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EMERGENCY NURSING

Care given to patients with urgent and critical needs


Also for non-urgent cases or whatever the patient or
family considers an emergency
Serious life-threatening cardiac conditions (Myocardial
infarction, Acute heart failure, Pulmonary edema Cardiac
dysrhythmias)

The Emergency Nurse


Applies the ADPIE on the human responses of
individuals in all age groups whose care is made
difficult by the limited access to past medical history
and the episodic nature of their health care
Triage and prioritization.
Emergency operations preparedness.
Stabilization and resuscitation.
Crisis intervention for unique patient populations,
such as sexual assault survivors.
Provision of care in uncontrolled and unpredictable
environments.
Consistency as much as possible across the
continuum of care
The Nursing Process
Provides logical framework for problem solving in
this environment
Nursing assessment must be continuous, and nursing
diagnoses change with the patients condition
Although a patient may have several diagnoses at a
given time, the focus is on the most life-threatening
ones
Both independent and interdependent nursing
interventions are required
Emergency Nursing in Disasters
The emergency nurse must expand his or her
knowledge base to encompass recognizing & treating
patients exposed to biologic and other terror weapons
The emergency nurse must anticipate nursing care in
the event of a mass casualty incident.
Documentation of Consent
Consent to examine and treat the patient is part of the
ER record.
The patient must consent to invasive procedures
unless he or she is unconscious or in critical
condition and unable to make decisions.
If the patient is unconscious and brought to the ER
without family or friends, this fact should be
documented
After treatment, a notation is made on the record
about the patients condition on discharge or transfer
and about instructions given to the patient and family
for follow-up care.
Exposure to Health Risks
All emergency health care providers should adhere
strictly to standard precautions for minimizing
exposure.
Early identification and adherence to transmissionbased precautions for patients who are potentially
infectious is crucial.
ER nurses are usually fitted with a personal highefficiency particulate air (HEPA)-filter mask
apparatus to use when treating patients with airborne
diseases.
Providing Holistic Care

P. Chan 2017

Sudden illness or trauma is a stress to physiologic


and psychosocial homeostasis that requires
physiologic & psychological healing.
When confronted with trauma, severe disfigurement,
severe illness, or sudden death, the family
experiences several stages of crisis beginning with
anxiety, and progress through denial, remorse &
guilt, anger, grief & reconciliation.
The initial goal for the patient and family is anxiety
reduction, a prerequisite to recovering the ability to
cope.
Assessment of the patient and familys psychological
function includes evaluating emotional expression,
degree of anxiety, and cognitive functioning.

Nursing Diagnoses
Possible nursing diagnoses include: Anxiety related to
uncertain potential outcomes of the illness or trauma and
ineffective individual coping related to acute situational
crises
Possible diagnoses for the family include: Anticipatory
grieving and alterations in family processes related to
acute situational crises
Patient-Focused Interventions
Those caring for the patient should act confidently
and competently to relieve anxiety.
Reacting and responding to the patient in a warm
manner promotes a sense of security.
Explanations should be given on a level that the
patient can understand, because an informed patient
is better able to cope positively with stress.
Human contact & reassuring words reduce the panic
of the severely injured person and aid in dispelling
the fear of the unknown.
The unconscious patient should be treated as if
conscious (i.e. touching, calling by name, explaining
procedures)
As the patient regains consciousness, the nurse
should orient the patient by stating his or her name,
the date, and the location.
Family-Focused Interventions
The family is kept informed about where the patient
is, how he or she is doing, and the care that is being
given.
Allowing the family to stay with the patient, when
possible, also helps allay their anxieties.
Additional interventions are based on the assessment
of the stage of crisis that the family is experiencing.
Helping Them Cope With Sudden Death
Take the family to a private place.
Talk to the family together, so they can mourn
together.
Reassure the family that everything possible was
done; inform them of the treatment rendered.
Show the family that you care by touching, offering
coffee, and offering the services of the chaplain.
Helping Them Cope With Sudden Death
Encourage family members to support each other &
to express emotions freely.
Avoid giving sedation to family members; this may
mask or delay the grieving process, which is
necessary to achieve emotional equilibrium and to
prevent prolonged depression.
Encourage the family to view the body if they wish;
this action helps integrate the loss.
Spend time with the family, listening to them and
identifying any needs that they may have.

Allow family members to talk about the deceased and


what he or she meant to them; this permits ventilation
of feelings of loss.
Avoid volunteering unnecessary information.

Discharge Planning
Instructions for continuing care are given to the
patient and the family or significant others.
All instructions should be given not only verbally but
also in writing, so that the patient can refer to them
later.
Instructions should include information about
prescribed medications, treatments, diet, activity, and
contact info as well as follow-up appointments.

The Primary Survey: Focuses on stabilizing life-threatening


conditions; employs the ABCD Method
The ABCD Method
Airway - Establish the airway
Breathing - Provide adequate ventilation
Circulation - Evaluate & restore cardiac output by
controlling hemorrhage, preventing & treating shock,
and maintaining or restoring effective circulation
Disability - Determine neurologic disability by
assessing neuro function using the Glasgow Coma
Scale

Principles of Emergency Room Care


Triage: comes from the French word trier, which means "to
sort; A method to quickly evaluate and categorize the patients
requiring the most emergent medical attention.
ER Triage
Emergent (immediate): patients have the highest
priority; must be seen immediately
Urgent (delayed or minor): patients have serious
health problems, but not immediately life-threatening
ones; seen w/in 1 hour
Non-urgent (minor or support): patients have
episodic illnesses addressed within 24 hours.
Determination of Priority in ER Triage: Classified based
on principle to benefit the largest number of people
Determination of Priority in Field Triage
Critical clients are given lowest priority
Victims who require minimal care and can be of help to
others are treated first.
1. Red Emergent (immediate)
2. Yellow Immediate (delayed)
3. Green Urgent (minor)
4. Blue Fast track or psychological support needed
5. Black Patient is dead or progressing rapidly
towards death

Triage Tags should be used on all calls involving 3 or


more patients.
The general placement location should be on one of the
patients arms.
When a triage tag has been utilized, remember to
document the tag number in the history portion of your
run report.

