THERMAL ENERGENCIES

1. THERMAL EMERGENCIES
AND
WOUND ASSESSMENT
VENBA.E
M.SC., NURSING II YEAR,
COLLEGE OF NURSING,
MMC,CHENNAI -03.

2. INTRODUCTION
Thermal emergencies encompasses a spectrum of conditions resulting
from exposure to extreme temperatures, including heat-related and cold-related
illnesses. These emergencies can occur due to environmental factors, such as
high temperatures during heatwaves or extreme cold during winter storms, as
well as individual factors like dehydration, inadequate clothing, or prolonged
exposure to harsh conditions. Understanding and recognizing the signs and
symptoms of thermal emergencies is crucial for prompt intervention and
preventing serious complications.

3. Thermal or heat emergencies fall into three categories of increasing severity
Heat stroke
Heat exhaustion
Heat cramps

4. HEAT CRAMPS
DEFINITION
Heat cramps are painful muscle contractions or spasms that typically occur
during or after intense physical activity in hot environments. They are caused by
dehydration and electrolyte imbalances, particularly a deficiency in sodium,
potassium, or magnesium. Heat cramps commonly affect muscles that have been
heavily used during exercise, such as those in the arms, legs, abdomen, and back.

5. CAUSES
1.Dehydration: sweating during physical activity leads to loss of fluids and
electrolytes, which can disrupt the balance necessary for proper muscle function.
2.Electrolyte imbalances: inadequate replenishment of electrolytes, especially
sodium, potassium, and magnesium, can contribute to muscle cramping.
3.Intense physical activity in hot environments: heat cramps are more likely to
occur during prolonged or strenuous exercise in high temperatures, where the
body's cooling mechanisms, such as sweating, may not be sufficient to maintain
normal body temperature.

6. CLINICAL MANIFESTATIONS
Muscle cramps: painful muscle contractions or spasms, often in the legs, arms,
abdomen, or back.
Muscle tightness: the affected muscles may feel firm or knotted.
Sweating: heat cramps typically occur during or after periods of heavy sweating.
Thirst: dehydration often accompanies heat cramps, leading to increased thirst
Rapid heartbeat
Dizziness
Fainting and exhaustion
Nausea and vomiting

8. TREATMENT:
1.Rest: stop the activity causing the cramps and rest in a cool, shaded area.
2.Hydration: drink plenty of fluids, preferably water or sports drinks containing
electrolytes, to replenish lost fluids and minerals.
3.Stretching: gently stretch and massage the affected muscles to help relieve
cramping.
4.Cooling: apply cool compresses or ice packs to the cramping muscles to reduce
discomfort and promote relaxation.
5.Electrolyte replenishment: if available, consume foods or drinks containing
electrolytes, such as bananas (potassium) or sports drinks, to help restore
electrolyte balance.

9. HEAT EDEMA
 Self limited process manifested by mild swelling of feet, ankles
and hands that appears within the first few day .
 Increase in the secretion of aldosterone and diuretics hormone
in response to the heat stress contributes to the mild edema .
 No specific treatment is necessary .
 Diuretics are not effective.

10. PRICKLY HEAT
 Prickly heat is a pruritic ,maculopapular , erythematous rash over
normally clothed areas of the body
 Itching is the predominant clinical features during this phase and can
be treated successfully with antihistamines.
 Chlorhexidine can be apply for relief .

11. HEAT TETANY
 Heat tetany consist of typical hyper ventilation resulting in respiratory
alkalosis , paraesthesia of the extremities, circumoral paraesthesia ,
and carpopedal spasm.
 Heat tetany can be differentiate from heat cramps-little pain or
cramping in the muscles compartments and paresthesias of the
extremities are most prominent.

12. HEAT SYNCOPE
Heat syncope is a variant of postural hypotension resulting from the
cumulative effect of relative volume depletion, peripheral vasodilatation and
decreased vasomotor tone.
It occurs most commonly in non acclimatized individual during the early
stage of heat exposure.
Highest incidence- elderly.
Treatment consist of removal from the heat source, oral or intravenous
rehydration and rest.

13. MANAGEMENT
1. INITIAL RESUSCITATION
 Standard resuscitation measures
 Cooling techniques
 Treatment of complications.

14. INITIAL RESUSCITATION
 Airway, breathing, circulation maintain .
 Administration of high- flow oxygen;
 Initiation of continuous cardiac monitoring and pulse oximetry, establishment of
IV access . glucose levels should be evaluated on arrival.
 Iv fluids should be initiated at a rate that ensures adequate urine output ,
beginning with 250ml/h ns.
 In elderly patients, fluid therapy should be monitored using a central venous
pressure line or pulmonary artery catheter , if possible.

