Question
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Asked by BrigadierWallaby1911
The nurse is caring for a 42-year-old male client who was admitted for frostbite of the upper and lower limb extremities.
History and Physical:
The client states that he was driving home from a conference and his car slid off into a ditch, The client did not wear a jacket and had no gloves to insulate his fingers. Unable to retrieve his car, he walked to the nearest gas station which was 45 minutes away and entered the convenience store because his cell phone had run out of battery. By the time he reached the gas station, his clothing was drenched from the wet snow. Worried, the store manager called an ambulance for the client to be cared for.
Nurses Notes:
The client is oriented to person, place, and time. He appears fatigued and is shivering. Skin is cool to touch, pale, and dry. The client reports numbness and loss of sensation in distal phalanges. Phalanges of upper and lower extremities appear pale, waxy, and mottled, with fluid-filled blisters; pain is rated as 6/10. Lung sounds are clear bilaterally with no adventitious sounds. Unable to assess capillary refill time. Peripheral pulses are diminished. Abdomen is soft and nontender, bowel sounds heard x4, but client reports feeling nauseous.
Vital Signs:
P: 110
RR: 22
BP: 137/82
T: 34.4 C (93.7 F)
O2 sat: 96% on Room Air
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Which of the following interventions are anticipated for this client?Â
Select all that apply:
1. Remove all clothing and change to dry attire
2. Provide a warm water bath
3. Administer NSAIDs
4. Massage affected areas
5. Apply clean gauze/dressing between toes and fingers after thawing
6. Provide cold drinks to keep hydrated
7. After thawing, keep feet below the level of heart
8. Administer tetanus injection if not up to date
SCIENCE
HEALTH SCIENCE
NURSING
NUR 134