E Cart
Located in designated areas where medical emergencies
and resuscitation is needed
Purpose: to maximize the efficiency in locating
medications/supplies needed for emergency situations.
Drawer 5: Contains respiratory supplies such as
oxygen tubing, a flow meter, a face shield, and a bagvalve-mask device for delivering artificial respirations
Drawer 4: Contains suction supplies & gloves
Drawer 3: Contains intravenous fluids
Drawer 2: Contains equipment for establishing IV
access, tubes for laboratory tests, and syringes to flush
medication lines.
Drawer 1: Contains medications needed during a code
such as epinephrine, atropine, lidocaine, CaCl2 and
NaHCO3
The back of the cart usually houses the cardiac board.
Assessment and Intervention in the ER
P. Chan 2017

Eye opening
response

Spontaneous
To voice
To pain
None

4
3
2
1

Verbal response

Oriented
Confused
Inappropriate words
Incomprehensible sounds
None

5
4
3
2
1

Motor response

Obeys command
Localizes pain
Withdraws
Flexion
Extension
None

6
5
4
3
2
1

Assess and Intervene: The Secondary Survey includes:


A complete health history & head-to-toe assessment
Diagnostic & laboratory testing
Application of monitoring devices
Splinting of suspected fractures
Cleaning & dressing of wounds
Performance of other necessary interventions based on the
patients condition.
Airway Obstruction

An acute upper airway obstruction is a blockage of the


upper airway, which can be in the trachea, laryngeal
(voice box), or bronchi areas
Causes: Viral and bacterial infections, fire or inhalation
burns, chemical burns and reactions, allergic reactions,
foreign bodies, and trauma.
o In adults, aspiration of a bolus of meat is the
most common cause.
o In children, small toys, buttons, coins, and other
objects are commonly aspired in addition to
food.
Clinical Manifestations
1. Choking
2. Apprehensive appearance
3. Inspiratory & expiratory stridor
4. Labored breathing
5. Flaring of nostrils
6. Use of accessory muscles (suprasternal & intercostal
retractions)
7. anxiety, restlessness, confusion
8. Cyanosis & loss of consciousness develops as hypoxia
worsens.
Assessment and Diagnostics
Involves simply asking whether the patient is choking &
requires help
If unconscious, inspection of the oropharynx may reveal
the object.
X-rays, laryngoscopy, or bronchoscopy may also be
performed.

For elderly patients, sedatives & hypnotic medications,


diseases affecting motor coordination, & mental
dysfunction are risk factors for asphyxiation of food.
Victims cannot speak, breath or cough.
If victim can breathe spontaneously, partial obstruction
should be suspected; the victim is encouraged to cough it
out.
If the patient has a weak cough, stridor, DOB & cyanosis,
do the Heimlich.
After the obstruction is removed, rescue breathing is
initiated; if the patient has no pulse, start cardiac
compressions.

Head-Tilt-Chin-Lift Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on the victims
forehead, and apply firm backward pressure with the
palm to tilt the head back.
3. Place the fingers of the other hand under the bony
part of the lower jaw near the chin and lift up.
4. Bring the chin and teeth forward to support the jaw.
Jaw-Thrust Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on each side of
the victims jaw, followed by grasping and lifting the
angles, thus displacing the mandible forward.
Oropharyngeal Airway Insertion
A semicircular tube or tube-like plastic device inserted over
the back of the tongue into the lower pharynx
Used in a patient who is breathing spontaneously but
unconscious.

1.
2.
3.
4.
5.

Cool, moist skin


Hypotension
Tachycardia
Delayed capillary refill
Oliguria

Management
Fluid Replacement
Two large-bore intravenous cannulae are inserted to
provide a means for fluid and blood replacement, and
blood samples are obtained for analysis, typing, & crossmatching.
Replacement fluids may include isotonic solutions (LRS,
NSS), colloid, and blood component therapy.
Packed RBCs are infused when there is massive
hemorrhage
In emergencies, O(-) blood is used for women of childbearing age.
O(+) blood is used for men and postmenopausal women.
Additional platelets and clotting factors are give when
large amounts of blood is needed.
Control of External Hemorrhage
Physical assessment is done to identify area of the
hemorrhage.
Direct, firm pressure is applied over the bleeding area or
the involved artery.
A firm pressure dressing is applied, and the injured part is
elevated to stop venous & capillary bleeding if possible.
If the injured area is an extremity, it is immobilized to
control blood loss.

ET Intubation: Indications
1. To establish an airway for patients who cannot be
adequately intubated with an oropharyngeal airway.
2. To bypass an upper airway obstruction
3. To prevent aspiration
4. To permit connection of the patient to a resuscitation
bag or mech. ventilator
5. To facilitate removal of tracheobronchial secretions

Control of Bleeding: Tourniquets


Applied only as a last resort just proximal to the wound
and tied tightly enough to control arterial blood flow; tag
the client with a T stating the location and the time
applied
Loosened periodically to prevent irreparable vascular on
neuro damage
If still with arterial bleeding, remove tourniquet and apply
pressure dressing
If traumatically amputated, the tourniquet remains in
place until the OR.

Cricothyroidotomy
Used in the following emergencies in w/c ET intubation is
contraindicated:
1. Extensive maxillofacial trauma
2. Cervical spine injuries
3. Laryngospasm
4. Laryngeal edema
5. Hemorrhage into neck tissue
6. Laryngeal obstruction

Control of Internal Bleeding


Watch out for tachycardia, hypotension, thirst,
apprehension, cool and moist skin, or delayed capillary
refill.
Packed RBC are administered at a rapid rate, and the
patient is prepped for OR.
Arterial blood is obtained to evaluate pulmonary
perfusion & to establish baseline hemodynamic
parameters
Patient is maintained in a supine position and closely
monitored.

