Chapter 16

1. Chapter 16 First Aid, Emergency Care, and Disaster Management

2. Learning Objectives • List the principles of emergency and first aid care. • List the steps of the initial assessment and interventions for the person requiring emergency care. • Describe the components of the nursing assessment of the person requiring emergency care. • Outline the steps of the nursing process for emergency or first aid treatment of victims of cardiopulmonary arrest, choking, shock, hemorrhage, traumatic injury, burns, heat or cold exposure, poisoning, bites, and stings. • Discuss the roles of nurses and nursing students in relation to bioterrorism and natural disasters. • Explain the legal implications of administering first aid in emergency situations.

3. General Principles of Emergency Care Cardinal rule: Remain Calm! Priority is to preserve life and minimize effects of injuries; manner in which you conduct yourself also can soothe and reassure the victim Assessment and intervention must be done quickly and efficiently to identify and treat priority needs immediately

4. General Principles of Emergency Care The primary survey looks for life-threatening injuries and intervenes immediately in the following sequence Assess ABCs: airway, breathing, circulation Initiate CPR or rescue breathing as needed Look for uncontrolled bleeding, identify the source, and apply pressure Assess for injuries from head to foot, and immobilize spine, limbs, or both as indicated Look for a medical alert necklace or bracelet

5. General Principles of Emergency Care Splint injured parts in the position they are found Prevent chilling, but do not add excessive heat Do not remove penetrating objects Do not try to give anything by mouth to an unconscious person or one with serious injuries Stay with the injured person until medical care or transportation arrives

6. Nursing Assessment in Emergencies Chief complaint Determine problem, signs and symptoms, and how the injury or illness occurred If the victim is or has been unconscious, note the length of time unconscious if possible Medical treatment Determine treatment and its effect; note whether the victim has been moved

7. Nursing Assessment in Emergencies Medical history Determine known health problems; may provide clues to immediate problem or influence care provided Check for a medical alert tag; may provide essential information if the patient cannot Identify current medications and allergies Note any evidence of alcohol or other drugs

8. Physical Examination The first priority: ABCs Airway, breathing, and circulation Watch chest for rhythmic breathing; listen near mouth and nose for air movement Palpate the carotid and peripheral pulses Once respiration and circulation established, assess for uncontrolled bleeding and shock If none, assess systematic head-to-toe

9. Systematic Head-to-Toe Assessment

10. Systematic Head-to-Toe Assessment Evaluate comprehension: ask patient to follow simple commands, such as opening and closing the eyes Inspect eyes to assess pupil size, equality, and reaction to light Ask about neck pain or stiffness and the ability to swallow Inspect for chest wall movement symmetry

11. Systematic Head-to-Toe Assessment Assess breathing, dyspnea, and abnormal sounds associated with respirations Examine contour of abdomen for distention Light palpation to detect pain or tenderness Inspect the extremities for deformity or injury, and evaluate movement Assess peripheral pulses and warmth and sensation in the extremities

12. Cardiopulmonary Arrest Absence of a heartbeat and respirations Causes Myocardial infarction, heart failure, electrocution, drowning, drug overdose, anaphylaxis, and asphyxiation Signs and symptoms Collapse and quickly lose consciousness No pulse or respiration

13. Figure 16-3

14. Cardiopulmonary Arrest Interventions Determine responsiveness Open airway Check for breathing (look, listen, feel) If nonresponsive and not breathing, palpate for a pulse If no pulse in 10 seconds, begin compression:ventilation cycles of 30:2 If a pulse, deliver 10-12 rescue breaths per minute In no advanced airway, continue the 30:2 ratio With advanced airway, compressions of 100 per minute without pausing for ventilations which are done at a rate of 8-10 per minute

15. Cardiopulmonary Arrest Two-rescuer CPR One rescuer compresses the chest at a rate of 100 per minute without pausing for ventilations Second rescuer ventilates with 8-10 breaths/minute Swap roles about every 2 minutes to avoid tiring Recovery position Unresponsive victim who is breathing should be log-rolled to one side if no cervical trauma is suspected

