Tattoos, piercings, and other body modifications (such as scarification, branding, and subdermal or transdermal implants) often bring out strong opinions in people, including healthcare personnel. Some nurses may strongly support or reject a patient or peer's choice of self-expression through tattoos, piercings, or other body modifications. As nurses, we must ensure that we don't impose our personal beliefs or feelings onto our patients because this will cause tension and potentially sever a trusting relationship.
Tattoos and body piercings are a growing trend among all age groups. Recent research has shown that 24% of Americans between ages 18 and 50 are tattooed; that's almost one in four people. According to another study, approximately one in seven people has a piercing in an area other than in the soft lobe of the ear. That total rises to nearly one in three for the 18-to-29 age group.
It's up to us to provide welcoming care for this diverse population. Here are some tips to get you started.
More than skin deep
Providing nursing care for a heavily tattooed or pierced patient can cause concern for nurses. Some of us may be uncomfortable because of our own opinions about body modification, but we must treat the patient as equally as any other. We may also fear that diagnosis or treatment may be impaired by tattoos or body piercings.
Although, on occasion, the treatment plan may have to be adjusted because of the placement of a tattoo or piercing, most of the time diagnosis and treatment can be achieved with minimal inconvenience to the patient.
Before starting an assessment, ask your patients if they have any body modifications. If they do, conduct a thorough head-to-toe skin assessment before starting treatment. Patients may have piercings in both visible and nonvisible areas of the body, such as the mouth and tongue, nose, eyebrow, navel, nipple, and genital area. Tattoos may also be visible or nonvisible.
If a patient with metal body jewelry is undergoing diagnostic testing, such as magnetic resonance imaging (MRI), the jewelry may have to be temporarily removed. Explain to the patient that body jewelry should be removed because metal materials can actually be heated and pulled by the magnetic field during an MRI, resulting in a soft tissue tear to the surrounding pierced tissue or blockage of the visual diagnostic field. After the MRI is complete, the patient can reinsert the body jewelry.
Ask the patient about the metal content of his or her body jewelry; implant-grade titanium may be more MRI compatible because it contains virtually no nickel. If the patient is reluctant to remove his or her body jewelry, you may be able to wrap the area in gauze in an attempt to insulate it. The patient should be offered the option of using a nonmetal retainer to keep the pierced channel open during the procedure as an alternative to removing body jewelry.
Tattoo pigments can also act as an electrical heat conduction agent during an MRI due to a process called magnetic hysteresis, which can result in second-degree burns. Closely monitor the sites of your patient's tattoos before and after an MRI to assess for erythema, pain, irritation, or any other signs of an iatrogenic burn. Because an MRI can cause the patient's intracellular water temperature to rise, his or her skin should be closely monitored for potential burn risk for 48 hours after the procedure.
Pain, burning sensations, and image artifact can occur; if this happens, the MRI should be terminated immediately to minimize the risk of second-degree burns. Take note that darker colors such as black tattoo pigments may have more iron oxide and conduct more heat during an MRI. Some newer tattoo inks are metal free, containing nontoxic ingredients that don't pose a burn risk.
Most professional tattooists and piercers adhere to strict sterile techniques; however, some patients may allow friends or family members to tattoo or pierce them who don't have the proper certification, don't adequately clean their equipment between uses, or reuse single-use sterile needles or ink cups. In nonregulated tattoo shops or home-based studios, impromptu artists may use writing ink or printer ink that can be damaging to the skin, presenting such health risks as allergic dermatitis, cellulitis, infection, and septicemia. All tattoos and body piercings should be performed by a professional who's certified to pierce and/or tattoo (see supplemental content on the Nursing made Incredibly Easy! iPad app).
If a patient presents with symptoms of an infection, ask to inspect any areas of the patient's body that have been recently tattooed or pierced. An elevated white blood cell count or procalcitonin level may indicate a localized or systemic infection. Assess the patient for signs of inflammation or infection that may be caused by allergic reactions to the metal used in inexpensive body jewelry or reactions to tattoo ink, especially red pigments.
