Emergency First Aid Nursing Chapter 24 Mosby items and derived items © 2011, 2006, 2003, 1999,...

Emergency First Aid Nursing

Chapter 24Chapter 24

Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.


Obtaining Medical Emergency AidObtaining Medical Emergency Aid

• The nurse’s ability to recognize the need for medical assistance and knowledge of how to obtain medical emergency aid can mean the difference between life and death to an injured or ill person.

• Health care providers must be prepared to provide cardiopulmonary resuscitation (CPR) if needed until emergency medical assistance arrives.


Moral and Legal Responsibilities of the NurseMoral and Legal Responsibilities of the Nurse

• Good Samaritan Laws Enacted in most state to protect health professionals

from legal liability when providing emergency first aid Follow a reasonable and prudent course of action

• Victim must give verbal permission.

• The law assumes that an unconscious person would give consent if he or she were able.

• Once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training.


Assessment of the Emergency SituationAssessment of the Emergency Situation

• Primary Assessment Airway Breathing Circulation (pulse and severe bleeding)

• Life-threatening Situations Arrested or abnormal breathing or pulse

• Observe for indications of skull injury and brain or spinal cord damage.

• Fractures, dislocations, and superficial ecchymoses or wounds require attention after the more serious conditions are treated.


Ethical ImplicationsEthical Implications

• Reasons why individuals choose not to perform CPR Lack of motivation Fear of doing harm Lack of knowledge Fear of contracting communicable diseases


Ethical ImplicationsEthical Implications

• Once CPR is started, it may not be discontinued except for the following reasons. The victim recovers. The rescuer is exhausted and cannot continue CPR. Trained medical personnel arrive on the scene and

take over CPR. A licensed physician arrives on the scene,

pronounces the victim dead, and orders CPR to be discontinued.


Events Requiring CPREvents Requiring CPR

• CPR is indicated in any syndrome where respiration or respiration and circulation are absent.

• Two Purposes of CPR To keep the lungs supplied with oxygen when

breathing has stopped To keep the blood circulating and carrying oxygen to

the brain, heart, and other parts of the body



• Clinical Death The heartbeat and respirations have ceased.

• Biological Death This results from permanent cellular damage caused

by lack of oxygen. The brain is the first organ to suffer from lack of

oxygen. In many cases, CPR can reverse clinical death if

initiated before 4 minutes of cardiopulmonary arrest. After 10 minutes without CPR, brain death is certain.



• Brain Death This is an irreversible form of unconsciousness

characterized by a complete loss of brain function while the heart continues to beat.

The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration; pupils that are fixed and dilated; and absent electric activity of the brain on two electroencephalograms (EEGs) performed 12 to 24 hours apart.


Adult One-Rescuer CPRAdult One-Rescuer CPR

• Airway Determine responsiveness.

• Gently shake and shout, “Are you OK?” Call for help. Open the airway. To determine breathlessness

• Look for the rise and fall of the chest.

• Listen for sounds of breathing.

• Feel for the warmth of the victim’s mouth against the cheek.



• Breathing Mouth-to-mouth ventilation is the quickest method of

supplying oxygen to the victim’s lungs. Rescuer takes a deep breath, seals the lips around

the outside of the victim’s mouth, and gives two full breaths lasting 1.5 to 2 seconds.

If the initial attempt to ventilate the victim is unsuccessful, the rescuer should reposition the head and attempt to ventilate again.

If the second attempt is also unsuccessful, proceed to foreign body airway obstruction management.



• Circulation Assess for the presence of the pulse. Cardiac compressions on a person with a pulse may

result in severe damage. If pulse is present, initiate rescue breathing. Pulselessness indicates the need for external cardiac

compressions. To determine pulselessness, palpate the carotid

pulse. External cardiac compressions will circulate blood to

the heart, lungs, brain, and the rest of the body.



• Circulation (continued) External cardiac compressions are performed on the

lower half of the sternum with the heel of both hands; elbows are locked, arms straight; the rescuer leans forward, creating pressure to depress the sternum.

Perform 15 compressions and 2 slow breaths for 4 cycles; check the pulse; if no pulse, continue.


