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SKIN DISORDERS
Medical-Surgical Nursing
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Anatomy&Physiology Largest Organ of the body in surface
area and weight.
In Adults
skin covers an area of about 2 sq.mt.
Thickness is 0.5-4mm,depending uponthe location.
weighs 4-5kg.
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Anatomy&PhysiologyCont
Consists of 2 PrincipalParts:-
Epidermis Superficial,thinportion composed of epithelialtissue.
Dermis Deeper,thickercomposed of connective
tissue.
Deep to the dermis is asubcutaneous layer called asHYPODERMIS consists of
aerolar & adipose tissues
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FUNCTIONS OF THE SKIN
Regulation of body temperature.
Protection
Sensation Excretion
Immunity
Blood reservoir
Synthesis of Vitamin D
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SKIN LESIONS
Primary Lesions:-
MaculaFlat,circumscribed
discoloration of skin,mayhave any size or shape.
PapuleSolid,elevatedlesion,1cmwide,extended deep intodermis.
Macule
Papule
Nodule
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SKIN LESIONS- Cont.
VesicleCircumscribedelevated lesion1cm wide e.g. 2nddegreeburn.
PustuleCircumscribedraised lesion that containspus; may form as a result ofpurulent changes in avesicle.
Vesicle
Pustule
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SKIN LESIONS- Cont.
WhealElevation of the skinthat lasts 1cm e.g. psoriasis & leukoplakia. CystSoft or firm mass, filled
with semisolid or liquid materialcontained in a sac.
Wheel
Cyst
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SKIN LESIONS- Cont.
SECONDARY LESIONS:-
ScaleHeaped-up,horny layerof dead epidermis; may developas a result of inflammatorychanges e.g.dandruff.
CrustCovering formed by thedrying of serum,blood,or pus onthe skin.
ExcoriationLinear scratchmarks or traumatized areas of theskin e.g.visible sign of itching.
Scales Excoriation
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SKIN LESIONS- Cont.
SECONDARY LESIONS:- Fissure Cracks in the
skin,usually from markeddrying & longstandinginflammation.
Ulcer Lesion formed bylocal destruction of theepidermis & by part orall of theunderlyingdermis.
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SKIN LESIONS- Cont.
SECONDARY LESIONS:- Lichenification
Thick,leathery skin,usually
the result of constantscratching & rubbing.
Scar New formation ofconnective tissue thatreplaces the loss ofsubstance in the dermis as aresult of injury or diseasee.g.mark left skin.
Atrophy loss of skin cells
that cause thinning of theskin.
Lichenification
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SHAPE OF SKIN LESIONS
Annular Ring shaped
Confluent Lesions runtogether or joinedtogether.
Grouped Clustering oflesions.
Herpetiform Groupedvesicles.
Linear In lines
Iris Ring or series of
concentric circles.
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SHAPE OF SKIN LESIONS
Solitary Single lesion
Satellite Single lesion
occurring in close proximity tobut separate from a large groupof lesions.
Zosteriform Band likedistribution,limited to one ormore dermatomes of skin.
Nummular Coin shaped
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SHAPE OF SKIN LESIONS-Cont.
Reticulated Lace like network.
Serpiginous Snake like
Telangiectasia Tiny superficial,dilatedcutaneous vessel seen as red thread orline.
Discrete Lesions remain separate. Guttate Drop like.
Multiform More than one kind of skinlesion.
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SKIN TURGOR
Gently squeeze the skinon the forearm orSternal area between
your thumb &forefinger.
If the skin quicklyreturns to its originalshape - normal skin
turgor. If the skin doesnt
return to its originalshape within 30 sec.orif it maintains a tentedposition - poor turgor.
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ASSESSMENT FINDINGS
History:
Change in skin color,texture,& temp.
Perspiration or dryness. Itching
Brittle,thick,Soft nails
Fever Hair loss
Rash
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ASSESSMENT FINDINGS
Physical Examination:-
Pattern of pigmentation & hair distribution.
Skin texture,turgor,color & temp. Peripheral Edema.
Skin lesions
Pruritis Erythema
Petechiae & ecchymosis.