Nursing Diagnoses For Airway Obstruction


1. Ineffective airway clearance due to obstruction of the
tongue, object, or fluids (blood, saliva)
2. Ineffective breathing pattern due to obstruction or injury
Hemorrhage

Bleeding that may be external, internal or both


External: Laceration, avulsion, GSW, stab wound
Internal: Bleeding in body cavities and internal organs

Assessment
Results in reduction of circulating blood vol., w/c is
the principal cause of shock
Signs and symptoms of shock:
P. Chan 2017

Hypovolemic Shock

A condition where there is loss of effective circulating


blood volume due to rapid fluid loss that can result to
multi-organ failure
Causes
1. Massive external or internal bleeding
2. Traumatic, vascular, GI and pregnancy related
3. Burns

Nursing Diagnoses for Hypovolemic Shock


1. Altered tissue perfusion related to failing circulation
2. Impaired gas exchange related to a V-P imbalance
3. Decreased cardiac output related to decreased
circulating blood volume

Clinical Manifestations
1. Weakness, lightheadedness, and confusion
2. Tachycardia
3. Tachypnea
4. Decrease in pulse pressure
5. Cool clammy skin
6. Delayed capillary refill
Hypovolemic Shock: Management
1. Rapid blood and fluid replacement; blood component
therapy optimizes cardiac preload, correct hypotension, &
maintain tissue perfusion
2. Large-bore intravenous needles or catheters are inserted
into peripheral vv.
3. A central venous pressure catheter may also be inserted in
or near the RA.
4. LRS approximates plasma electrolyte composition and
osmolarity
5. A Foley catheter is inserted to record urinary output every
hour; urine volume indicates adequacy of kidney
perfusion
6. Ongoing nursing surveillance of the total patient is
maintained to assess the patients response to treatment; a
flow sheet is used to document parameters
7. Lactic acidosis is a common side effect & causes poor
cardiac performance
Wounds

A type of physical trauma wherein the skin is torn, cut or


punctured (open wound), or where blunt force trauma
causes a contusion (closed wound).
Specifically refers to a sharp injury which damages the
dermis of the skin.
Types of Wounds
1. Open (Incised wound, Laceration, Abrasion,
Puncture wound, Gunshot wound)
2. Closed (Contusion, Hematoma, Crushing injury)

Incised Wound
A clean cut by a sharp edged object such as glass or
metal.
As the blood vessels at the wound edges are cut straight
across, there may be profuse bleeding
Laceration
Ripping forces or rough brushing against a surface which
can cause rough tears in the skin or lacerations.
Laceration wounds are usually bigger and can cause more
tissue damage due to the size of the wound.
Abrasion
Superficial wounds that occur at the surface of the skin.
Friction burns and slides can cause abrasion
Characteristic in the way that only the top most layer of
the skin is scrapped off.
Bleeding is not profuse though wounds
Puncture Wound
Small entry site
Though not large in surface area, wounds are deep and
can cause great internal damage.
Gunshot Wound (GSW)
Caused by firing bullets or any other small arms.
Have a clean entry site but a large and ragged exit site.
Contusion a.k.a. bruise: Caused by blunt force trauma that
damages tissue under the skin
Hematoma: Also called a blood tumor
P. Chan 2017

Caused by damage to a blood vessel that in turn causes


blood to collect under the skin
Caused by a great or extreme amount of force applied
over a long period of time
Patterned Wound: Wound representing the outline of the
object (e.g. steering wheel) causing the wound
Management: Wound Cleansing
1. Hair around wound may be shaved.
2 . NSS is used to irrigate the wound.
3 . Betadine & hydrogen peroxide are only used for initial
cleaning & arent allowed to get deep into the wound
without thorough rinsing.
4 . Use local or regional block anesthetics if indicated.
Wound Management
1. Use of antibiotics depends on how the injury occurred, the
age of the wound, & the risk for contamination
2. Site is immobilized & elevated to limit accumulation of
fluid
3. Tetanus prophylaxis is administered based on the
condition of the wound and the immunization status
Wound Healing: By First Intention
Occurs when tissue is cleanly incised and reapproximated and healing occurs without complications.
The incisional defect re-epithelizes rapidly and matrix
deposition seals the defect.
Wound Healing: By Second Intention
Healing occurs in open wounds.
When the wound edges are not approximated and it heals
with formation of granulation tissue, contraction and
eventual spontaneous migration of epithelial cells.
Wound Healing: By Third Intention
Occurs when a wound is allowed to heal open for a few
days and then closed as if primarily.
Such wounds are left open initially because of gross
contamination.
Trauma

The unintentional or intentional wound or injury inflicted


on the body from a mechanism against w/c the body
cannot protect itself
Leading cause of death in children and in adults younger
than 44 y/o
Alcohol & drug abuse are implicated in both blunt &
penetrating trauma
Collection of Forensic Evidence: Included in
documentation are the ff:
1. Descriptions of all wounds
2. Mechanism of injury
3. Time of events
4. Collection of evidence
5. Statements made by the patient
If suicide or homicide is suspected in a deceased patient,
the medical examiner will examine the body on site or
have it moved to the medico-legal office for autopsy.
All tubes & lines are left in place.
Patients hands are covered with paper bags to protect
evidence.

Injury Prevention Components


1. Education: Provide information and materials to
help prevent violence, and to maintain safety at home
and in vehicles.
2. Legislation: Provide universal safety measures
without infringing on rights (Seatbelt Law).

3.

Automatic Protection: Provide safety without


requiring personal intervention (Airbags, seatbelts).
High incidence of injury to hollow organs,
particularly the small intestines
The liver is the most frequently injured solid organ.
High velocity missiles create extensive tissue
damage.

Intra-abdominal Injuries: Blunt (MVA, falls, blows)


Associated with extra-abdominal injuries to chest, head,
extremity
Incidence of delayed & trauma-related complications is higher
Leads to massive blood loss into the peritoneal cavity
Trauma: Assessment
1. Inspection of abdomen for signs of injury (bruises,
abrasions)
2. Auscultation of bowel sounds
3. Watch out for signs of peritoneal irritation like
distention, involuntary guarding, tenderness, pain,
muscular rigidity, or rebound tenderness together
with absent BS.
Trauma: Diagnostic Findings
1. Urinalysis to detect hematuria
2. Serial hematocrit to detect presence or absence of
bleeding
3. WBC count to detect elevation associated with
trauma
4. Serum amylase to detect pancreatic or GIT injury