15. COOLING TECHNIQUES
Only physical methods of cooling are recommended.
• Antipyretics have no role.
• Dantrolene is ineffective in heat stroke.
• The choice of cooling method depends on the setting and condition
of the patient.
• With all cooling method, the goal is to reduce the core temperature
to 39°c (102.2°F) and then stop to avoid overshoot hypothermia.

16. EVAPORATIVE COOLING
Patient clothing is removed and cool water [15°C(59°F)] is sprayed
on most of the patient’s body surface .
• directing a fan over the patient facilities evaporation.

17. Immersion cooling
Placing the undressed patient into a tube of ice water deep enough to cover the trunk
and extremities , while keeping the patient’s head out of the water.
Shivering, displacement of monitoring leads , and inability to perform defibrillation or
resuscitation procedure.
Other methods
 Cold water gastric lavage , cold water urinary bladder lavage, and cold water rectal
lavage.
 Cold wate peritoneal lavage but not effective.
 Iv infusion of cold fluid is not considered effective treatment.

18. TREATMENT OF COMPLICATIONS
• Hypotension is a common. Small fluid bolus (500 ml NS) and body cooling.
• Low cardiac output warrants the use of dopamine or dobutamine.
• Severe vasoconstriction by norepinephrine.
• Hypokalaemia due to total-body depletion of potassium may be noted.
• Hypernatremia seen in severely dehydrated patients.
 Hyponatremia occurs in patients who hydrate with oral hypotonic solution.

19.  Thermal injury to the liver is a common , always reversible , with a
full recovery.
 Renal failure ,adult respiratory distress syndrome may also occur.
 Seizure may occur during cooling and can be controlled with
benzodiazepines .
Home remedy
 Lemon water
 Intake adequate water
 ORS
 Taking a cool shower or bath

20. HEAT EXHAUSTION
Heat exhaustion is less dangerous than heat stroke. It is caused by fluid loss
which in turn causes blood flow to decrease in vital organs, resulting in a form of
shock.
Heat exhaustion is a heat-related illness characterized by a combination of
symptoms resulting from exposure to high temperatures and inadequate fluid intake.
It typically occurs during prolonged periods of physical activity or exposure to hot
environments, especially when combined with high humidity. Heat exhaustion is
considered less severe than heat stroke but requires prompt recognition and
treatment to prevent progression to heat stroke, a potentially life-threatening
condition.

21. CAUSES:
1.High temperatures: exposure to hot and humid environments,
particularly during the summer months, can increase the risk of heat
exhaustion.
2.Dehydration: inadequate fluid intake or excessive fluid loss through
sweating can lead to dehydration, impairing the body's ability to
regulate temperature.
3.Strenuous physical activity: engaging in prolonged or intense
exercise in hot conditions can generate excess heat, leading to heat
exhaustion if the body's cooling mechanisms become overwhelmed.

22. RISK FACTORS
• Dehydration
• Age (the elderly age )
• Illness or chronic disability
• Obesity
• Pregnancy
• Cardiovascular disease
• Hypertension
• Respiratory disease
• Drinking alcohol
• Physical exertion in hot or humid environment (athletes)

23. SIGNS AND SYMPTOMS
• Heavy sweating
• People with heat exhaustion may experience the following signs and symptoms
• Fatigue
• Headache
• Pale, clammy skin
• Thirst
• Rapid heartbeat
• Dizziness , fainting
• Nausea , vomiting
• Muscle and abdominal cramps

25. TREATMENT:
1.Move to a cooler environment: immediately relocate to a shaded or air-conditioned area
to avoid further heat exposure.
2.Hydrate: drink cool water or sports drinks to replenish lost fluids and electrolytes. Avoid
alcoholic or caffeinated beverages, as they can contribute to dehydration.
3.Rest: lie down and elevate the legs to promote blood circulation and alleviate symptoms
of weakness or dizziness.
4.Cooling measures: apply cool, wet cloths or towels to the skin, or take a cool shower or
bath to help lower body temperature.
5.Loosen clothing: remove tight or unnecessary clothing to allow heat to dissipate more
efficiently.
6.Monitor symptoms: keep track of symptoms and seek medical attention if they worsen
or do not improve within 30 minutes.

26. PREVENTION:
1.Stay hydrated: drink plenty of fluids, particularly water, before, during, and after
outdoor activities, even if you do not feel thirsty.
2.Avoid excessive heat: limit outdoor activities during the hottest parts of the day
and take frequent breaks in shaded or air-conditioned areas.
3.Wear appropriate clothing: choose lightweight, loose-fitting clothing that allows
sweat to evaporate and helps regulate body temperature.
4.Acclimatize: gradually expose yourself to hot environments to allow your body to
adapt and build tolerance to heat stress.
5.Know your limits: recognize signs of heat exhaustion and take prompt action to
prevent further heat-related illness.

