Frostbite (COLD
Injury)
Definition
Frosbite is a localized
cold injury caused by exposure to cold temperatures (Thompson, JM, 1986, p
630).
Predisposing Factors
There are many
predisposing factors associated with the occurrence of frosbite. People who can
not adapt to the cold climate terhadp from warmer climates will experience a
severe vasospasm and reduced heat production in ekstremitasnya when he is
exposed to cold temperatures. Given the influence of race as a predisposing
factor, ie, those who were black. Fatigue, hunger, young or old age, impaired circulation
/ peripheral vascular disease (due to atherosclerosis, diabetes mellitus,
Raynaud's syndrome), alcohol, nicotine and hypoxia increase the risk or
vulnerable to the occurrence frosbite frosbite. Factors that increase spending
as contact with hot metal, wet skin frosbite contribute to the onset and
severity of injury frosbite (Thompson, 1986, p 630; Kneisel, 1986, p 2213)
Classification
Frosbite
diklasifikasian into 2 types: frosbite surface (superficial) and frosbite in
(deep). Frosbite frosbite surface is on the skin to the subcutaneous tissue,
with characteristic white area of injury, such as candles, soft and anestetic. The
capillary (capillary refill) no. At the time disbursement injury area becomes
red, edema, pain, and later became mottled / discolored or purplish. Blister
can form within 24 hours and broke in about 10 days, leaving a black eschar and
rude. After 3-4 weeks apart eschar, leaving sensitive new epithelium. Throbbing
pain (throbbing) and heat pain / burning (burning) which lasted several weeks.
This area is sensitive to heat and cold for about a month, and part of that
experience can frosbite excessive sweating.
Frosbite in causing
injury to the skin, subcutaneous tissue, muscles, tendons and neurovascular
structures. The part that suffered injury coarse and dense, cool, mottled /
striped and blue or gray after thawing. Blister may not form but can also be
formed after several weeks in places where there is a network that is able to
live (viable) and non-viable tissue (nonviable). Edema usually affects the
limbs and takes about a month to heal. When the blisters dry, black and basins
formed, a visible dividing line because the network is still alive, regardless
of the network or are interested dead.
Kneisel (1986)
bedasarkan frosbite split into four levels of tissue injury degrees with their
respective characteristics, namely:
Grade I: injury
resulting in erythema after warmed back
Grade II: the
formation of blisters
Grade III: Skin
necrosis
Degree IV: soft tissue
damage and gangrene may occur in the fingers or extremities.
Patofosiologi
Frosbite cell injury
caused by freezing directly in the cell when injury or because of inadequate
tissue perfusion as a result of vascular spasm and occlusion of small vessels
in the area of injury.
By freezing the cells
directly (Crystallization), ice crystals form in the extracellular fluid and
intracellular fluid osmotic pull, causing cell dehydration. Vascular changes
that occur include vasoconstriction, decreased capillary perfusion and increased
blood viscosity, accompanied by deposition and thrombus formation.
After thawing,
vascular stasis occurs in the area of injury as a result of obstruction of the blood
vessels at the base. Edema occurred in the area of injury and lasts for
2-3 days after thawing. Thrombus, interstitial hemorrhage and leukocyte
infiltration can occur. Tissue necrosis occurs and becomes more apparent as
edema were broke.
The extent of the
injury is determined by the speed and heat of the skin expenditure.
Clinical Manifestations
Damage to small /
light can also extensive to be able to cause the loss of a body part. Adapaun
body part that is often affected include the hands, feet, nose and ears.
Clinical picture can be observed depending on the type (see classification, as
described above).
Management
Surgery
1. Escharotomy
2. Sympathectomy for
severe spasm and pain
3. Debridement after
retraction of viable tissue (13 weeks - 4 months after injury)
4. Nonviable extremity
amputation after tissue retraction viable, maybe a few months
after injury.
Medications
1. Tetanus
immunization 0.5 ml IM
2. Plasma expanders:
dextran 40, 20 ml / kg IV every 24 hours to reduce sediment;
therapy is still
controversial.
3. Antibiotics:
tetracycline or ampicillin for prophylaxis, 250 mg po every 6 hours.
