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Frostbite, References: Ignatavicius, D., Workman, L., Rebar, C., &…
Frostbite
Patient Education
educate the patient on how to prevent frostbite
educate them on what frostbite looks like in each stage
educate on the correct clothing to wear when being in a cold enviroment
educate patient to not stay out very long in really cold weather if possible
avoid wet clothing especially when outside in the cold
make sure to have adequate accessories (hat, gloves, ear warmers)
Assessment
grade 1 - involves hyperemia (increased blood flow) of involved area and edema formation
grade 2 - large, clear - to milky, fluid filled blisters develop with partial thickness skin necrosis
grade 3 - small blisters that contain dark fluid and affected body part is cool, numb, blue or red and does not blanch
grade 4 - blisters form over the carpal or tarsal, the part is numb, cold, and blood less, full thickness necrosis can extend into muscle and bone, at this stage gangrene can develop
look for white, waxy appearance to exposed skin especially on nose, cheeks and ears
Interventions
amputation if gangrene is present
rapid rewarming in water bath ant temp of 99-102
the part should be swirled in the water and not allowed to touch the sides of the container
pain will be high in this process (ibuprofen)
after rewarming handle injured areas gently and elevate them above heart level
splints can be used to immobilize the effected extremity
watch for signs of compartment syndrome (increasing pain with analgesics, paresthesias)
apply only loose nonadhearant sterlie dressing to damaged areas, avoid compression of the area
Pathophysiology
main risk factor - inadequate insulation against cold weather (skin is exposed to cold, clothing isn't enough protection)
wet clothing is also a poor insulator which can cause frostbite
Fatigue, dehydration, poor nutrition, smoking, previous incidence, and people with impaired peripheral circulation are also at higher risk/increase your risk.
body tissue freezes and causes damage to tissue integrity. Can be superficial, partial or full thickness
References:
Ignatavicius, D., Workman, L., Rebar, C., & Heimgartner, N. (2021). Medical-surgical nursing: Patient-centered collaborative care.
Evolve
, (10th ed.). ISBN: 978-0-323-61242-5
Holman, H. C., Williams, D., Johnson, J., Ball, B. S., Wheless, L., Leehy, P., & Lemon, T. (2019). RN Adult medical surgical nursing: Review module. Assessment Technologies Institute