27. HEAT STROKE
Heat stroke is a severe and potentially life-threatening form of heat-related
illness characterized by a significant elevation in body temperature (above 104°F or
40°C) accompanied by central nervous system dysfunction. It is considered a
medical emergency requiring immediate intervention to prevent serious
complications, including organ damage and death. This is the most serious type of
heat emergency. It is life- threatening and required immediate and aggressive
treatment. Heat stroke occurs when the body’s heat regulations mechanism fails.
Heat stroke usually results from doing heavy work in hot environment usually
accompanied by inadequate fluid intake. Infant, children, obese adult and elderly
people are more prone to heat than young and healthy issue.

28. CAUSES
1.Prolonged exposure to high temperatures: heat stroke typically occurs when the body's
cooling mechanisms become overwhelmed due to prolonged exposure to hot and humid
environments, especially during heatwaves.
2.Dehydration: inadequate fluid intake or excessive sweating can lead to dehydration,
impairing the body's ability to regulate temperature effectively.
3.Exertion in hot conditions: strenuous physical activity or work in hot environments can
generate excess heat, further contributing to heat stroke risk.
4.Underlying health conditions: certain medical conditions, such as heart disease,
diabetes, obesity, and respiratory conditions, can increase susceptibility to heat-related
illnesses, including heat stroke.
5.Medications: certain medications, such as diuretics, antihistamines, can affect the body's
ability to regulate temperature and increase the risk of heat stroke.

29. PREDISPOSING FACTORS
• Non-accimilitation to high temperature
• Pre – existing illness with fever
• Obesity
• Diabetes
• Alcoholism
• Birth defect with absence of sweat gland
• Excess physical exertion or exercise
• Administration of sweat inhibiting drug

31. CLINICAL MANIFESTATIONS
1.High body temperature: core body temperature above 104°F (40°C) is a
hallmark sign of heat stroke.
2.Altered mental status: confusion, agitation, delirium, irritability, or even loss of
consciousness may occur due to central nervous system dysfunction.
3.Hot, dry skin: unlike heat exhaustion, where the skin may be cool and moist, the
skin in heat stroke is typically hot, dry, and flushed.
4.Rapid heartbeat: the heart rate may be elevated as the body attempts to circulate
blood and dissipate heat.
5.Rapid, shallow breathing: breathing may become rapid and shallow as the body
works to cool itself.

32. 6.Nausea and vomiting: gastrointestinal symptoms such as nausea,
vomiting, and diarrhea may occur.
7.Headache: severe headaches may develop due to dehydration and
increased intracranial pressure.
8.Muscle cramps or weakness: muscular symptoms, such as cramps or
weakness, may be present but are less common compared to heat
exhaustion.
•

33. Others…..
Dizziness
Restlessness
Loss of consciousness/ possible coma ,
Hallucinations
Confusion
Agitation
Disorientation
Possible seizure or muscular twitching

35. EMERGENCY CARE PROCEDURE
1.Remember heat stroke is a life- threatening emergency and required prompt
action.
2.Rapidly cool the victim in any manner possible.
3.Get victims out of the sun into a cooler area.
4.Remove clothing and wrap with wet towel or sheet if possible.
5.If cooled pack or ice packs are available,
6.The patient’s clothes have to be loosened so as to allow active air circulation.

37. 7. Body and limbs have to be massaged in order to improve the blood circulation
with body.
8. Do not give victim anything by mouth.
9. Provide victim high concentration of oxygen.
10. Victim must be transported to definitive care as soon as possible.
11. Drugs to treat epileptic fits are administered, if the need arises.
12. Shock is treated by supplying the body with sufficient fluids

38. IMMEDIATE TREATMENT
Heat stroke is essential as death or permanent brain damage can occur with in
minute.
Emergency treatment is focused on cooling the patient as quickly as to possible to
a core body temperature of 102°f (38.9°c).
Cooling may be done by spraying water on the body, covering the patient with
sheets soaked in ice water, or placing ice packs in the patient ‘s armpits and groin
area.
If the patient is conscious , they may be given additional oxygen to breathe and
intravenous fluids to restore their blood volume .
Patients who are haven muscle or convulsions are usually given.

39. PREVENTION:
1.Stay hydrated: drink plenty of fluids, particularly water, to prevent dehydration
during hot weather or strenuous activity.
2.Limit outdoor activity: avoid prolonged exposure to high temperatures,
especially during heatwaves or extreme heat events.
3.Wear appropriate clothing: choose lightweight, loose-fitting clothing and wear a
hat to protect against sun exposure.
4.Take breaks: take frequent breaks in shaded or air-conditioned areas during
outdoor activities, especially if engaging in strenuous exercise.
5.Know the signs: be aware of the symptoms of heat-related illnesses, including
heat stroke, and take prompt action if symptoms occur.