16. Choking or Airway Obstruction Assessment Universal sign of choking is grabbing the throat with one or both hands First determine if airway completely blocked If victim is able to speak, breathe, or cough with good air exchange, do nothing If unable to speak, breathe, or cough with good air exchange, act quickly to prevent suffocation

17. Figure 16-4

18. Choking or Airway Obstruction Victim is conscious Perform the Heimlich maneuver If effective, air expels foreign body from the airway If not, repeat maneuver until the object is expelled or victim loses consciousness

19. Figure 16-5A

20. Choking or Airway Obstruction Victim unconscious/loses consciousness Lift the jaw and sweep a finger through the mouth to try to remove the object Tilt the head back, lift the chin, pinch the nostrils, and try to ventilate by breathing into the mouth once If the airway is still obstructed, attempts at ventilation will fail Reposition the head and attempt once more to ventilate If unsuccessful, proceed to the next step Straddle the victim’s thighs, place one hand on top of the other, and deliver up to five abdominal thrusts Repeat these three steps until the airway is clear

21. Figure 16-5B

22. Shock Results from acute circulatory failure caused by inadequate blood volume, heart failure, overwhelming infection, severe allergic reactions, or extreme pain or fright

23. Hemorrhage The loss of a large amount of blood Loss of more than 1 liter (L) of blood in an adult may lead to hypovolemic shock Death from continued uncontrolled bleeding Bleeding may be external or internal Internal bleeding is suspected if signs of shock but no external bleeding is evident

24. Hemorrhage Immediate treatment for external bleeding is direct, continuous pressure Elevate and immobilize the injured part (unless fracture is suspected) After bleeding stops, secure a large dressing, if available, over the wound Reinforce the dressing but do not change it If direct wound pressure and elevation fail to control bleeding, apply indirect pressure to the main artery that supplies the area

25. Figure 16-6

26. Hemorrhage Epistaxis Blood from anterior or posterior portion of the nose Most anterior nosebleeds respond to pressure Instruct the patient to sit down and lean the head forward Pinch the nostrils shut for at least 10 minutes Advise patient not to blow or pick at nose for several hours Continued bleeding or bleeding from the posterior area of the nose requires medical treatment

27. Figure 16-7

28. Fracture A break in a bone Simple (closed) fracture Does not break the skin Compound (open) fracture Broken bone protrudes through the skin Complete fracture Broken ends are separated Incomplete fracture Bone ends are not separated

29. Fracture Assessment Primary symptom is pain Numbness/tingling from nerve injury and blood vessels Signs: deformity, swelling, discoloration, decreased function, and bone fragments protruding through the skin

30. Nursing Diagnoses, Goals, and Outcome Criteria Risk for Trauma related to movement of unstable fractures Immobilize the injured part Apply direct pressure to the artery above the injury to stop bleeding

31. Strains and Sprains Strains Injuries to muscles or tendons, or both Sprains Injuries to ligaments These injuries are painful; may be swelling Emergency treatment is immobilization, elevation, and application of a cool pack Victim to see physician for further evaluation

32. Head Injury Suspected with any type of blow to the head or any unexplained loss of consciousness Assessment Inspection and palpation of the head Evaluate for signs and symptoms of increased intracranial pressure Be alert for the leakage of cerebrospinal fluid that occurs with basilar skull fractures

33. Head Injury Must be assessed by a physician as soon as possible Immobilize neck and keep victim flat with proper alignment of the neck and head Backboard used for transporting victim

34. Neck and Spinal Injuries Assessment Assess breathing and circulation and then begin resuscitation if needed Remember to use the jaw-thrust method to open the airway! Assess movement and sensation in all extremities

35. Nursing Diagnosis, Goal, and Outcome Criteria Risk for trauma related to improper movement of the fractured spine Outcome criteria include continuous immobilization of the spine and transport for medical care

