Medical Surgical Critical Care Hypothermia & Frostbite #3

Question

A client with superficial frostbite was admitted to the floor. The client’s hands were blue mottled and had a waxy yellow appearance. Which intervention would the nurse implement as priority?

Answers

  1. Cover the client's hands with wool gloves and a warm blanket.
    • Rationale:

      This answer is not correct because although covering the client’s hands with wool gloves and a warm blanket would be nice, the priority is warm water soaks in the whirlpool for 30 minutes.

  2. Warm water soaks in the whirlpool for 30 minutes.
    • Rationale:

      This answer is correct because warm water soaks in the whirlpool for 30 minutes is priority.

  3. Apply pressure dressings to the client's hands.
    • Rationale:

      This answer is not correct because applying pressure dressings to the frostbite areas only decreases circulation of blood even more and is contraindicated.

  4. Massage and rub cream on the client's hands.
    • Rationale:

      This answer is not correct because it is contraindicated to rub cream on the client’s frostbite hands until rewarming has occurred. Massaging is still contraindicated because it can cause more damage, but applying a soothing gel or lotion to the client’s affected area several times a day does offer relief for some clients.

Overview

Superficial frostbite is ice crystal formation in the cells of the body. Usually caused from extreme cold, ice, or metal that is frozen. With severe frostbite, the cells rupture causing tissue death.

Explanation

Learning Outcomes

Superficial frostbite is ice crystal formation in the cells of the body. Usually caused from extreme cold, ice, or metal that is frozen. Symptoms of superficial frostbite may include blue mottled skin with a waxy yellow appearance. Interventions include removing wet/frozen clothes, jewelry, and watches to prevent vasoconstriction; warm water soaks in a whirlpool for 30 minutes; elevating the extremity once rewarmed; providing pain medications; no pressure to sites; no rubbing or massaging areas, and no occlusive dressings.

Test Taking Tip

Know the priority interventions for superficial frostbite.

Video Rationale