PE for Internal Bleeding


Inspect body for bluish discoloration, asymmetry,
abrasion, & contusion
FAST (Focused Assessment for Sonographic
Examination of the Trauma Patient) exam through
CT scan to assess hemodynamically unstable patients
and detect intraperitoneal bleeding
Pain in the left shoulder is common in a patient with
bleeding from a ruptured spleen.
Pain in the right shoulder can result from a laceration
of the liver.
Administration of opioids is avoided during the
observation period.
Trauma: Genitourinary Injury
A rectal or vaginal exam is done to determine any injury
to the pelvis, bladder, and intestinal wall.
To decompress the bladder & monitor urine output, a
Foley catheter is inserted AFTER DRE.
A high-riding prostate gland indicates a potential urethral
injury.
Trauma: Management of Intra-abdominal Injuries
1. A patent airway is maintained.
2. Bleeding is controlled by applying direct pressure to any
external bleeding wounds & by occlusion of any chest
wounds.
3. Circulating blood vol. is maintained with intravenous
fluid replacement including blood component therapy.
4. In blunt trauma, cervical spine immobilization is
maintained until cervical x-rays have been obtained &
injury is ruled out.
5. All wounds are located, counted & documented.
6. If abdominal viscera protrude, the area is covered with
sterile, moist saline dressing to prevent drying.
7. Oral fluids are withheld and stomach contents are
aspirated with an NGT in anticipation of surgery.
Tetanus and broad-spectrum antibiotics are given as
prescribed.

P. Chan 2017

8.

If still with evidence of shock, blood loss, free air under


the diaphragm, evisceration, hematuria or suspected
abdominal injury, transport to OR.

Trauma: Crushing Injuries


Occur when a person is caught between objects, run over
by a moving vehicle, or compressed by machinery
Watch out for hypovolemic shock from extravasation of
blood & plasma into injured tissues after compression has
been released.
Crushing Injuries: Assessment
Watch out for paralysis of a body part, erythema &
blistering of skin, damaged part appearing swollen, tense
& hard.
Renal dysfunction is secondary to prolonged hypotension.
Myoglobinuria is secondary to muscle damage causing
ARF.
In conjunction with ABCs, the patient is observed for
acute renal insufficiency
Major soft tissue injuries are splinted early to control
bleeding and pain.
A serum lactic acid concentration to <2.5 mmol/L
indicates successful resuscitation.
If an extremity is involved, it is elevated to relieve
swelling & pressure.
A fasciotomy is done to restore neurovascular function.
Medications for pain & anxiety are given as prescribed,
and the patient is transported to the OR for debridement &
fracture repair
Trauma: Multiple Injuries
Requires a team approach with one person responsible for
coordinating the treatment
Immediately after injury, the body is hypermetabolic,
hypercoagulable, and severely stressed.
Mortality is related to the severity & the number of
systems involved.
Multiple Injuries: Nursing Responsibilities
1. Assessing & monitoring the patient
2. Ensuring venous access
3. Administering prescribed meds
4. Collecting laboratory specimens
5. Documenting activities and the patients response
6. Gross evidence may be slight or absent; the injury
regarded as the least significant may be the most lethal.
7. Determine the extent of injuries & establish priorities of
treatment (ABCs)
8. Establish airway & ventilation.
9. Control hemorrhage.
10. Prevent & treat hypovolemic shock & monitor intake &
output.
11. Assess for head & neck injuries.
12. Evaluate for other injuries reassess head & neck, chest;
assess abdomen, back & extremities.
13. Splint fractures.
14. Carry out a more thorough and ongoing examination &
assessment.
FRACTURES

When a client is being examined for a fracture, the body


part is handled gently & as little as possible.
Clothing is cut off to visualize the body & assessment is
done for pain over or near a bone, swelling, & circulatory
disturbance, ecchymosis, tenderness & crepitation.

Management of Fractures
ABCD Method & evaluation for abdominal injuries is
performed BEFORE an extremity is treated unless a
pulseless extremity is seen.

If the extremity is pulseless, repositioning of the


extremity to proper alignment is required.

Pulseless Extremities
If the pulseless extremity involves a fractured hip or
femur, a Hare traction may be applied to assist w/
alignment.
If repositioning is ineffective in restoring the pulse, a
rapid total body assessment is completed, followed by a
transfer to the operating room for arteriography and
possible arterial repair.
Management of Fractures
After the 1 survey, the 2 survey is done using a head-totoe approach.
Observe for lacerations, swelling & deformities including
angulation, shortening, rotation, & symmetry.
Palpate all peripheral pulses.
Assess extremity for coolness, blanching, decreased
sensation & motor function.
Splinting of Extremities
Before moving the patient, a splint is applied to
immobilize the joint above & below the fracture
Relieves pain, restores circulation, prevents further tissue
injury

Procedure:
1. One hand is placed distal to the fracture & some
traction is applied while the other hand is placed
beneath the fracture for support.
2. The splint should extend beyond the joints adjacent
to the fracture.
3. Upper extremities must be splinted in a functional
position.
4. If a fracture is open, moist, sterile dressing is applied.
5. Check the vascular status by assessing color,
temperature, pulse, and blanching of the nail bed.
6. If there is neurovascular compromise, the splint is
removed and reapplied.
7. Investigate complaints of pain or pressure.

People at Risk:
those not acclimatized to heat
elderly and very young people
those unable to care for themselves
those w/ chronic & debilitating dse
those taking tranquilizers, diuretics, anticholinergics, and
beta blockers.
exertional heat stroke occurs in healthy individuals during
sports or work activities.
Heat Stroke
An acute medical emergency caused by failure of the
heat-regulating mechanisms.
Usually occurs during extended heat waves, especially
when accompanied by high humidity
Pathophysiology
Hyperthermia results because of inadequate heat loss,
which can also cause death.
Most heat-related deaths occur in the elderly, because
their circulatory systems are unable to compensate for the
stress imposed by heat
Elderly people have ability to perspire as well as a
thirst mechanism to compensate for heat.
Assessment
Causes thermal injury at the cellular level, resulting to
widespread damage to the heart, liver, kidney, and blood
coagulation
P. Chan 2017

Watch out for profound CNS dysfunction (confusion,


delirium, bizarre behavior, coma), body temperature
(>40.6C), hot, dry skin, anhidrosis, tachypnea,
hypotension, and tachycardia.

