Content Reviewers:

Yifan Xiao, MD, Lisa Miklush, PhD, RNC, CNS, Jodi Berndt, PhD, RN, CCRN-K, PCCN-K, CNE,
CHSE, Gabrielle Proper, RN, BScN, MN
Contributors:
Abbey Richard, Alaina Mueller, Marisa Pedron, Filip Vasiljević
Christine Lee is a 46-year-old woman who presents to your emergency department after
changing a flat tire in the cold with her bare hands. The temperature outside was around 29
degrees F, or minus 1.7 degrees C. Ms. Lee is concerned about her hands and fingers. She says
that her fingers feel numb and tingly. Her fingertips are pale and cool, while her knuckles are
red, warm, and swollen. The physician diagnoses Ms. Lee with frostbite.

Frostbite is defined as a severe localized injury that occurs when a part of the body such as
hands, feet, and face, is exposed to temperatures below 31 degrees F or minus 0.5 degrees C. It
typically occurs within 30 minutes where the skin is exposed to low temperatures and windy
weather.
Normally, our body responds to low temperatures by constricting small blood vessels close to the
skin. This way, it prevents loss of heat by shifting the warm blood from the extremities to
internal organs. As a result, the exposed skin becomes pale, cold, and numb; and a person starts
to experience a tingling and aching sensation.
Next, low temperatures cause intracellular and extracellular fluids to freeze and form small ice
crystals that give the tissue a firm, solid feel. Furthermore, these ice crystals directly damage the
surrounding tissue and vascular endothelial cells. And, if the exposure to low temperatures
continues, blood vessels can lose their vascular tone, eventually causing the pooling of blood and
changing the skin color from pale to purplish.

Now, when the affected part of the body is rewarmed, the blood flow is restored and reperfusion
injury occurs. In reperfusion injury, damaged blood vessels leak fluid into surrounding tissue,
eventually causing edema. At this point, the skin develops a blotchy appearance. The blotchy
skin can be followed by fluid-filled blisters, which most commonly occurs in the next 24-48
hours. At the same time, damaged blood vessels initiate platelet aggregation, eventually causing
thrombosis and further reduction of the blood flow. On the flip side, damaged tissue stimulates
leukocytes to produce cytokines, thereby inducing inflammation and further destruction of the
affected part of the body. In severe cases, tissue destruction can progress to skin necrosis, which
typically presents as a blue-gray discoloration of the skin. 

So, the diagnosis of frostbite is based on the detection of these changes on the skin during a
physical exam. Additionally, we can check whether or not the person has peripheral pulses in the
affected extremity. In some cases the pulse may not be palpable, so pulses should be checked
using Doppler ultrasound.
Now, there are some factors that can put a person at risk for frostbite and they can be subdivided
into several groups. The first group includes environmental factors like low temperature, the
duration of exposure, high altitude, wind, and wet clothes. Next, we have individual risk factors,
such as age, gender, and race. For example, infants and the elderly have limited thermoregulation
abilities so they have a harder time producing and retaining body heat. The third group includes
health risk factors, such as exhaustion and dehydration, which can further decrease the ability of
the body to adapt to low temperatures. Other important health risk factors include
previous frostbite or cold injuries, and medical conditions associated with poor circulation, such
as diabetes. Additionally, the use of vasoconstrictive substances, such as beta blockers and
nicotine from smoking, increases the risk of freezing because they narrow small blood vessels in
the hands and feet. Finally, we have behavioral risk factors, such as alcohol, and substance
abuse, which can all lead to an altered mental status that prevents the person from seeking
shelter.

Now, it’s important to note that frostbite can lead to some serious complications. First, it can
progress to hypothermia, which is a condition when a person’s core body temperature drops
below 95 degrees F or 35 degrees C. Next, damaged skin offers little protection against
pathogens so there’s an increased risk of infection. Moreover, bacterial infection can progress to
gangrene, which is a condition associated with severe tissue destruction that might require the
amputation of the affected extremity. On rare occasions, the bacteria called Clostridium
tetani can enter the body and cause severe generalized muscle contractions, often referred to as
tetanus.
Treatment of frostbite requires rewarming of the affected part using warm water that ranges from
98.6 to 102.2 degrees F, or 37 to 39 degrees C. Additionally, clients should take nonsteroidal
anti-inflammatory drugs to relieve pain; and thrombolytics to reduce the risk of thrombosis and
reperfusion injury. Finally, severe frostbites associated with necrosis require wound care and
removal of dead tissue.