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DIAGNOSTIC TESTS &
PROCEDURESSkin Biopsy:-Removal of apiece of skin by scalpel
to detect malignancy orother skin disorders.
Types of Biopsy:-
Shave Biopsy Punch Biopsy
Excisional Biopsy
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DIAGNOSTIC TESTS &
PROCEDURESSkin Scrapings:-
Procedure calling for cells scraped by a
scalpel and covered with potassiumhydroxide
Purpose:- Microscopic examination of
scales,nails and hair. Nsg.Intervention:- Check the scrapping
site for bleeding & infection.
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DIAGNOSTIC TESTS &
PROCEDURESWoods Light:- Used to detect
bacterial or fungal
infections. Performed in dark
room with the help ofUV rays.
Infected area willfluorescence or shineunder UV rays.
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DIAGNOSTIC TESTS & PROCEDURES
PATCH TESTING:- Done to find out the different
types of allergies.
Materials are applied in patchesto the skin & checked for reaction48 hours after application &possibly again later.
Erythema,swelling,papules and
vesicles indicate an allergiccontact dermatitis rather than anirritant contact dermatitis.
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GENERAL PROCEDURES
BATHS:-
A therapeutic bath is used to applymedications to the entire skin surfaceand is useful in treating widespread
eruptions and general Pruritis
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GENERAL PROCEDURES
Indications of Therapeutic Baths:-
Vesicular,bullous and ulcerativedisorders.
Acute inflammatory conditions. Erosions and exudative, crusted
surfaces
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TYPES OF THERAPEUTIC
BATHSBath Solution Desired EffectWater Remove crusts,relieve
inflammation
Saline Relieve inflammation
Colloidal e.g.oatmeal Antipruritic,soothingeffect,lubricates,soften
Sodium bicarbonate Cooling effect,relieves skinirritation.
Starch e.g.Corn starch Soothing effect
Tar baths E.g.for Pruritis,eczema
Bath Oils E.g.Eczematous eruptions
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THERAPEUTIC BATHSNsg.Care:-
Prepare a warm bath at 32 to 38 degree
centigrade(90-100 deg.F) with the tub halffilled.
Add prescribed quantity of medication & mixwell.
Do not rub the skin. Soaking for at least 15 min.will promote
removal of loosened scales.
Keep the room & water at comfortable temp.
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THERAPEUTIC BATHSNsg.Care:-
Limit bathing to 20 to 30 min.
The bath area should be well ventilated if tarsare used,because they are volatile.
Tell the patient to use a bath mat inside thetub & to use a rug outside the tub when
bathing at home. Blot skin dry with a towel & apply emollient or
topical medication to moist skin, if prescribed.
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GENERAL PROCEDURES
Wet Dressings:- Wet dressings & soaks
are damp compresses
that contain water,normalsaline,aluminiumacetate, magnesiumsulfate solution.
They may be sterile orclean,or warm orcool,depending on skincondition and the areato which they areapplied.
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GENERAL PROCEDURESOpen Wet Dressings:-
Indications:
Bacterial infections that requiredrainage.
Inflammatory and pruritis conditions.
Oozing and crusting conditions
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GENERAL PROCEDURES Open Wet Dressings:-Related Nsg.Care:
Apply dressing to the affected area & keep
moisten to the point of slight dripping. Remoisten as necessary.
Use ice cubes for cooling effect & warm tapwater for warm effect.
Rewarm or recool every 5 min. Apply for 15 min.-3 to 4 times a day.
Do not treat one third of body area at a time.
Prevent burns & chills.
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GENERAL PROCEDURESOcclusive Dressings:-
It is an airtight plastic orvinyl film applied overmedicated areas of skin(usually withcorticosteroids)to enhanceabsorption of medication &to promote moistureretention.
Indication:-Psoriasis
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GENERAL PROCEDURES
Occlusive Dressings:-Related Nsg.Care: Wash area and pat dry.
Apply medication while skin is still moist.
Cover with plastic wrap.
Seal edges with paper tape or other dressingto hold in place.
Dont apply on ulcerated skin.
