape the patient for privacy and accessibility
Observe standard precautions throughout the procedure; modify technique, as necessary, if the procedure is to be performed
under sterile conditions
If using a basin or bathtub, verify that the tub or basin has been disinfected prior to use and
fill the basin or bathtub with enough warm fluid to allow the submersion of the affected area of the patients body
use a bath thermometer to check fluid temperature. Add warm or cool fluid as needed to adjust the temperature of the fluid
in the basin to the desired range of105110 F (40.643.3 C); if a bath thermometer is not available, test the temperature
of the fluid with your forearm to make sure it is comfortably warm
if prescribed, add medication to the fluid
If using a basin, assist the patient to a comfortable position that permits submersion of the affected body area and instruct
the patient to
- sit erect for an arm soak
- lie down and bend the appropriate knee for a leg or foot soak
- sit on the edge of the bed or transfer the patient to a chair for a foot soak that is desired in the sitting position
- Verify that the patient can reach the call button and instruct him or her to call for assistance before moving from the
basin
If using a bathtub, assist the patient into a comfortable position in the tub
- Many facilities require that a towel be placed on the floor of the tub to provide a cushion for the patient, to keep the
perineum off the tub floor, and to help prevent the patient from slipping in the tub
- Do not use inflatable donuts because these devices may prevent full exposure of the body to the warm fluid
- Patient safety note: Avoid leaving the patient unattended in the bathtub in order to reduce the patients risk for injuries
related to slipping/falls
Evaluate the patient after 5 minutes to confirm patients comfort and that the fluid has remained within the therapeutic
temperature range
Continue the warm soak for the prescribed time period
Assist the patient out from the basin or bath
If administering warm soaks using wet dressings,
fill the basin with warmed fluid, as ordered
use the bath thermometer to check temperature of the fluid. Add warm or cool water, as needed, to adjust temperature of
the fluid in the basin to the desired range of 105110 F (40.643.3 C)
if prescribed, add medication to the fluid in the basin
soak 4 x 4 gauze in the warmed solution in the basin
squeeze the gauze to remove enough of the solution to leave it damp but not soaking or dripping wet
lightly place two layers of the wet gauze squares on the area of the patients body that is to be treated
cover the treated area with the waterproof pad. A waterproof heating pad or an aquathermia pad set to a low temperature
may be placed on top of the waterproof pad if instructed by facility protocol or by orders of the treating clinician
evaluate the patient after 5 minutes to confirm comfort and that the warmed, wet dressing is intact
continue the warm soak for the prescribed period of time
at the end of the prescribed time for treatment, remove the aquathermia pad/heating pad, waterproof pad, and damp gauze
Remove skin crusts or exudate, if indicated, using moist gauze
Use a towel to pat dry the patients skin; redress wounds, if present
Assess the patients response to the procedure, including any change in pain level from baseline; assess skin integrity and the
condition of the treated area
Assist the patient in dressing and to a comfortable position in a bed or chair
Dispose of used materials in appropriate receptacles and perform hand hygiene
Verify that the tub is disinfected after use
Update the patients plan of care, as appropriate, and document administration of warm soak in the patients medical record,
including the following information:
Date and time of the warm soak therapy
Description of the procedure, including the type of solution used, whether medication was added to the solution, whether
the patient received any medication prior to the procedure, and the length of time for which heat therapy was applied
Patient assessment findings, including pain level and the appearance of the affected area before and after the procedure
Patients tolerance of the procedure
 Any unexpected patient events or outcomes, interventions performed, and whether the treating clinician was notified
Patient/family education, including topics presented, response to education provided/discussed, plan for follow-up
education, and details regarding any barriers to communication and/or techniques that promoted successful communication

Other Tests, Treatments, or Procedures That May Be Necessary Before or After

Administering Warm Soaks
If a skin lesion or infection is present, topical medication (e.g., antibiotic ointment) may be applied to the affected area after
the warm soak
Emollient may be applied to the surface of the patients skin after the procedure
Debridement may be necessary if the purpose of the warm soak was to dissolve skin secretions, or loosen crusts or eschar

What to Expect After Administering Warm Soaks

The patient will experience, without adverse consequences,
a reduction of symptoms
decrease in pain
enhanced healing
delivery of topical medication, if prescribed

Red Flags
Areas of pain or persistent blanching, redness, swelling, and/or blistering of skin suggest that the area has been excessively
heated during the procedure, increasing the patients risk for temperature-related tissue injury at the site. Stop the warm soak
if these conditions are observed, and allow the area to return to room temperature. Do not rapidly cool the area as this can
contribute to tissue injury. If symptoms remain after the skin has cooled to room temperature, contact the treating clinician
for evaluation of possible thermal injury

What Do I Need to Tell the Patient/Patients Family?

Educate the patient/family about what will happen during and after warm soak therapy; answer any questions
If the patient is cared for at home or will be discharged after the procedure,
provide homecare instructions according to the treating clinicians orders and explain how to contact the healthcare
provider, if questions or problems arise
instruct the patient and family members about the clinical signs and symptoms following warm soak therapy that should be
reported to the treating clinician, such as
blistering and/or blanching
redness, and/or swelling at the site that persists after the treated area has cooled to room temperature
new onset of pain or tenderness
explain the importance of keeping follow-up medical appointments to allow continued medical surveillance of the patients
condition

Note
Recent review of the literature has found no updated research evidence on this topic since the previous publication on July
17, 2015

References
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2. Hanson, M., & Day, J. (2012). Effects of different heating modalities on hip flexion passive range of motion. International Journal of Athletic Therapy & Training, 17(6), 27-30.
3. Hess, C. L., Howard, M. A., & Attinger, C. E. (2003). A review of mechanical adjuncts in wound healing: Hydrotherapy, ultrasound, negative pressure therapy, hyperbaric
oxygen, and electrostimulation. Annals of Plastic Surgery, 51(2), 210-218.
4. Lynn, P. (2011). Skin integrity and wound care. In Taylor's clinical nursing skills (3rd ed., pp. 424-427). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins.
5. Perry, A. G. (2014). Therapeutic use of heat and cold. In A. G. Perry, P. A. Potter, & W. Ostendorf (Eds.), Clinical nursing skills & techniques (8th ed., pp. 976-986). St. Louis,
MO: Elsevier Mosby.
6. Robinson, M., Visscher, M., Laruffa, A., & Wickett, R. (2010). Natural moisturizing factors (NMF) in the stratum corneum (SC). II. Regeneration of NMF over time after soaking.
Journal of Cosmetic Science, 61(1), 23-29.
 7. Sadruddin, N., Chinoy, M. A., & Javed, M. I. (2007). Soak the cast off. Journal of the College of Physicians and Surgeons - Pakistan, 17(6), 380-381.
8. Smith, S. F., Duell, D. J., & Martin, B. C. (2012). Local heat therapies (thermotherapy). In Clinical nursing skills: Basic to advanced skills (8th ed., pp. 864-867). Upper Saddle
River, NH: Pearson Education, Inc.
9. Soaks. (2013). In J. P. Kowalak (Ed.), Lippincott's nursing procedures (6th ed., pp. 660-661). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
10. Soaks. (2015, July 15). Lippincott procedures. Retrieved August 5, 2015, from http://procedures.lww.com/lnp/view.do?pId=792684&hits=soaks,soak&a=false&ad=false