40. NURSING DIAGNOSIS
• Hyperthermia related to prolonged exposure to hot weather as evidenced by core
body temperature of 40 degrees Celsius, rapid and shallow breathing, racing
heart rate, flushed skin, and profuse sweating.
• Fluid volume deficit related to dehydration due to heat stroke as evidenced by
temperature of 40 degrees Celsius, skin turgidity, dark yellow urine output,
profuse sweating, hypotension.
• Acute pain related to muscle cramps secondary to fluid and electrolyte loss.
• Risk for ineffective perfusion (cerebral, cardiac, or renal) related to decreased
cardiac output.
• Risk for altered consciousness
• Risk for complication related to ineffective thermoregulation.

41. COLD INJURIES
Cold injuries encompass a range of conditions caused by
exposure to cold temperatures, including frostbite, hypothermia, and
non-freezing cold injuries. These injuries can occur when the body loses
heat faster than it can produce it, leading to tissue damage, impaired
physiological function, and potentially life-threatening complications.

42. FROST BITE
Frostbite is a cold-related injury that occurs when skin and underlying
tissues freeze due to prolonged exposure to cold temperatures, usually below
freezing point. It commonly affects extremities such as fingers, toes, ears, and the
nose, but it can occur on any exposed skin surface.
Cold injuries divided into two categories
These are those that occur without the freezing of body tissue[chilblains and
trench foot].
 Those that occur with the
freezing of body tissue[Frost bite].

43. STAGES OF FROSTBITE
Frostbite progresses through several stages, each with distinct characteristics:
1.Frostnip: This is the mildest form of frostbite. It causes the skin to become pale or
red and feel cold and numb. Frostnip doesn't typically cause permanent damage
and can be reversed with rewarming.
2.Superficial frostbite: In this stage, the skin freezes, leading to ice crystal
formation in the outer layers of the skin. The affected area may appear pale, hard,
and cold to the touch. Thawing may cause stinging, burning, or throbbing pain.
3.Deep frostbite: This is the most severe stage of frostbite, where both the skin and
underlying tissues freeze. The affected area may appear white, blue, or mottled,
and the skin may feel hard and numb. As deep frostbite progresses, tissue damage
becomes more extensive, potentially leading to gangrene and permanent loss of
function.

45. Classification
Superficial frost bite :
it is involves the skin ,subcutaneous tissues. Skin is cold, waxy white, and
non blanching frozen part anesthetic but become painful and flushed with thawing.
Edema develops and clear bullae filled with serous fluid appear with in 24hr.
Deep frost bite:
it is involves in the muscle, tendons, neurovascular structures, and bone, in
addition to the skin and subcutaneous tissues. Frozen part is hard, wood like, and
anesthetic. It appear ashen gray, cyanotic, or mottled and may remain unchanged
even rewarming. Edema develops, but bullae may be absent or delayed. Bullae, if
present, are filled with hemorrhagic fluid.

46. RISK FACTORS
 Intoxication with alcohol or other substance
 Very young or very old age
 Cardiovascular disease
 Peripheral vascular disease
 Outdoor work
 Windy or wet weather
 Homelessness
 Previous frostbite

47. CONT….
 Skin damage
 Poor circulation
 Taking beta-blockers
 Diabetes
 Exhaustion,
 Malnutrition,
 Dehydration,
 Sever injury,
 Smoking,
 Depression
 Constricting clothing and footwear
 Winter sports at high altitudes.

48. CLINICAL MANIFESTATIONS
 Pins and needles'' sensation followed by numbness
 Early throbbing or aching
 Skin is hard, pale, cold, and has no feeling
 Flushing from blood rushing to area it's rewarded
 Burning sensation and swelling from collected fluid that may last four weeks
 Blisters
 Black scab like crust, which may develop several weeks after exposure
 Damage to deep structures such as tendons, muscles, nerves and bone.

49. TREATMENT
Analgesics
•Nsaids
•Antibiotics
•Tetanus toxoids
•Coldand move him or her to a warmer place.
•Remove constricting jewellery and wet clothing.
•If immediate care is not available,rewarming first aid may be given.
•Soak the affected areas in warm water or repeatedly apply warm
clothes to affected ears, nose or cheeks for 20 to 30 minutes.

50. Cont…
 Keeps circulating the water to aid the warming process.
 Refreezing of thawed extremities can causes more severe damage. Prevent refreezing
by wrapping the thawed areas and keeping the person warm.
 If frost bite has caused tissue death in any area, such as a hand or foot, amputation
may be necessary.
 If, however the person has serious infection, wet gangrene, or pain that won't respond
to treatment, surgery may be required sooner.
 Apply dry sterile dressing to the frostbitten areas. Put dressing between frostbitten
fingers or toes to keep them separated.