Management
The primary goal is to reduce the high temperature as
quickly as possible, because mortality is directly related
to the duration of hyperthermia.
Simultaneous treatment focuses on stabilizing
oxygenation using the ABCs of basic life support.
After clothing is removed, core temperature is reduced to
39C ASAP by one or more of the ff methods:
1. Cool sheets & towels or continuous
sponging with cool H2O
2. Ice applied to neck, groin, chest, & axillae
while spraying with tepid water; cooling
blankets
3. Iced saline lavage of stomach or colon if
temperature does not decrease
4. Immersion in cold water bath

During cooling, the patient is massaged to promote


circulation and maintain cutaneous vasodilation.
An electric fan is positioned so that it blows on the patient
to augment heat dissipation by convection and
evaporation.
Clients core temperature is constantly monitored w/ a
thermometer placed in the rectum, bladder, or esophagus
Avoid hypothermia; prevent spontaneous recurrence of
hyperthermia

Nursing Interventions
Monitor vital signs, ECG, CVP and level of
responsiveness
Administer 100% oxygen to meet tissue needs
exaggerated by the hypermetabolic condition.
NSS or LRS is initiated to replace fluid losses and
maintain circulation
Urine output is monitored to detect acute tubular necrosis
from rhabdomyolysis.
Blood specimens are obtained to detect DIC and to
estimate thermal hypoxic injury to the liver, heart, and
muscle tissue
Dialysis is done for renal failure.
Give benzodiazepines or chlorpromazine for seizures; K
for hypokalemia; Na bicarbonate for metabolic acidosis
Nurse Teachings
Advise client to avoid immediate exposure to high
temperature (10am-2pm).
Emphasize importance of adequate fluid intake, wearing
loose clothing, and reducing activity in hot weather.
Monitor weight and fluid losses during workouts; replace
fluids
Use a gradual approach to physical conditioning; allow
acclimatization
FROSTBITE
Trauma from exposure to freezing temperatures that
results to actual freezing of the tissue fluids in the cell and
intracellular spaces
Results in cellular and vascular damage
Body parts most frequently affected are the feet, hands,
nose and ears
Ranges from 1st (erythema) to 4th degree (full-depth tissue
destruction)
Assessment
Frozen extremity may be cold, hard, and insensitive to
touch

Appears white or mottled blue-white


Extent of injury from exposure to cold is not initially
known; assess for concomitant injury
History includes environmental temperature duration of
exposure, humidity, and presence of wet conditions

Management
The goal is to restore normal body temperature; controlled
yet rapid rewarming is instituted
Constrictive clothing and jewelry that could impair
circulation are removed.
Patient should NOT be allowed to ambulate if the lower
extremities are involved.
Place extremity in a 37 to 40C circulating bath for 30to 40-min.
Repeat treatment until circulation is effectively restored.

Early rewarming amount of tissue loss.


Analgesic is given during rewarming since process may
be very painful.
Avoid handling of body part to prevent further injury.
ELEVATE to prevent further swelling.
Sterile gauze or cotton is placed between affected fingers
or toes to prevent maceration.
A foot cradle is used to prevent contact with bedclothes.
Blebs are left intact and not ruptured, especially if they
are hemorrhagic.
Risk for infection is great; strict aseptic technique is used
during dressing changes, and tetanus prophylaxis & antiinflammatory medications are given
Whirlpool bath for affected extremity to aid circulation,
debride necrotic tissue and prevent infection
Escharotomy to prevent further tissue damage, allow
normal circulation and permit joint motion; fasciotomy
After rewarming, hourly active motion of affected digits
is done to promote maximal restoration of function and to
prevent contractures.
Refreezing is avoided
Avoid tobacco, alcohol, and caffeine because of
vasoconstrictive effects which further reduce the already
deficient blood supply to injured tissues.

Hypothermia
A condition in which core temperature is 35C or less as a
result of exposure to cold
Occurs when patient loses ability to maintain body
temperature
Urban hypothermia is associated with a high mortality
rate affected are the elderly, infants, patients with
concurrent illnesses, and the homeless.
Alcohol ingestion susceptibility due to systemic
vasodilation.
Trauma victims are at risk resulting from treatment with
cold fluids, unwarmed oxygen, and exposure during
examination.
Hypothermia takes precedence in treatment over frostbite.
Assessment
Watch out for progressive deterioration, with apathy, poor
judgment, ataxia, dysarthria, drowsiness, pulmonary
edema, acid-base abnormalities, coagulopathy & coma
Shivering may be suppressed below 32.2C due to
ineffective mechanism
Peripheral pulses are weak and become undetectable;
cardiac irregularities, hypoxemia and acidosis may occur.
Management: Monitoring
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VS, CVP, urine output, arterial blood gas levels, blood


chemistry and chest xray are frequently evaluated.
Body temp is monitored with a rectal, esophageal, or
bladder thermometer.
Continuous ECG monitoring is done because coldinduced myocardial irritability can lead to v. fibrillation.

Management: Core Rewarming


Include cardiopulmonary bypass, warm fluid
administration, warm humidified oxygen by ventilator,
and warm peritoneal lavage
Done for severe hypothermia
Monitoring for ventricular fibrillation as the patient
passes through 31 to 32C is essential.
Management: Passive External Rewarming
Includes the use of warm blankets or over-the-bed heaters
Increases blood flow to the acidotic, anaerobic extremities
Cold blood returning to the core can cause cardiac
dysrhythmias & electrolyte imbalances
Supportive Care
External cardiac compression
Defibrillation of v. fibrillation (ineffective if core temp is
<31C)
Mechanical ventilation and heated, humidified oxygen
Warmed IVF to correct hypotension and maintain urine
output and core rewarming
Sodium bicarbonate to correct metabolic acidosis if
necessary
Antiarrhythmic medications
Insertion of Foley catheter to monitor fluid status
Near-Drowning
Survival for at least 24 hours after submersion
Most common consequence is hypoxemia
One of the leading causes of death in children younger
than 14 y/o; children younger than 4 y/o account for 40%
of all drownings
Risk Factors
1. Alcohol ingestion
2. Inability to swim
3. Diving injuries
4. Hypothermia
5. Exhaustion
Rescue
Successful resuscitation with full neurologic recovery has
occurred in drowning victims after prolonged submersion
in cold water.
After surviving submersion, ARDS resulting in hypoxia,
hypercarbia, & respiratory or metabolic acidosis can
occur.