Advise patients who have congenital heart disease to avoid getting tattooed or pierced because they're at higher risk for complications such as endocarditis. Patients who are immunocompromised, including those who have had an organ transplant, should elect to minimize any potential risks of infection, which means it's best to avoid tattoos and piercings. Patients who have diabetes may also have a higher risk of complications, such as infection or an impaired healing process. Patients who take blood-thinning medications, such as aspirin or warfarin, may experience exaggerated bleeding at the piercing or tattoo site.
Remember that tattoos can mask early diagnosis of certain conditions such as skin cancer. When providing care for a heavily tattooed patient, perform a careful skin assessment to observe for changes in the structure of a mole or other symptoms that might indicate skin cancer.
Caring for the culturally creative
An increasing number of patients are tattooed and pierced, and as nurses we must be sensitive to their healthcare needs. It's acceptable to compliment your patient on his or her unique body art choice; however, it may be considered rude to inquire why the patient selected a specific tattoo or body piercing. Many patients elect to get a tattoo in memory of a friend, loved one, or a life-changing event. This may be highly personal and cause strong emotions for the patient. Remember not to pass judgment because this will hinder the trusting nurse-patient relationship for which we strive.
Our job as healthcare providers is to ensure that our patients' choices of self-expression don't pose potential health risks. Let's be supportive of our culturally creative patients.
You have a 21-year-old male patient admitted to your unit after a motor vehicle accident for a possible closed head injury. The patient has extensive facial piercings. He's alert and oriented, stating that his body jewelry is made of inexpensive, low-grade metals. A computed tomography scan reveals that he has a small ruptured aneurysm on his middle cerebral artery. As you begin to prepare the patient for emergency surgery, you offer him the options of either replacing the body jewelry with nonmetal retainers to keep the pierced channels open during the surgical procedure or removing the jewelry.
did you know?
The FDA indicates that state and local authorities oversee the practice of tattooing and that ink pigments used for tattoos are subject to FDA regulation as cosmetics and color additives. However, because of other public health priorities and a previous lack of evidence of safety concerns, the FDA hasn't traditionally regulated tattoo ink or the pigments used in it.
According to the FDA, risks associated with tattoo ink are:
- infections—used needles or ink cups can pass infections, such as hepatitis and HIV, from one person to another
- allergies—allergic reactions to various ink pigments in both permanent and temporary tattoos have been reported
- scarring—unwanted scar tissue may form when getting or removing a tattoo
- granulomas—these small knots or bumps may form around material that the body perceives as foreign, such as particles of tattoo pigment
- MRI complications—patients may have swelling or burning in the tattoo when they have an MRI, although this happens rarely.
When providing care for patients with body piercings, observe for:
- erythema, edema, or drainage at the insertion site that may be indicative of infection
- splitting, shearing, or tearing of the skin tissue, which may cause the formation of scar tissue
- allergic reaction to the jewelry (hypoallergenic jewelry, such as implant-grade surgical stainless steel or titanium, gold, platinum, niobium, and glass, is the only type of jewelry that should be used in a new piercing)
- damage to underlying blood vessels or nerves
- scarring of the piercing site
- cracking or chipping of teeth or gums and difficulty chewing or swallowing in patients with piercings in or near the mouth.
Don't remove body jewelry unless it's necessary; if removal is necessary in an emergency situation, learn the correct way to remove the various types of jewelry.
You have a 69-year-old male patient admitted to your unit after a motor vehicle accident. He's awake, alert, and complains of a severe headache that he describes as the “the worst headache of my life.” During your head-to-toe skin assessment, you note that he's heavily tattooed. The patient proudly shows you his Army tattoos that cover 75% of his anterior and posterior chest and upper arms with black pigment. He states that he acquired all of the tattoos during his military service almost 50 years ago. As you prepare the patient for a head and chest MRI, you inform him that although most new tattoo inks contain no metal, the majority of older black tattoos contain various forms of metal oxide, which can cause a burning sensation during an MRI. You tell the patient to notify you immediately if he feels any intense burning. After the procedure, you closely monitor all areas of his skin for 48 hours.
Learn more about it
Pfeifer GM. Attitudes toward piercings and tattoos. Am J Nurs
Schmidt R, Armstrong ML. Body piercing in adolescents and young adults. UptoDate. 2014. http://www.uptodate.com
Westerfield HV, Stafford AB, Speroni KG, Daniel MG. Patients' perceptions of patient care providers with tattoos and/or body piercings. J Nurs Adm