36. Neck and Spinal Injuries Immediately summon expert emergency team In remote or life-threatening settings, the victim may have to be moved A rolled towel or article of clothing can be used as a collar to support the neck The victim can then be moved by log-rolling to one side and then rolling back onto a board, keeping the spine as straight as possible Throughout the movement, one rescuer supports the head while two others support the shoulders, hips, and legs

37. Eye Injury Assessment Inspect eyelid for trauma and the eye for redness, foreign bodies, or penetrating objects To inspect for foreign bodies, evert the eyelids

38. Nursing Diagnosis, Goal, and Outcome Criteria Risk for injury related to foreign body, direct trauma, or exposure to harmful substances Goal is to minimize injury to the eye Outcome criteria may be removal of a foreign body or chemical or protection of the eye from further damage while medical attention is obtained

39. Figure 16-8

40. Ear Trauma Assessment Assess extent of injury; note if any tissue is fully separated and severity of bleeding Apply direct pressure to injury to control bleeding

41. Nursing Diagnosis, Goal, and Outcome Criteria Impaired tissue integrity related to trauma Goal: preserve the tissue to maximize successful repair Outcome criteria for successful interventions are recovery and protection of avulsed tissue

42. Ear Trauma If injured part is actually separated, reattachment may be possible Retrieve the tissue, wrap it in plastic, keep it cool, and transport it with the victim

43. Chest Injury Critical injuries: open pneumothorax, flail chest, massive hemothorax, and cardiac tamponade Assessment Note rate and character of respirations, skin color, pulse rate and rhythm, symmetry of the chest wall movement, and the presence of any apparent injuries to the chest Signs and symptoms of chest injuries that impair respirations are dyspnea, tachycardia, restlessness, cyanosis, asymmetric or other abnormal chest wall movement, abnormal sounds of breathing Note mental state and level of consciousness

44. Figure 16-9

45. Nursing Diagnosis, Goal, and Outcome Criteria Impaired gas exchange related to altered anatomic structure Goal is adequate oxygenation; outcome criteria are absence of dyspnea, normal pulse and respiratory rates, and normal skin color See Table 16-3, p. 234

46. Abdominal Injury: Assessment Assess abdomen for evidence of injury Ask patient about abdominal symptoms Inspect abdomen for abnormalities Suspect internal abdominal injuries if victim complains of abdominal pain or abdomen shows evidence of trauma or distention Protrusion of internal organs through a wound is called evisceration

47. Abdominal Injury: Interventions Require medical evaluation Give nothing by mouth in preparing for transport Do not attempt to replace eviscerated organs in the abdomen; this may cause additional harm Cover organs with material, such as plastic wrap or foil, to conserve moisture and warmth A saline-soaked sterile dressing is ideal but is not likely to be available on the scene of an accident Cover wound with clean cloth; transport to hospital

48. Traumatic Amputation If partially/completely detached, reattachment possible Clean the wound surfaces with sterile water or saline and place the tissue in its normal position A body part that is completely detached should ideally be wrapped in sterile gauze moistened with sterile saline, placed in a watertight container such as a resealable plastic bag, and placed in an iced saline bath The tissue should not be frozen or placed in contact with ice Amputated extremities may be healthy enough for reattachment for 4-6 hours; digits as long as 8 hours

49. Burns: Assessment Determine the type of burn If patient has a flame burn or was in a closed, smoke-filled area, assess respirations first Determine the extent and depth of the burns Inspect skin for color, blisters, tissue destruction Superficial burns: typically pink or red and painful Deeper burns: red, white, or black; may destroy not only the skin but also the underlying tissues Electrical: difficult to assess; full extent of tissue damage may not be apparent for several days Chemical: immediately remove any remaining chemical

50. Burns: Interventions Ensure a patent airway and respirations for burn victims Rescue breathing, if needed See Table 16-4, p. 235