Pathophysiology
Fresh water aspiration results in loss of surfactant, hence
the inability to expand the lungs.
Salt water aspiration leads to pulmonary edema from the
osmotic effects of the salt within the lungs.
Treatment Goals
Maintaining cerebral perfusion and adequate oxygenation
to prevent further damage to vital organs
Immediate CPR is the factor with the greatest influence
on survival

Prevention of hypoxia by ensuring an adequate airway


and respiration, thus improving ventilation and
oxygenation

Management
ABG analyses are performed to evaluate O2, CO2, HCO3
and pH
If the patient is not breathing spontaneously, ET
intubation with positive-pressure ventilation improves
oxygenation, prevents aspiration, and corrects
intrapulmonary shunting and V-P abnormalities
If the patient is breathing spontaneously, supplemental O2
may be given by mask
Because of submersion, the patient is usually
hypothermic; use a rectal probe to assess
Prescribed warming procedures such as corporeal
rewarming, warmed PD, inhalation of warmed
aerosolized O2, and torso warming depends on the
severity & duration of hypothermia.
Intravascular volume expansion & inotropic agents are
used to manage hypotension & impaired tissue perfusion;
ECG monitoring is done to monitor dysrhythmias.
A Foley catheter is used to measure output; NGT
intubation is used to decompress the stomach & prevent
aspiration of gastric contents.
Close monitoring continues with serial VS, serial ABGs,
ECG monitoring, ICP assessments, serum electrolyte
levels, I & O, & serial CXR.
Complications include hypoxic or ischemic cerebral
injury, ARDS, pulmonary damage 2 to aspiration, &
cardiac arrest.
Decompression Sickness (DCS)
Occurs in patients who have engaged in diving, highaltitude flying, or flying in a commercial aircraft 24 hrs
after diving
Results from nitrogen bubbles trapped in joint or muscle
spaces, resulting in musculoskeletal pain, numbness, &
hyperesthesia
Bubbles can become emboli in the bloodstream & cause
stroke, paralysis, or death.
A rapid history & recompression is done ASAP & may
necessitate a low altitude flight to the nearest hyperbaric
chamber.
Assessment
Evidence of rapid ascent, loss of air in the tank, buddy
breathing, recent alcohol intake or lack of sleep, or a
flight within 24 hours after diving are risk factors.
Signs and symptoms:
1. Joint/extremity pain
2. numbness, hypesthesia
3. loss of ROM
4. neuro Sx mimicking CVA
5. CP arrest in severe cases
Management
A patient airway and adequate ventilation are established
& 100% O2 is given throughout treatment & transport
A CXR is obtained to identify aspiration, and at least 1 IV
line is started with LRS or NSS.
If a head injury is suspected, the head of the bed is
lowered.
Wet clothing is removed and the patient is kept warm.
Transfer to the closest hyperbaric chamber is done.
Antibiotics may be prescribed if aspiration is suspected.
Anaphylaxis
An acute systemic hypersensitivity reaction that occurs
w/in seconds or min. after exposure to foreign substances
such as medications & other agents
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Repeated administration of oral & parenteral therapeutic


agents may cause this when initially only a mild allergic
response occurred

Pathophysiology
Antigen-antibody interaction
Antigen allergen
Antibody IgE previously sensitized basophils and mast
cells
Release of mediators like histamine and prostaglandin
cause the systemic reactions
Causes
Penicillins most common
Contrast media
Bee stings
Food
Anaphylaxis Signs and Symptoms
1. Respiratory Signs:
nasal congestion
itching, sneezing, coughing
bronchospasm & laryngeal edema
chest tightness, dyspnea
wheezing & cyanosis
2.

Skin:
flushing with sense of warmth & diffuse erythema;
generalized itching over entire body (systemic
reaction)
urticaria (hives);
massive facial angioedema (with accompanying
upper respiratory edema)

3.

Cardiovascular:
Tachycardia or bradycardia
Peripheral vascular collapse indicated by
pallor, imperceptible pulse, BP, circulatory
failure, coma & death

4.

GIT:
nausea & vomiting
colicky abdominal pains, diarrhea

Anaphylaxis Management
Establish an airway & ventilation while another gives
epinephrine.
Early ET intubation avoids loss of the airway, &
oropharyngeal suction removes secretions.
If glottal edema occurs, a crico-thyroidotomy is used to
provide an airway.
Anaphylaxis: Epinephrine Administration
Subcutaneous injection for mild, generalized symptoms
IM injection for more severe & progressive reactions with
the possibility of vascular collapse
IV route for rare instances where there is LOC & severe
cardiovascular collapse; may cause dysrhythmias
Anaphylaxis: Additional Treatments
Antihistamines are given to block further histamine
release
Aminophylline by slow IV trans-fusion for severe
bronchospasm & wheezing refractory to treatment
Albuterol inhalers or humidified treatment to
bronchoconstriction
Crystalloids, colloids, or vasopressors for prolonged
hypotension
Isoproterenol or dopamine for reduced cardiac output; O2
to enhance tissue perfusion

IV benzodiazepines for seizure control; corticosteroids


for prolonged reaction with persistent hypotension or
bronchospasm

Anaphylaxis Prevention
Be aware of the danger signs of anaphylaxis.
Ask the patient about previous allergies (e.g. allergies to
eggs)
Before giving antigenic agents, ask caregiver whether
agent was received at an earlier time.
Avoid giving medications to patients with allergic
disorders unless necessary.
Perform a skin test before administration of certain
agents; have epinephrine readily available.
If dealing with outpatients, keep them in the clinic for at
least 30 min after injection of any agent.
Caution patients who are highly sensitive to carry medical
kits.
Encourage wearing of medical IDs.
Poisoning: Ingested Poisons
May be corrosive (alkaline and acid agents that cause
tissue destruction)
Alkaline products: Lye, drain and toilet bowl cleaners,
bleach, non-phosphate detergents, button batteries
Acid products: toilet bowl and metal cleaners, battery
acid
Poisoning Management
Control the airway, ventilation and oxygenation.
ECG, VS, and neurologic status are monitored for
changes.
Shock resulting from the cardio-depressant action of the
ingested substance, or from circulating blood volume
due to capillary permeability, is treated.
A Foley catheter is inserted to monitor renal function and
blood examinations are done to test for poison
concentration.
The amount, time since ingestion, signs and symptoms,
age and weight and health history are determined.
Patient who ingested a corrosive poison is given water or
milk to drink for dilution (not attempted if patient has
acute airway obstruction, or if with evidence of gastric or
esophageal burn or perforation.
The following procedures may be done:
Ipecac syrup to induce vomiting in the alert patient
Gastric lavage for the obtunded patient; aspirate is tested
Activated charcoal administration if poison can be
absorbed by it
Cathartic, when appropriate
Ingested Poison Warnings
Vomiting is NEVER induced after ingestion of caustic
substances or petroleum distillates.
The area poison control center should be called if an
unknown toxic agent has been taken or if it is necessary to
identify an antidote for a known toxic agent.
Gastric Lavage Guidelines
1. Remove dentures and inspect for loose teeth.
2. Measure the distance between the bridge of the nose
and the xiphoid process and mark tube with indelible
pencil or tape.
3. Lubricate tube with KY-Jelly.
4. If comatose, patient is intubated with cuffed
nasotracheal or endotracheal tube before placement
of NGT.
5. Place patient in a left lateral position with head
lowered 15.
6. Pass the tube orally while keeping the head in neutral
position. Pass tube to marking (50 cm).