52. CHILBLAINS
Definition
Chilblains are the painful inflammation of small blood vessels in skin that
occur in response to sudden warming from cold temperature. Also known as pernio,
chilblains can cause itching, red patches, swelling and blistering on extremities, such
as on toes, fingers, ears, and nose.

53. TYPES
ACUTE
Developing within 12-24 hours after exposure to the cold and getting better
after one to two weeks if you keep warm.
CHRONIC
 Lasting for a minimum of five months a years and causing persistent sores that can
lead to scarring.
 Cold weather related injuries can be divided into two general categories.
 These are those that occur without the freezing of body tissue[chilblains and
trench foot] and those that occur with the freezing of body tissue [Frost bite].

54. CAUSES
 Exposure of skin to cold
 A family history of chilblains
 Being female
 Being underweight
 Area with high humidity
 More common from November to April
 Wearing ill fitting shoes
 Having poor circulation
 Having been diagnosed with Raynaud's phenomenon
 Peripheral vascular disease due to diabetes, smoking, hyperlipidemia.

55. CLINICAL MANIFESTATIONS
 Red or purple patches: chilblains appear as red or purple patches on the skin,
often accompanied by swelling.
 Itching and burning sensation: the affected area may feel itchy or painful,
with a burning sensation.
 Skin discoloration: over time, the affected skin may become darker in color.
 Warm to touch: the skin affected by chilblains may feel warm to the touch.

56. TREATMENT
•Topical corticosteroids
•Nifedipine
•Lanoline ointment
•Antiseptic cream or lotion
COMPLICATIONS
 In severe cases, chilblains can lead to complications such as ulceration,
 Infection, or tissue damage.
 It's essential to monitor the condition closely and seek medical attention if
complications arise.

57. TRENCH FOOT [IMMERSION INJURY]
Exposure to damp, cold conditions can results in tissue damage of
the foot. This condition called trench foot or immersion foot. It was
named after the condition suffered by many soldiers in the trenches
during world war I. Trench foot develops after prolonged exposure to a
wet, cold environment and is typically a more serious condition than
chilblain.
Trench foot is the term is used to described injuries of the foot
due to water and cold exposure at sustained temperatures ranging from
32-65 degrees farenheit.

58. CAUSES:
Trench foot occurs when the feet are exposed to moisture and cold
temperatures for an extended period. Prolonged exposure to dampness can cause the
blood vessels in the feet to constrict, reducing blood flow and oxygen delivery to the
tissues.

59. RISK FACTORS:
Prolonged exposure to dampness: spending extended periods in wet or damp
conditions, such as standing in water or wearing wet footwear, increases the risk of
developing trench foot.
Cold temperatures: exposure to cold temperatures exacerbates the constriction of
blood vessels and contributes to tissue damage.
Poor circulation: individuals with poor circulation or pre-existing vascular
conditions may be more susceptible to trench foot.
Inadequate footwear: ill-fitting or improperly insulated footwear can exacerbate
the risk of trench foot, as they may not provide adequate protection against moisture
and cold.

60. CLINICAL MANIFESTATIONS
• Numbness and tingling: Initially, the affected feet may feel numb and tingly.
• Swelling: Swelling of the feet and toes may occur, accompanied by a pale or
bluish discoloration.
• Pain and discomfort: As the condition progresses, the feet may become painful,
with a sensation of pins and needles.
• Skin changes: The skin may appear wrinkled, white, or mottled, resembling the
appearance of a "prune."
• Blisters and ulcers: In severe cases, blisters, open sores, or even gangrene may
develop due to tissue damage.

61. TREATMENT
•Antihistamine and anticholinergic
•Benadryl, banthine or pro-banthine
•Aluminium chloride
•Formalin
•Use talc or baby powder daily to wick away moisture
•Rotate your shoes every other day to allow them to dry thoroughly
•Avoid synthetic materials like rubber or vinyl. Wear leather or cloth that can absorb moisture.
•Frequent changes of socks to wick away moisture.
• Avoid synthetic materials like rubber or vinyl. Wear leather or cloth that can absorb moisture.
•Frequent changes of socks to wick away moisture.

62. COMPLICATIONS:
Without prompt intervention, trench foot can lead to
Tissue damage,
Infection,
And in severe cases, gangrene.
Complications can result in long-term disability or the need for surgical
intervention.

63. PREVENTION
• Keep feet dry: change wet socks and footwear promptly, and keep the feet clean
and dry.
• Wear proper footwear: choose waterproof and insulated footwear appropriate for
the conditions.
• Take regular breaks: if possible, alternate periods of rest with opportunities to
dry feet and change socks.
• Foot care: keep toenails trimmed, and avoid tight-fitting footwear that may
restrict blood flow.
• Stay hydrated and nourished: proper hydration and nutrition support overall
foot health and resilience against cold-related injuries.