Adult Two-Rescuer CPRAdult Two-Rescuer CPR

• When One-Rescuer CPR Is Already in Progress The most logical time for entrance of the second

rescuer is after a completed cycle of 15 compressions and 2 slow breaths.

The second rescuer identifies himself by saying, “I know CPR”; moves to the head; opens the airway; and checks a carotid pulse.

The other rescuer takes position at the chest and finds the proper hand placement for chest compressions.



• When No CPR Is in Progress One rescuer activates EMS while the other initiates

one-rescuer CPR. If the EMS can be activated by another person, the

two rescuers should proceed as follows.


• First Rescuer Determine unresponsiveness. Position the victim. Open the airway. Assess for breathing. If breathing is absent, say “No breathing” and give

2 ventilations. Assess for pulse; if pulse is absent, say “No pulse.”




• Second Rescuer, at the Same Time, Does the Following Finds the location for external cardiac compressions Assumes proper hand position Begins external cardiac compressions after the “No

pulse” statement is made by the first rescuer



• Switching Procedures Switching the positions of the ventilator and the

compressor prevents fatigue of both rescuers and allows time for the ventilator to evaluate the effectiveness of CPR.

The switch is initiated by the rescuer performing chest compressions at the end of the 15:2 sequence.

After giving a breath, the ventilator moves to the chest and gets into position to give compressions.

The compressor moves to the head and checks the pulse. If no pulse, state, “Resume CPR.”


Pediatric CPR Child/InfantPediatric CPR Child/Infant

• The basic steps of CPR and foreign body airway obstruction management are the same whether the victim is an infant, a child, or an adult.

• For the purpose of life support Infant: younger than 1 year Child: between the ages of 1 and 8 years



• Airway Unresponsiveness should be determined

• Gently shake the child; tap the heels of an infant. Call for help

• If the rescuer cannot immediately activate EMS, perform BLS for 1 minute before going to activate EMS.

• Position victim on a firm, flat surface for effectiveness of CPR.

• Open the airway; do not hyperextend in infants.



• Breathing Look for movement of the chest, listen for breath

sounds, and feel for exhaled airflow. If there is no breathing, inhale and seal the mouth and

nose of the infant. Two breaths are given, with a pause between each

breath; the volume of air in the infant’s lungs is smaller than that in an adult’s; adjust to allow for appropriate rise and fall of the chest.



• Circulation Assessment of pulse

• Carotid artery of the child

• Brachial artery of the infant If there is a pulse, rescue breathing should be

continued at a rate of 1 breath every 3 seconds. If there is no pulse, external cardiac compressions

must be performed.



• Circulation Infant CPR (two health care providers)

• Visualize an imaginary line between the nipples.

• Use a two-thumb, encircling-hands compression technique, performing compressions with the thumbs.

• The breastbone is compressed to a depth of 0.5 to 1 inch at a rate of at least 100 times per minute.

• At the end of each compression, pressure is released and the sternum is allowed to return to normal position.

• The sequence is 5 compressions to 1 breath.



• Circulation Child CPR

• The lower margin of the child’s rib cage is palpated with the middle and index fingers while the head tilt is maintained.

• Place the heel of the hand on the sternum, avoiding the xiphoid process.

• The chest is compressed 1 to 1.5 inches, 100 times per minute.

• The sequence is 5 compressions to 1 breath.


Foreign Body Airway Obstruction ManagementForeign Body Airway Obstruction Management

• Food is the most common cause of choking or airway obstruction in the adult.

• Foreign objects are the most common cause of airway obstruction in children.

• If the air exchange is good and the victim is able to cough forcibly, do not interfere.

• The victim should be monitored closely, because he or she may regress to a state of poor exchange.


• Poor Air Exchange Weak, ineffective cough High-pitched, “crowing” noise while inhaling Increased respiratory difficulty Cyanosis Complete airway obstruction: cannot speak, breathe,

or cough and may clutch the neck

• Ask the victim, “Are you choking?”



• Conscious Victim Abdominal thrusts

• Abdominal thrusts given below the diaphragm

• This is an emergency procedure for dislodging a bolus of food or other obstruction from the trachea to prevent asphyxiation.