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7.

Aspirate gastric contents with the syringe attached to


the tube before instilling water/antidote & save
specimen.

8.

Remove syringe and attach funnel to the end of the


tube or use a 50mL syringe to instill solution into
tube.
Elevate funnel above patients head and 150-200mL
of solution into it.
Lower funnel and siphon the gastric contents, or
connect to suction.
Save the samples of the first two washings.
Repeat the lavage until the returns are clear and no
particulate matter is seen.
The stomach may be left empty, and an absorbent or
saline cathartic is instilled and allowed to remain
inside.
Pinch out the tube during removal or suction while
withdrawing and keep head lower than the body.
Warn patient that stools will turn black from the
charcoal.

9.
10.
11.
12.
13.
14.
15.

Management
The specific chemical is given as early as possible to
reverse effects.
Procedures include administration of charcoal, diuresis,
dialysis, and hemoperfusion.
If poisoning is due to a suicide attempt, psychiatric
evaluation is requested; if accidental, home poisonproofing directions are given
Inhaled Poisons: CO Poisoning
A result of industrial or household incidents, or attempted
suicide
Implicated in more deaths than any other toxins, except
alcohol.
CO exerts its toxic effects by binding to circulating
hemoglobin, reducing its oxygen-carrying capacity.
Hemoglobin absorbs CO 200x more readily than O2.
Carboxyhemoglobin doesnt have O2
CNS symptoms predominate with CO toxicity. Watch out
for headache, muscle weakness, palpitation, dizziness,
and confusion, which rapidly leads to coma.
Skin color ranges from cherry-red to pale and is not a
reliable sign.
Pulse oximetry will record false (+)s.
CO Poisoning Management
Goal: to reverse cerebral and myocardial hypoxia and
hasten elimination of CO by:
1. Carrying the patient to fresh air immediately and
opening doors and windows
2. Loosening all tight clothing
3. Initiate CPR if required; give O2.
4. Prevent chilling; wrap in blankets.
5. Keep patient as quiet as possible.
6. Do NOT give alcohol in any form.
7. Upon arrival at the ER, analyze carboxyhemoglobin
levels and give 100% O2 until level is <5%.
8. Watch out for psychoses, spastic paralysis, ataxia,
visual disturbances, and deterioration in mental status
and behavior which may be symptoms of brain
damage.
9. If accidental poisoning occurs, the DOH should be
informed so that the dwelling could be inspected.
Food Poisoning
A sudden illness that occurs after ingestion of
contaminated food or drink

Some of the most common diseases are infections caused


by bacteria, such as Campylobacter, Salmonella, Shigella,
E. coli O157:H7, Listeria, and botulism

Campylobacter
A bacterium that causes acute diarrhea
Transmitted through ingestion of contaminated food,
water, or unpasteurized milk, or through contact with
infected infants, pets or wild animals.
Salmonella
Transmitted by drinking unpasteurized milk or by eating
undercooked poultry and poultry products such as eggs
Any food prepared on surfaces contaminated by raw
chicken or turkey can also become tainted
May also stem from food contaminated by a food worker
Shigella
Transmitted through feces. It causes dysentery, an
infection of the intestines causing severe diarrhea. The
disease generally occurs in tropical or temperate climates,
especially under conditions of crowding, where personal
hygiene is poor
E. Coli O157:H7
Associated with eating undercooked, contaminated
ground beef. Drinking unpasteurized milk and swimming
in or drinking sewage-contaminated water can also cause
infection

Determine the source and type of food poisoning.


Food, gastric contents, vomitus, serum and feces are
collected for examination.
Patients VS, sensorium and muscular activity are closely
monitored.
Support the respiratory system and assess fluid and
electrolyte balance; watch out for lethargy, PR, fever,
oliguria, anuria, hypotension, and delirium.
Administer IV antiemetic medications for mild nausea,
give sips of weak tea, carbonated drinks, or tap water.
Clear liquids for 12 to 24 hrs after nausea and vomiting
subside, and then progressed to a low-residue bland diet.

Burns
Alteration in skin and underlying tissues as a result of:
Too much exposure to sun and UV
Direct contact with heat and burning object
Hot water and liquids
Chemicals

Factors considered when assessing the severity of a burn:


depth of the burn and size
the part of the body burned
the age of the client, and the
client's previous and past medical history

Rule of Nines Chart

Listeria
found in many types of uncooked foods, such as meats
and vegetables, as well as in processed foods that become
contaminated after processing, such as soft cheeses (such
as feta and crumbled blue cheese) and cold cuts.
Unpasteurized milk or foods made from unpasteurized
milk may also be sources of listeria infection

Assessment of Damage
Lund & Browder Method: Assigns percentage of BSA for
various
anatomic parts; more precise method of estimating the
extent of burn
Palm Method: The size of the palm (approximately 1% of
BSA)
can be used to assess the extent of burn injury in patients
with scattered burn.