64. HYPOTHERMIA
DEFINITION
Hypothermia occurs when the body loses heat faster than it
can produce heat, causing the core body temperature to drop
below the normal range (typically below 95°F or 35°C). It is a
potentially life-threatening condition that requires immediate
medical attention.

65. CAUSES
Hypothermia can occur when the body is exposed to cold temperatures for
an extended period, especially in wet or windy conditions. Certain factors can
increase the risk of hypothermia, including
 Inadequate clothing
 Prolonged exposure to cold water
 Exhaustion
 Malnutrition
 Dehydration
 and certain medical conditions that impair the body's ability to regulate
temperature.

66. STAGES OF HYPOTHERMIA
Mild hypothermia:
In the early stages, the body's core temperature drops slightly below normal
(around 90-95°F or 32-35°C). Symptoms may include shivering, cold and pale skin,
numbness or tingling in extremities, and mild confusion.
Moderate hypothermia:
As hypothermia progresses, the core body temperature drops further (below
90°f or 32°c). Shivering may become more intense or cease altogether. Symptoms
may include slurred speech, clumsiness, confusion, slowed breathing and heart rate,
and difficulty coordinating movements.

67. Severe hypothermia:
In severe cases, the core body temperature drops dangerously low (below
82.4°F or 28°C). Shivering stops, and the individual may lose consciousness. Vital
signs such as breathing and heart rate may become extremely slow or undetectable.
Severe hypothermia can lead to coma and death if not treated promptly.

68. RISK FACTORS
• Cold weather exposure: exposure to cold temperatures, especially in wet or
windy conditions, increases the risk of hypothermia.
• Inadequate clothing: insufficient clothing or improper layering can leave
individuals vulnerable to heat loss.
• Wet clothing: wet clothing or exposure to cold water accelerates heat loss from
the body.
• Medical conditions: certain medical conditions, such as diabetes, thyroid
disorders, and neurological conditions, can impair the body's ability to regulate
temperature and increase the risk of hypothermia.

69. • Shivering: shivering is the body's natural response to generate heat and maintain
core temperature.
• Cold and pale skin: the skin may appear cold, pale, and feel cool to the touch.
• Slurred speech: as hypothermia progresses, speech may become slurred or
difficult to understand.
• Fatigue and weakness: hypothermia can cause fatigue, weakness, and lethargy.
• Confusion and impaired judgment: confusion, disorientation, and impaired
decision-making are common symptoms of moderate to severe hypothermia.
• Loss of coordination: coordination and motor skills may be impaired, making it
difficult to perform tasks.
• Unconsciousness: in severe cases, hypothermia can lead to loss of consciousness
and coma.

70. TREATMENT:
• Move to warmth: move the individual to a warm, dry location as soon as
possible.
• Remove wet clothing: remove wet clothing and replace it with dry clothing or
blankets.
• Rewarm gradually: gradually rewarm the person by wrapping them in blankets,
applying warm compresses to the trunk, and providing warm fluids to drink. Avoid
using direct heat sources such as hot water bottles or heating pads, as they can
cause burns.
• Monitor vital signs: monitor the individual's vital signs, including breathing and
heart rate. If necessary, seek medical attention immediately.

71. COMPLICATIONS
Untreated hypothermia can lead to severe complications, including
Frostbite
Cardiac arrhythmias
Organ failure
 And death
 Prompt recognition and treatment are essential to prevent complications and
ensure a positive outcome.

72. PREVENTION:
• Dress appropriately: wear layers of clothing to trap heat and protect against cold
temperatures. Choose clothing made of moisture-wicking materials and avoid
cotton, which retains moisture.
• Stay dry: keep clothing and skin dry to prevent heat loss through evaporation.
• Stay hydrated and nourished: drink plenty of fluids and eat regular meals to
maintain energy levels and support the body's ability to generate heat.
• Avoid alcohol and caffeine: alcohol and caffeine can impair judgment and
increase the risk of hypothermia by dilating blood vessels and increasing heat loss.
• Seek shelter: seek shelter from cold and windy conditions, especially during
extreme weather events.

73. Hypothermia related to exposure to cold environment as evidenced by
temperature of 29 degrees celsius, shivering, confusion, shallow breathing, and
slow, weak pulse
Ineffective tissue perfusion (peripheral) related to decreased peripheral blood flow
to frostbite injuries secondary to severe hypothermia.
Risk for infection related to hypothermia secondary to sepsis.
Risk for impaired body image secondary to amputation of frostbite injury
Risk for impaired elimination

74. WOUND ASSESSMENT

75. INTRODUCTION
A wound is a disruption to the integrity of the skin that leaves the body
vulnerable to pain and infection. The skin is the body’s largest organ and is
responsible for protection, sensation, thermoregulation, metabolism, excretion and
cosmetic. Poorly managed wounds are one of the leading causes of increased
morbidity and extended hospital stays.