• Thrusts put pressure on the diaphragm, forcing air from the lungs to move and expel the foreign object.



• Conscious Victim (continued) Abdominal thrusts (continued)

• Stand behind the victim.

• Wrap your arms around the victim’s waist.

• Make a fist with one hand and place the thumb of the fist against the middle of the victim’s abdomen slightly above the navel and well below the xiphoid process.

• Wrap the other hand over the fist into the victim’s abdomen with a quick upward thrust.

• Repeat thrusts until the foreign body is expelled or the victim becomes unconscious.



• Unconscious Victim Place victim in a supine position with the face up. Perform a finger sweep. Open the airway and attempt to ventilate. If unsuccessful, perform abdominal thrusts by

kneeling astride the victim’s thighs and place the heel of one hand against the victim’s abdomen, in the midline slightly above the navel but well below the xiphoid process; second hand remains on top of the first hand for additional force.

Press into the abdomen with a quick, upward thrust. Open the mouth and perform a finger sweep.



• Unconscious Victim (continued) Infant (continued)

• The infant is straddled over the rescuer’s arm with head lower than the trunk, with the face down.

• With this arm resting on the rescuer’s thigh, the other arm delivers five back blows between the shoulder with the heel of the hand.

• The rescuer places his or her free hand on the infant’s back so that the victim is sandwiched between the two hands.



• Unconscious Victim (continued) Infant (continued)

• The rescuer turns the infant and places the infant on the rescuer’s thigh with the head lower that than the trunk.

• Five chest thrusts are performed with the hands in the same position as when performing external cardiac compressions.



ShockShock

• Shock is an abnormal condition of inadequate blood flow to the body’s peripheral tissues, with life-threatening cellular dysfunction, hypotension, and oliguria.

• It results from failure of the cardiovascular system to provide sufficient blood circulation to the body’s tissues and decreased metabolic waste removal.

• To maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient volume of blood.


ShockShock

• Classification of Shock Classified according to cause

• Severe blood loss

• Intense pain

• Extensive trauma; burns

• Poisons

• Emotional stress or intense emotions

• Extremes of heat and cold

• Electrical shock

• Allergic reactions

• Sudden or severe illness


ShockShock

• Assessment Level of consciousness Skin changes Blood pressure Pulse Respirations Urinary output Neuromuscular changes Gastrointestinal effects


ShockShock

• Nursing Interventions Establish airway. Control bleeding. Reduce pain. Position the victim flat with the head slightly lower

than the rest of the body (elevate the feet and legs). If victim is unconscious or is vomiting or bleeding

around the nose or mouth, position on the side. If victim is having breathing problems, elevate head

and shoulders.


Figure 24-10, AFigure 24-10, A

Body positions for shock. A, Modified Trendelenburg.


Figure 24-10, BFigure 24-10, B

Body positions for shock. B, If head, neck, or spinal injuries are

suspected.


Figure 24-10, CFigure 24-10, C

Body positions for shock. C, Breathing problems.


ShockShock

• Nursing Interventions (continued) Cover victim with a blanket or other covering to keep

warm. Do not give anything to eat or drink. Relieve pain: support injury; avoid rough handling;

adjust tight or uncomfortable clothes. Do not give analgesics unless directed by a physician. Provide emotional support and reassurance.


Bleeding/HemorrhageBleeding/Hemorrhage

• Effects of Blood Loss Blood loss from internal or external bleeding causes a

decrease in oxygen supply to the body. Blood pressure drops. Heart pumps faster to compensate for the decreased

volume and blood pressure. The body will attempt to clot the blood to halt

bleeding, usually requiring 6 to 7 minutes. Uncontrolled, bleeding can result in shock and death.



• Types of Bleeding Capillary

• Most common; results from damaged or broken capillaries and causes oozing of minor cuts, scratches, and abrasions

Venous• Occurs when the vein is severed or punctured

• Results in a slow, even flow of dark red blood

• Embolism may occur if air enters the severed vein.



• Types of Bleeding (continued) Arterial

• Least common; usually protected by bones, fat, and other structures

• Heavy spurting of bright red blood in the rhythm of the heartbeat



• Nursing Interventions Direct pressure

• The most effective general treatment of bleeding is to apply direct pressure over the bleeding site.

• Raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body’s ability to clot at this site.


Figure 24-11Figure 24-11

Applying pressure to wound site.

(From Sorrentino, S.A. [1996]. Mosby’s textbook for nursing assistants. [4th ed.]. St. Louis: Mosby.)



• Nursing Interventions (continued) Indirect pressure

• If direct pressure and elevation do not control bleeding, indirect pressure may be applied to any of the pressure points situated along main arteries.

Application of a tourniquet• A tourniquet must be used only when the other methods

have failed and the victim’s life is in danger.

• It can cause extensive damage to the body part.



Applying pressure to wound site.

(From Kidd, P.S., Stuart, P.A. [1996]. Mosby’s emergency nursing reference. St. Louis: Mosby.)


Skill 24-1: Step 7Skill 24-1: Step 7

Applying a tourniquet.



• Epistaxis Nosebleed Common but seldom a serious emergency Causes

• Trauma

• Epistaxis digitorum (trauma from nasal picking)

• Infections

• Hypertension

• Strenuous activity

• Low humidity



• Epistaxis Nursing interventions

• Keep the victim’s head tilted slightly forward.

• Apply steady pressure to both nostrils for 10 to 15 minutes.

• Remind the victim to breathe through the mouth and to expectorate any accumulated blood.

• Apply ice compresses over the nose at the same time.

• Look in the victim’s mouth at the back of the throat to assess for bleeding from a posterior site.



• Internal Bleeding This is a potentially life-threatening situation. Common causes are fractures, knife or bullet wounds,

crushing injuries, organ injuries, and medical conditions such as ruptured aneurysms.

Assessment• Signs and symptoms of shock

• Vertigo

• Hemoptysis or hematemesis

• Melena

• Hematuria



• Internal Bleeding Nursing interventions

• This is a priority medical emergency.

• Place on a flat surface with legs elevated.

• Establish an airway.

• Cold compress or ice is placed on the area of injury.

• Maintain body temperature with blankets.

• Assess vital signs.

• Oxygen may be ordered by the physician.


Wounds and TraumaWounds and Trauma

• Closed Wounds The underlying tissue of the body is involved; the top

layer of skin is not broken. Ecchymoses (bruises) and contusions occur. Signs and symptoms

• Edema, discoloration, deformity, shock, pain and tenderness, and signs of internal bleeding

Nursing interventions• Small wound: ice packs and elastic bandage

• Large wound: treat for shock; cold compresses and pressure bandage



• Open Wounds Openings or breaks in the mucous membrane or skin Always danger of bleeding or infection Types

• Abrasions

• Puncture wounds

• Incisions

• Lacerations

• Avulsions

• Chest injuries



Flail chest.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)



• Dressings and Bandages General principles of bandaging

• Bleeding should be controlled before bandage is applied.

• Use sterile material if possible; if not use, the cleanest material possible.

• Dressing should never cover the entire wound.

• Wounds should be bandaged firmly but not too tightly.

• Bandage in alignment is desired.

• Tips of fingers and toes should remain exposed if possible.



• Application of Common Types of Bandages Bandage compress

• Most common type of dressing; consists of several thicknesses of gauze, covered with tape or gauze

Triangular bandage• Made of a piece of cloth that is folded diagonally and

cut along the fold; used as a sling to support injured bones

Roller bandage• Used to support an injured part apply pressure to a

dressing, or secure a splint to immobilize a part



Use of roller bandage.

(From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2nd ed.]. Philadelphia: Saunders.)


PoisonsPoisons

• General Assessment of Poisonings Signs and symptoms may be delayed for hours. Indications may be respiratory distress; nausea,

vomiting, or diarrhea; seizures; decreased level of consciousness; restlessness, delirium, agitation; color changes; signs of burns; pain on swallowing; unusual urine color; abnormal constriction or dilation of pupils; abnormal eye movement; skin irritation; and shock or cardiac arrest.


PoisonsPoisons

• Ingested Poisons Poisoning by mouth is the most common type of

poisoning, especially in children. Common substances include household cleaning

products, garden and garage supplies, drugs, medications, food, and plants.


