N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide tiny capillaries (micro vascular occlusion). This vasoconstriction is most common on the ears, extremities, face, and other areas that depend on smaller blood vessels. When frostbite is deep enough it goes into the deep tissues, muscles, and tendons and can result in gangrene due to tissue necrosis. Signs and symptoms of superficial frostbite: • Tingling • Numbness • Itching • Edema/swelling • Mottled color • Blue-gray appearance Signs and symptoms of deep tissue frostbite: • Stiffness • Burning pain • Paresthesia • White/yellow color • Purple-blue color • Blisters • Necrosis • Numbness • Edema Nursing assessment for frostbite: • Re-warm affected areas in tepid water (100 ◦ F) prior to assessment and offer pain control • Assess whether injury is superficial or deep frostbite; superficial will show swelling on palpation, deep will show absence of mobility to skin • Assess peripheral pulses • Review studies: Doppler or nuclear scan Nursing diagnosis for frostbite: • Risk for infection related to tissue necrosis • Altered tissue perfusion related to cold injury • Risk for hypothermia related to excessive exposure to cold • Pain related to tissue damage Nursing interventions for frostbite: • Medicate for pain per MD order • Give attention to broken skin: give antibiotics per MD orders, cleanse wound, and wrap in sterile gauze • Give tetanus booster if needed • Continue re-warming in tepid water; do not rub the affected body part • Give warm oral fluids and instruct patient to avoid caffeine and alcohol • Assess peripheral pulses frequently, check skin color, check capillary refill, and check skin ©2017 Achieve Test Prep Page 150 of 204