Remove within 12 to 24 hours. Dont use occlusive dressings excessively as it
leads to skinatrophy,Telangiectasia,erythema,no healing
ulceration
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ASTHETIC PROCEDURES Aesthetic procedures are a type of
reconstructive (plastic) surgery
performed to reconstruct or to alter
congenital or acquired defects or to
restore or improve the bodys
appearance.
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ASTHETIC PROCEDURES
Types of procedures:- Rhytidectomy- Face lift
Blepharoplasty- Toremove excess skin or
fat from the upper &lower eyelids.
Rhytidectomy
blepharoplasty
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ASTHETIC PROCEDURES Dermabrasion- To
removescars,nevi,tattoo.
Liposuction/BodyContouring-Reduces localizeddeposits of fat fromface,neck,breasts,abdomen,flanks,hips,buttocks&extremities.
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BENIGN TUMORS Benign Tumors are
common skin growths.
Characteristics:- Seborrheic Keratoses:-
Benign wart like lesions of
varying size andcolor,ranging from light tanto black.Common in middle
age and older age people.
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BENIGN TUMORSCont. Actinic (Solar)
Keratoses:-Premalignant
skin lesions appearing asrough,scaly patches withunderlyingerythema,which develop
as a result of prolongedexposure to ultravioletrays and graduallytransform into squamous
cell carcinoma.
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BENIGN TUMORSCont. Verrucae (Warts):-A circumscribed
elevation of skin tends to disappearspontaneously.
Angiomas (Birthmarks):- Benignvascular tumors involving the skin andsubcutaneous tissue.May occur asflat,violet-red patches(port-wineangiomas) or as raised,bright-red nodular
lesions(Strawberry angiomas).Strawberryangiomas may involute spontaneously,whereas port-wine angiomas usuallypersist indefinitely.
Warts
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BENIGN TUMORSCont. PigmentedNevi(Moles):-Flat,macular
lesions,elevatedpapules,or nodules thatoccasionally containhair ranging fromyellowish to brown to
black. Keloids:-Benign
overgrowth ofconnective tissue atsite of scar or trauma.
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DERMATITIS Dermatitis:- Refers to a group of
inflammatory skin disorders thatvary in cause,morphology &
distribution.They are oftenhighly pruritic.
Types:-
Acute:WET,erythematous,edematous, oozing.
Chronic:-DRY,scaling,crusting,powdery.
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CONTACT DERMATITISDef.:-Inflammatory response of the skin aftercontact with a specific antigen.
Causes:- Mechanical,biological,& chemical irritants.
Cosmetics and hair dyes.
Detergents,cleaning agents,& soaps.
Insecticides.
Poison Ivy
Wool
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CONTACT DERMATITISPathophysiology:-
Contact with an
antigen triggers alocalized inflammatoryresponse.
Inflammatoryresponse producesskin changes.
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CONTACT DERMATITISAssessment Findings:-
Pruritis &Burning
Erythema at point of contact. Localized edema
Vesicles and papules
Lichenification Thick,leathery skin. Pigmentation changes
Eczema
Scaling
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CONTACT DERMATITISDiagnostic test findings:- Patch testing
Visual Examination
Medical Management:- Position: Elevation of extremity.
Activity: as tolerated
Monitor V/S & neurovascular checks.
Apply cool,wet dressings with aluminum acetatesolution (Burrow's solution).
Antibiotic: Ampicillin
Antipruritic/Antihistamine: (benadryl)
Corticosteroids: Hydrocortisone.
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CONTACT DERMATITISNursing Interventions:-
Assess & record neurovascular status.
Maintain elevation of affected extremity.
Monitor & record vital signs. Administer medications.
Provide tepid baths,bed cradle,&cool,wet
dressings Avoid soaps,heating pads or blankets.
Prevent scratching & rubbing.
Maintain cool environment.
Provide diversional activity.
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PSORIASIS
Definition:- Chronic,noninfectious skininflammation that occurs in patchescharacterized by frequent remission &reoccurrence.
Age Group:- Late childhood or youngadulthood.