76. PHYSIOLOGY OF WOUND HEALING
• Wound healing occurs in four stages, homeostasis, inflammation, proliferation and
remodeling, and the appearance of the wound will change as the wound heals. The
goal of wound management is to understand the different stages of wound healing
and treat the wound accordingly.
• Homeostasis(occurs within the first few seconds): blood vessels constrict to stop
bleeding and form blood clots
• The goal of wound management: to stop bleeding

77. • Inflammation(0-4 days): neutrophils and macrophages work to remove debris and
prevent infection. Signs and symptoms include redness and swelling.
• The goal of wound management: to clean debris and prevent infection
• Proliferation(2-24 days): the wound is rebuilt with connective tissue to promote
granulation and repair the wound
• The goal of wound management: to promote tissue growth and protect the
wound
• Remodeling(24 days- 1 year): epithelial tissue forms in a moist healing
environment

78. DEFINITION
A loss of continuity of the skin or mucous membrane, which may
Involve soft tissues, muscles, bone and other anatomical structures.
_ COLLIER, 1994.

79. TYPES OF WOUND CLASSIFICATION
Wounds can be classified as follows,
According to the etiology
according to rank-wakefield classification system
according to the duration of the wound healing
according to the integrity of the skin
according to wound depth
according to morphological characteristics
According to degree of contamination
according to severity according to the etiology

80. ACCORDING TO THE ETIOLOGY
SURGICAL WOUND
PENETRATING
BLUNT
BURN WOUNDS

81. According to rank-wakefield classification system
Tidy wounds
Untidy wounds
According to the duration of the wound healing
Acute wounds
Chronic wounds (> 4 weeks to 3 months )
According to the integrity of the skin
Open wounds
Closed wounds

82. According to wound depth
Superficial wounds
Partial thickness wounds
Full thickness wounds
According to morphological characteristics
Bruises / contusion
Hematoma
Crush wounds
Abrasion
Lacerated
Penetrated
Perforated wounds

83. Degree of contamination
Clean wounds
Clean contaminated
Contaminated
Dirty/ infected wounds

84. OTHER TYPES
Surgical wounds
Traumatic wounds
Diabetic/ neuropathic ulcer
Arterial ulcer
Venous ulcer
Pressure ulcer

85. WOUND ASSESSMENT
Time
TIME is a valuable acronym or clinical decision tool to provide systematic
assessment and documentation of wounds. It stands for tissue, infection or
inflammation, moisture balance and edges of the wound or epithelial advancement.
Tissue
Viable_epithelial, granulating
Non-viable_ slough, necrotic

87. • Granulation tissue
Small blood
vessels &
connective tissue,
mainly comprised
of
collagen
Red, granular,
rounded, healthy
• Slough
Yellow devitalised tissue,
can be soft or fibrous,
adherent or loose

88. • Epithelial tissue
The growth of epithelial cells
over the surface of the
wound to provide wound
closure

89. TISSUE
• Epithelial tissue: Appears pink or pearly white and wrinkles when touched. Occurs in the
final stage of healing when the wound is covered by healthy epithelium.
• Granulating tissue: Appears red and moist. Occurs when healthy tissue is formed in the
remodeling phase that is well vascularized and bleeds easily.
• Slough tissue: Appears yellow, brown or grey. Slough is devitalized tissue made of dead
cells or debris.
• Necrotic tissue: Appears hard, dry and black. Necrotic tissue is dead tissue that prevents
wound healing.
• Hyper granulating tissue: Appears red, uneven or granular. Occurs in the proliferative
phase when tissue is over grown.

91. INFECTION/INFLAMMATION
Inflammation is an essential part of wound healing; however, infection causes tissue
damage and impedes wound healing.
• Contamination: The presence of microorganisms that are contained and do not
multiply. It does not provoke a host response so healing is not impaired.
Antimicrobials are not indicated.
• Colonisation: Microorganisms multiply but do not provoke a host response. The
infection is contained but wound healing may be delayed. Antimicrobials are not
indicated.
• Local infection: Invasion by an agent that, under favorable conditions, multiplies
and produces effects that are injurious to the patient. When microorganisms and
bacteria move into the wound tissue and invokes a host response. Healing is
impaired and can lead to wound breakdown. Topical antimicrobials are indicated.