Let’s get back to assess Ms. Lee and see how she’s doing. As you assess Ms. Lee’s hands, you
notice that her fingertips are pale. Her knuckles look flushed and slightly swollen, forming a
reddened border around her mottled fingers. She has no visible blistering or necrosis, but has a
small amount of peeling skin along her fingers. The capillary refill in her fingertips is delayed,
around 4 seconds, but she has normal pulses in both radial arteries. Her vital signs are oral
temperature 97.5 degrees F, or 36.4 degrees C, heart rate 70 beats per minute and regular,
respiratory rate 18 breaths per minute with clear lungs on auscultation, and her SpO2 is 99% on
room air. She states that her pain is 4/10 and describes a burning sensation in her fingers that has
worsened since she has been inside. You document your assessment findings, share the
information with the physician, and begin to develop a care plan for Ms. Lee.
Based on the assessment data you collected, your nursing diagnoses include ineffective
peripheral tissue perfusion related to decreased blood flow; acute pain related to rewarming; and
risk for infection related to impaired skin integrity.

Now that you have established some nursing diagnoses, it’s time to collaborate with Ms. Lee and
the physician to plan some goals of care. By the time Ms. Lee is discharged from the ED, she
will have increased perfusion to her fingertips as evidenced by improved color, temperature, and
capillary refill; she will experience less pain as evidenced by her stated tolerable pain rating of
3/10; and there will be no evidence of infection. 
Next, you review the physician’s orders, and implement your plan of care. You start by removing
a class ring from Ms. Lee’s ring finger, explaining that as her hands are rewarmed they will
likely swell, causing the ring to feel tight and constrict blood flow to that finger. Next, you
administer the ordered analgesic and antiplatelet medication, aspirin, and begin rewarming Ms.
Lee’s hands in a circulating warm water bath. After 30 minutes, you dry her hands, patting
gently with a towel, and apply  antibiotic ointment and a loose non-adherent dressing, explaining
that it is important to avoid compressing the skin since it may blister or swell in the coming
hours. Next, you administer the ordered tetanus prophylaxis. Before discharge, you stress the
need to seek medical attention if she notices any signs of infection, especially pustules on the
skin or areas of red streaks near a blister or open area of skin. Lastly, you encourage Ms. Lee to
make an appointment with her primary care provider within 48 hours to reassess for any new
wounds or blisters and to ensure that her frostbite is healing.

The physician writes an order for Ms. Lee’s  discharge home including a close follow up with
her primary care provider. Let’s check back and evaluate how Ms. Lee is doing so far. Her hands
are now warm and her capillary refill is less than 3 seconds in both hands. Her skin is slightly
swollen and red, but no longer pale or mottled. The areas of peeling have remained the same, but
have not gotten worse, and she has not developed blisters or lesions. No signs of infection are
present at this time. Ms. Lee states that her pain is  2/10 and she is beginning to have more
sensation in her fingertips.
Summary
Alright, as a quick recap … Your assigned client, Christine Lee, presented to the ED with signs
and symptoms of frostbite, an injury caused when the skin freezes. Your assessment revealed
pale, mottled fingers, peeling skin, and delayed capillary refill. Your nursing diagnoses were
ineffective peripheral tissue perfusion, acute pain, and risk for infection. The goals you identified
when planning included increasing circulation and perfusion to the fingers, decreasing pain, and
preventing infection. You implemented your plan by safely rewarming Ms. Lee’s hands, treating
her pain, and dressing her hands appropriately. You explained to Ms. Lee the importance of
follow up with her primary care provider, and evaluated the effectiveness of her plan of care