Botulism
Linked to home-canned foods with a low acid content
Foods include asparagus, green beans, beets, and corn.
Other sources include chopped garlic in oil, chili peppers,
tomatoes, improperly handled baked potatoes cooked in
aluminum foil, and home-canned or fermented fish (such
as sardines)

Factors considered when assessing the severity of a burn:


depth of the burn and size
the part of the body burned
the age of the client, and the
client's previous and past medical history

Food Poisoning: MC Foods


Honey should NOT be given to children younger than 12
months of age, as it can contain spores of C. botulinum
and is known to cause infant botulism
Staphylococcus aureus in spaghetti
Bacillus cereus in fried rice
Toxins in mushrooms, shellfish, including the puffer fish

Assessment
1. How soon after eating did the symptoms occur?
2. What was eaten in the previous meal? Did the food
have an unusual odor or taste?
3. Did anyone else become ill from eating the same
food?
4. Did vomiting occur? What was the appearance of the
vomit?
5. Did diarrhea occur?
6. Any other neurologic symptoms?
7. Does the patient have a fever?
8. What is the clients appearance?
Management
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Depth of Burns: Superficial burn


The epidermal layer is damaged and hurt
Wound is quite painful.
Skin is characteristically red and dry.
Redness generally subsides within 24 to 48 hours
Scarring does not occur
Depth of Burns: Deep partial thickness
Burns affect the dermal layer of the skin.
The injured skin is red or mottled, possibly weepy with
vesicles
or blisters and considerable swelling.
When healing is complete, the skin is usually somewhat
discolored
Tightening and contracture may develop.
Depth of Burns: Full thickness burn
the injury extends all the way through the subcutaneous
tissue
sometimes to muscle and bone
no regeneration can occur
skin is leathery and charred.
The surface is dry and edema is present.
Part of the Body Burned

Special attention to the hands, head, neck, chest, ears,


face, perineum and feet
Prevention of contractures in these areas is crucial to good
healing.
Any time there is soot around the nose or mouth, burned
nasal hairs, stridor, hoarseness, decreased breath sounds,
upper airway damage should be suspected.

Burns in the Extremes of Age


In pediatric clients under age 2, the immunologic
response to stress and trauma is not fully developed, and a
burn injury can be overwhelming.
In the elderly, these responses are diminished and the
person's general health may be compromised by existing
medical problems.
Burn Management
Maintenance of Airway Patency
A. Assess the airway.
B. Auscultate the trachea, and monitor for adventitious
breath sounds or decreased breath sounds.
C. If client is dyspneic or if there is carbon monoxide
poisoning, a high liter flow of 8 to 10 liters of oxygen
is recommended.
D. If compromise is suspected, the victim may be
intubated and ventilated.
Indications for intubation are airway
obstruction and a PaO2 of less than 60 mm
Hg.
The continuous monitoring by means of a
pulse oximeter assists in assuring adequate
oxygenation.
E. The client's level of consciousness should be
carefully monitored. Burn victims are most often
alert, oriented and cooperative even with extensive
injuries.
Fluid Resuscitation
The maximum loss of fluid occurs within 12 to 18 hours
after the burn.
The total quantity of fluid required to correct this volume
deficit is replaced in the first 24 hours following the burn
injury.
The amount of fluid required to correct the deficit is
calculated to be 2 to 4 mL per cent burn per kilogram of
body weight.
Administration of the fluids takes place over a 24-hour
period with half the amount given in the first 8 hours and
the remainder over the next 16 hours.

Fluid Loss Management


1.

Consensus Formula: 2-4 mL x body weight (kg.) x %


body surface area burned. Half to be given in first 8
hours, remaining half to be given over next 16 hours.

2.

Evans Formula
Colloids: 0.5 mL x body weight (kg.) x %BSA
burned
Electrolytes: 1.5 mL x body weight (kg) x % BSA
burned
Glucose: 2000 mL for insensible loss
Day 1: Half to be given in the first 8 hours; remaining
half over next 16 hours

3.

Parkland Formula
Lactated Ringers Solution: 4 mL x body weight
(kg) x % BSA burned

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Day 1: Half to be given in first 8 hours; half to be


given over next 16 hours
Day 2: Varies. Colloid is added (e.g. albumin,
dextran)

Burn Management
Obtain laboratory data
Monitor urine output and vital signs
Administer tetanus antitoxin/toxoid
Hypertonic Saline Solution
Goal: to increase serum sodium level and osmolarity to
reduce edema and prevent pulmonary complications
Concentrated solutions of sodium chloride (NaCl) and
lactate are given sufficiently to maintain a desired volume
of urinary output.
Phases of Burn Care: Emergent
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Fluid Resuscitation

Assess for Acute Respiratory Failure


Assess for Acute Renal Failure
Assess for Distributive Shock
Assess for Compartment Syndrome (Assess peripheral
pulse, capillary refill.)
Assess for Paralytic Ileus (Auscultate bowel sounds,
abdominal distention.)
Assess for Curlings Ulcer (Assess gastric pH, occult
blood in stools.)

Burn Care: Acute Phase


Begins 48 to 72 hours post-injury
Assess for edema, jugular vein distention, crackles,
increased arterial pressure
Use asepsis & reverse isolation.
Give high-calorie, high-protein diet
Assess the graft sites. Report signs of poor healing, graft
take or trauma.
Prevent flexed position in burned areas.
Burn Care: Rehabilitation Phase
Wound healing, psychosocial support, and restoring
maximal functional activity remain priorities.
Chemical Burn
Most chemicals that cause burns are either strong acids or
bases
The severity of a chemical burn is determined by the
mechanism of action, the penetrating strength and
concentration, & the amount and duration of exposure of
the skin to the chemical.
Management
The skin should be continuously drenched immediately
with running water from a shower, hose or faucet as the
patients clothing is removed.
The skin of the health care professional assisting should
also be appropriately protected.
Chemical Poison Warnings
Water should NOT be applied on burns from lye or white
phosphorus because of a potential for an explosion or for
deepening of the burn.
All evidence of these chemicals should be brushed off the
patient before any flushing.
Management
Determine the identity and characteristics of the chemical
agent for future treatment.

The standard burn treatment for the size & location of the
wound (antimicrobials, debridement, tetanus toxoid) is
instituted.
The patient may require plastic surgery for further wound
management

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The patient is instructed to have the affected area reexamined at 24 & 72 hours and in 7 days because of the
risk of under-estimating the extent & depth of these types
of injuries.