92. • Spreading and systemic infection: Microorganisms spread from the wound
through the vascular and or lymphatic systems and involves either a part of the
body (spreading) or the whole body (systemic). Healing is impaired. A systemic
approach is needed e.g. Topical antimicrobials and the use of antibiotics to prevent
sepsis.
• Biofilms: Represent a survival mechanism of microorganisms and are therefore
ubiquitous in nature. They are complex, slime-encased communities of microbes
which are often seen as slime layers on objects in water or at water-air interfaces.
The degree of bioburden in the wound from the microorganisms is indicated by a
poor response to antimicrobial or antibiotic treatment, delayed wound healing or
increase in exudate or inflammation.

94. ODOUR
• ODOUR can be a sign of infection. It can be described as:
• No odour
• Slight malodour: Odour when the dressing is removed
• Moderate malodour: Odour upon entering the room when the dressing is
removed
• Strong malodour: Odour upon entering the room when dressing is intact
• If any of the above clinical indicators are present (including fever, pain, discharge
or cellulitis) a medical review should be initiated and consider a microscopy &
culture wound swab (MCS).

96. MOISTURE/EXUDATE
Moisture/ exudate is an essential part of the healing process. It is produced by all
wounds to:
• Maintain a moist environment
• Cleanse the wound
• Provide nutrients and white blood cells
• Promote epithelialization
• The overall goal of exudate is to effectively donate moisture and contain it within
the wound bed. Excess exudate leads to maceration and degradation of skin, while
too little moisture can result in the wound bed drying out.

97. EXUDATE DESCRIPTION:
• Serous: appears clear to yellow. Normal, typical in the inflammatory phase.
Serous drainage is clear, thin, and watery.
• Haemoserous: appears clear to yellow with a pink tinge. Typical in the
inflammatory or proliferative phase.
• Sanguineous: common exudate blood. Can be associated with hyper
granulation.
• Purulent: containing pus milky, typically thicker in consistency, grey, green
or yellow. This indicates infection.
• Haemopurulent: blood and pus. Often due to an established infection.

99. Cont….
Advancing of edges can be assessed by measuring the depth (cavity/sinus),
length and width of the wound using a paper tape measure.
• Advancing: Edges are pink. Healing is taking place.
• Not advancing: Edges are raised, rolled, red or dusky. Go back to stages of wound
healing and goals of wound management and consider factors affecting wound
healing (see below). Is there something that is not being addressed?

100. SURROUNDING SKIN
Assess the surrounding skin (peri wound) for the following:
• Cellulitis: redness, swelling, pain or infection
• Oedema: swelling
• Macerated: soft, broken skin caused by increased moisture

101. Pain is an essential indicator of poor wound healing and should
not be underestimated. Pain can occur from the disease process, surgery,
trauma, infection or as a result of dressing changes and poor wound
management practices.
Assessing pain before, during, and after the dressing change may
provide vital information for further wound management and dressing
selection.
Accurate assessment of pain is essential when selecting dressings
to prevent unnecessary pain, fear and anxiety associated with dressing
changes.

102. FACTORS AFFECTING WOUND HEALING
• Factors affecting wound healing can be extrinsic or intrinsic. It is essential for optimal
healing to address these factors.
EXTRINSIC/ LOCAL FACTORS
• Wound management practices and moisture balance (e.G. Wound dehydration or
maceration)
• Stable temperature (approximately 37oc)
• Neutral or acidic ph
• Infection
• Wound location
• Mechanical stress, pressure or friction
• Presence of foreign bodies

103. INTRINSIC/ SYSTEMIC FACTORS
• Nutrition
• Underlying or chronic disease
• Decreased mobility
• Impaired perfusion
• Medications (including immunotherapy, chemotherapy, radiation or NSAIDS)
• Mental health (including stress, anxiety or depression)
• Patient knowledge, understanding or compliance
• Age of patient

104. PROCEDURE
 Inform and consent patient
 Perform hand hygiene
 Clean surfaces to ensure you have a clean safe work surface
 Open and prepare equipment, peel open sterile equipment and drop onto aseptic field if used
(dressing pack, appropriate cleansing solution, appropriate dressings, stainless steel scissors,
tweezers or suture cutters if required)
 Perform hand hygiene, use gloves where appropriate
 Remove dressings, discard, and perform hand hygiene
 Clean and assess the wound (wound and peri wound should be cleaned separately if washing the
patient)

105. Perform procedure ensuring all key parts and sites are protected
Perform hand hygiene and change gloves if required
Apply new dressings
Apply fixation if required
Perform hand hygiene
Dispose of single-use equipment into waste bag and clean work surface

106. THE NINE C’S OF WOUND ASSESSMENT
• Cause(s) of the wound
• Clear picture of what the wound looks like
• Comprehensive picture of the patient
• Contributing factors
• Components of the wound care plan
• Communication to other healthcare providers
• Continuity of care
• Centralized location for wound care information
• Complications from the wound