4. Narcotic
analgesics: morphine 15 mg IM every 3 hours or
5. Antipyretic
analgesics: aspirin, 600 mg po every 3 hours.
Support
1. Soaking in warm
water for 20 minutes with a temperature of 38 ° - 45 ° C (100 ° - 112 ° F)
2. Protect the patient.
Assessment
Medical history
Clients may complain
of pain (burning sensation) or pulsed.
Sensitive to heat and
cold
Physical examination
Assess skin color,
lesion characteristics:
Frosbite surface
(superficial), will be obtained:
Injury-white areas,
such as candles; soft and anestetic.
-Charging capillary
(capillary refill) no.
-At the time
disbursement injury area becomes red, edema, pain, and later became
Dotted / stripe or
purplish.
-Blister, can be
broken, and coarse black eschar.
-Area frosbite to
excessive sweating.
Frosbite In, is likely
to be obtained:
-Areas injury rough
and dense, cool, mottled / striped and blue or gray after thawing.
-Blister may not form
but can also be formed
-Edema.
-When the blister dry,
black and basins formed
Kaji also an
infection, which is characterized by:
-There is a pussy
-Redness
-Smell
-Fever
Diagnostics: increased
leukocytes.
Nursing Diagnosis and
Intervention
Disorders of
peripheral tissue perfusion
§ Soak in warm water
with a temperature of 38 ° - 45 ° C for 20 min.
§ When soaked avoid
skin contact with the container
§ Instruct clients not
to smoke in order to avoid the vasoconstriction.
Impaired skin
integrity
§ Use a sterile linen
§ Isolation limb or
client to prevent infection
§ Use the bed cradle
§ Maintain order
intact blister
§ Elevate periodic
limb
Impaired physical
mobility and comfort
§ Begin the exercise
movement
§ Teach relaxation
techniques
§ Collaboration of
analgesic
Concept of self-body
image disturbance
§ Encourage clients to
express their feelings about your body and appearance.
§ Assess the client's
reactions fear rejection by others
§ Encourage clients to
express grievances, anger, a sense of sadness, a sense of
guilt, fear the possible
loss of the limb or function.
§ Assist in through
the stages of grieving
§ Observation of the
signs of depression and apathy
§ Inform the client
that the healing process takes a long time and not sure;
provide accurate
information about the healing
§ Encourage the client
to express his dissatisfaction and frustration.
§ Involve the client
in making decisions
§ Thank feeling angry
clients.
Lack of knowledge
§ Instruct the client
to protect the extremities of temperature extremes and
sudden changes in
temperature / fast, when the network is sensitive to
temperature and
cooling / freezing will cause the loss of tissue.
§ Instruct the client
to avoid tight clothing or menakan area can
lower circulation.
§ Instruct client to
avoid smoking to lower the vasoconstriction.
§ Instruct client
about precautions to prevent the next attack
or injury that is
often repeated in the experience frosbite: use heated clothing;
avoid fatigue, hunger,
alcohol when exposed to cold lingungan.
Evaluation
The network can be
protected
• Liquefaction occurs
rapidly with no clotting occurs again.
• The network is free
from infection.
• Healing enables
occur without surgical intervention
• Clients can perform
extension and flexion of the joints
Clients assess themselves
realistically
• Client start again
with the level of ability to perform activities.
• Clients develop
interest and activities in accordance with the level keterbatasnnya.
• State kepuasanya in
conducting interpersonal relationships
Clients avoid further
injury to the area frosbite and avoid repetitive injuries / next
• Clients avoid narrow
clothes, pressing area.
• Clients do not smoke
• Clients use
protective equipment.
• Clients avoid
fatigue, hunger and alcohol when exposed to a cold environment
Bibliography
Kneisel, C.R., Ames,
S.W., (1986). Adult Health Nursing a Biopsychosocial Approach, Addison-Wesley
Publishing Company, Massachusetts, pp. 2213-2215.
Thompson, J.M., et
al., (1986). Clinical Nursing Practice, The C.V. Mosby Co., St. Louis, pp.
630-632.
