Medical Surgical Critical Care Hypothermia & Frostbite #4

Question

A client is admitted with deep frostbite to the hands and feet. Which assessment finding would the nurse expect to find on the hands and feet?

Answers

  1. The hands and feet are blue, mottled with a waxy appearance.
    • Rationale:

      This answer is not correct because with superficial frostbite, the hands and feet are blue, mottled with a waxy appearance. With deep frostbite, the hands and feet are white, hard with decreased sensitivity to touch.

  2. The hands and feet are red, edematous, and very sensitive to touch.
    • Rationale:

      This answer is not correct because the hands and feet are not red, edematous, and sensitive to touch. With deep frostbite, the hands and feet are white, hard with decreased sensitivity to touch.

  3. The hands and feet are white, hard with decreased sensitivity to touch.
    • Rationale:

      This answer is correct because with deep frostbite, the hands and feet are white, hard with decreased sensitivity to touch.

  4. The hands and feet are maroon, swollen, with blisters on the tips.
    • Rationale:

      This answer is not correct because with deep frostbite, the hands and feet are white, hard with decreased sensitivity to touch. Blisters and swelling may appear after the rewarming process with superficial frostbite.

Overview

The nursing assessment finding on the client with a deep frostbite to the hands and feet would be that both are white, hard, with decreased sensitivity to touch. These areas are very painful to the client, so administration of pain medications are essential.

Explanation

Learning Outcomes

With deep frostbite, the nurse would assess for skin that is white hard and could eventually turn into gangrenous tips. These areas have decreased sensitivity to touch, yet are extremely painful to the client, so administration of pain medications are essential. Frostbite is defined as ice crystal formation in the cells of the body. Physical damage and many times permanent changes result and can result in cell death. Usually caused from extreme cold, ice, or metal that is frozen.

Test Taking Tip

Know the differences between superficial and deep frostbite and the priority interventions for each.

Video Rationale