Body parts involved:-Scalp,Elbows,knees,chest,back,arms,nails,folds between the buttocks
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PSORIASIS
Causes:- Stress
Epidermal Trauma
Streptococcal Infection Changes in Climate
Genetics
Anxiety
Alcoholism Rheumatoid Arthritis
DrugInduced:Lithium,Prapranolol,Betablockers
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PSORIASIS
Pathophysiology:-
Loss of normal regulatory mechanisms ofcell division leads to rapid multiplication ofepidermal cells that interfere withformation of normal protective layer ofskin.
Epidermal turnover occurs 6 to 9 timesfaster than normal.
Papules coalesce to form plaques.
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PSORIASISClinical Manifestations:- Erythematous,raised,
patches with silveryscales.
SymmetricInvolvement
Pruritic & painful
Pitting of
nails,yellowishdiscoloration
Arthritis in app.10%of patients(PsoriaticArthritis)
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PSORIASIS
Clinical Manifestations:-
Shedding,scaling plaques
Erythema Papules on sacrum,palms
Plaques, on visual examination.
Diagnostic test findings:-
Skin Biopsy: Positive
Serum Uric acid level: Increased
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PSORIASIS
Medical Management:-
Monitor V/S & neurovascular checks.
Treatments: Give daily soaks,usetepid,wet compresses & bed cradle.
Corticosteroids: Triamcinolone &
betamethasone used for occlusivedressing.
Antipsoriatics: Anthralin,coal tar,followed
by exposure to UV light.
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PSORIASIS
Medical Management:-
Antimetabolite: Methotrexate
Photo chemotherapy(PUVA therapy):Methoxsalen(Photosensitizer) followed byexposure to ultraviolet rays.
Keratolytics(Antiacne): Benzoyl peroxide,salicylic
acid Antimicrobial: Sulfasalazine
Diet: high protein,high calorie,frequent feedings.
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PSORIASIS Nursing Interventions:-
Assess & record neurovascular status.
Monitor and record V/S.
Administer medications. Administer UV light & PUVA therapy.
Apply occlusive dressings.
Prevent scratching. Maintain the patients diet.
Help the patient to remove scales during soaks.
Wear light cotton clothing over affected areas.
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HERPES ZOSTER(SHINGLES)
Definition:-
Acute viral infection of nerve structurecaused by varicella zoster(DNA virus).
Causes:-
Cytotoxic drug induced immunosuppression.
Hodgkins Lymphoma
Exposure to varicella zoster
Debilitating Disease.
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HERPES ZOSTER(SHINGLES)
Pathophysiology:-
Activation of dormant varicella zoster virus
causes an inflammatory reaction. Produces painful vesicles along the
distribution of nerves.
Affected areas spinal & cranial sensoryganglia and posterior gray matter of thespinal cord.
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HERPES ZOSTER(SHINGLES)
Assessment Findings:-
Neuralgia
Malaise
Pruritis & burning sensation
Clustered skin vesicles on trunk,thorax,face.
Erythema
Fever & headache
Paresthesia
Edematous skin
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HERPES ZOSTER(SHINGLES)
Diagnostic tests:- By clinical presentation
Skin cultures & stains
Medical management:-
Antibacterial ointmentAnalgesics: Acetaminophen,Oxycodone
Antianxiety drugs:Diazepam,Hydroxyzine
Antipruritic:DiphenhydramineCorticosteroids:Hydrocortisone,Triamcinolone
Nerve block agent:Lidocaine
Antiviral Agents:Acyclovir,Interferon
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HERPES ZOSTER(SHINGLES)
Nursing Interventions:- Assess Pain & Allay patients anxiety.
Monitor & record vital signs & neurologicalstatus.
Administer medications. Provide acetic acid compresses,tepid baths,bed
cradle & air mattress.
Prevent scratching and rubbing of affectedareas.
Recognize the signs & symptoms of hearingloss.
Avoid wool and synthetic clothing.
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HERPES ZOSTER(SHINGLES)
Medical complications:-
Infection
Chronic pain syndromeOphthalmic herpes zoster
Facial paralysis
Vertigo
Tinnitus
Hearing loss
Visceral dissemination
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PARONYCHIA
Definition:- Inflammation of the skin folds
surrounding the finger nail.
Clinical Manifestations:-
Acute Paronychia starts as ared,warm,painful swelling of the skin aroundthe nail.May progress to the formation of pusthat separates the skin from the nail.
In Chronic Paronychia,the redness &tenderness are less noticeable.The skinaround the nail can get boggy.Nail maybecome green because of pseudomonasinfection
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PARONYCHIA
Causes:- Trauma to the skin
e.g.ingrown nail,nail biting
The bacteria responsible forparonychia isStaphylococcusaureus,Streptococcus &Pseudomonas
Chronic infection occurs dueto repeated exposure todetergents & water.It canbe caused by Candidaalbicans & other fungi.
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PARONYCHIA
Treatment:-
Antibiotics: cephalexin
Topical Antibacterial ointments do noteffectively treat paronychia.
Incision & Drainage if pus formation isthere.
Antifungal medication such asKetoconazole cream can be used astopical agent.
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PARONYCHIA
Nursing Management:-
Encouraging soaking in warm water for
10-15 min.3-4 times a day while acutelyinflamed to relieve pain & promotedrainage.
Recommend use of rubber gloves overthin cotton gloves when working aroundmoisture.
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PARONYCHIA
Prevention of paronychia:-
Do not bite nails or cuticles.
Do not suck fingers.
Try to avoid soaking hands in waterwithout wearing waterproof gloves.
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Frost bite is damage to the bodytissue caused by the tissue
freezing,which may bepermanently affected.
Frost bite causes a loss of feelingand a white or pale appearancein extremities such asfingers,toes,ear lobes or the tipof the nose.
Frost Bite
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People at risk:-
People who have circulatory diseases
deep vein thrombosis. People taking beta blockers to lower the
blood pressure.
If deep tissues are damaged,gangrenemay result
Frostbite
Pathophysiology
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The fluids in the body tissues & cellularspaces freeze & crystallize.
This can cause damage to the bloodvessels & result in blood clotting & lackof oxygen to the affected area.
It can be very serious condition that itcan lead to amputation.
Pathophysiology
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Length of time a person is exposed to thecold.
Temperature outside.
Force of the wind.
Humidity in the air.
Wetness of clothing, shoes, & body
coverings. Ingestion of alcohol and other drugs & high
altitudes.
Causes of FrostBite
Si & t f F tbit
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Mild frostbite(frostnip) affects the outer skin layers& appears as a blanching or whitening of the skin.Usually, these symptoms disappear as warmingoccurs, but the skin may appear red for severalhours.
In severe cases, the frostbitten skin will appearwaxy looking with a white, grayish-yellow orgrayish-blue color.The affected parts will have nofeeling(numbness) & blisters may be present. Thetissue feel frozen or wooden.This indicates a veryserious condition.
Other symptoms that indicate frostbite are swelling,
itching, burning & deep pain as the area is warmed.
Sign & symptoms of Frostbite
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Proper clothing for winter weather.Wear severallayers of light, loose clothing that will trap air, yetprovide adequate ventilation.
Covering for the neck & head are important. Hats,hoods, scarves, earmuffs & facemasks are goodprotection.
Protect feet & toes. Wear 2 pairs of socks-wool isbest, or cotton socks with a pair of wool on top.Wear well fitted boots that are high enough tocover the ankles.
Prevention ofFrostbite
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Hand covering are vital. Mittens are warmerthan gloves, but may limit what you can dowith your fingers.Wear light weight glovesunder mittens so you will still have protection
if you need to take off your mittens. Be sure your clothing & boots are not tight. A
decrease in blood flow makes it harder to keepthe body parts warm & increases the risk offrostbite.
When in frostbite-causing conditions, dressappropriately, stay near adequate shelter,avoid alcohol & tobacco, & avoid remaining inthe same position for long periods.
Prevention ofFrost Bite
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Dont allow your injury to thaw thenrefreeze.This is very dangerous & can causeserious or permanent injury.It is better to delay
warming. Dont use dry heat (sunlamp,radiator, heating
pad, etc.)to thaw the injured area.
Dont thaw the injury in melted ice.
Dont rub the area with snow. Dont use alcohol, nicotine or other drugs that
may affect blood flow.
Don'ts