PoisonsPoisons

• Ingested Poisons Nursing interventions

• Immediately call the poison control center.

• Maintain airway.

• Possible instructions by the poison control center Dilute the poison by giving one or two glasses of water. Induce vomiting if gag reflex is present and poison is not

a corrosive.

• Treat for shock and administer CPR if needed.


PoisonsPoisons

• Inhaled Poisons Common sources

• Carbon monoxide, carbon dioxide, and refrigeration gases; poisonous fumes from chlorine and other liquid chemical sprays

Nursing interventions• Remove victim from the dangerous area only if there is

no danger to the rescuer.

• Maintain airway; perform CPR if needed.

• Victim should remain quiet and inactive while being transported to the nearest medical facility.


PoisonsPoisons

• Absorbed Poisons Poisons, caustic chemicals, and poisonous plants that

come in contact with the skin Causes burning, skin irritation, allergic responses, or

severe system reactions Signs and symptoms

• Nausea, vomiting, diarrhea, flushed skin, dilated pupils, cardiovascular abnormalities, and CNS reactions


PoisonsPoisons

• Absorbed Poisons Nursing interventions

• Quickly remove the source of the irritation; wash with soap and water.

• Skin preparations include baking soda, Burow’s solution, and oatmeal.

• Calamine lotion and hydrocortisone cream are effective to relieve pruritus.


PoisonsPoisons

• Injected Poisons Minor reactions to insect bites

• Remove stinger, if present, by scraping.

• Wash the bite with soap and water.

• Apply cold packs; baking soda paste. Severe reactions to insect bites

• Urticaria, wheezing, edema of the lips and tongue, generalized pruritus, and respiratory arrest

• Nursing interventions Apply a wide constricting band proximal to the wound;

keep affected part in dependent position; transport to the hospital immediately.


Drug and Alcohol EmergenciesDrug and Alcohol Emergencies

• Alcohol Mild intoxication signs and symptoms

• Nausea, vomiting, diarrhea, lack of coordination, and poor muscle control, flushing, erythema of the face and eyes, visual disturbances, rapid mood swings, slurred or inappropriate speech, inappropriate behavior and lethargy

Serious intoxication signs and symptoms• Drowsiness to coma, rapid weak pulse, depressed,

labored breathing or respiratory arrest, loss of control of urinary and bowel functions, disorientation, restlessness, and hallucinations



• Drugs Signs and symptoms

• Loss of reality orientation, hallucinations, and varying degrees of consciousness; slurred speech; extremes in mood swings; inappropriate behavior; anxiety; flushed skin; diaphoresis; lack of coordination; impaired judgment; increased or decreased pulse; pupils constricted or dilated; needle marks on the arms, legs, and neck



• Nursing Interventions Obtain information about the substance ingested. Life-threatening situations are handled first. Establish airway. If unconscious, turn on the side. Loosen clothing. If fever is present, apply cool, wet compresses. Protect the victim from injury during a seizure or

hallucination. Carefully assess mental status and vital signs

frequently.


Thermal and Cold EmergenciesThermal and Cold Emergencies

• Heat Injury Heat exhaustion

• The most common type of heat injury, this results from prolonged perspiration and the loss of large quantities of salt and water.

• Observe for signs and symptoms of headache, vertigo, nausea, weakness, and diaphoresis.

• Mental disorientation and brief loss of consciousness may occur.



• Heat Injury (continued) Heat exhaustion (continued)

• Nursing interventions Cool the victim as quickly as possible; use cold, wet

compresses and fan or air conditioner. Have victim lie down with feet elevated. If alert, give one-half glass of water every 15 minutes for

1 hour. In the clinical setting, IV fluids are given.



• Heat Injury (continued) Heatstroke

• This is a more serious heat injury; death can result.

• The most common cause is vigorous physical activity in a hot, humid environment.

• The body becomes overheated, but the cooling mechanism of perspiration does not operate.

• Assessment: rapidly rising body temperature; hot, dry, erythemic skin; no visible perspiration; pulse rapid initially and then slow and blood pressure falls; breathing deep and rapid; victim complains of headache, dry mouth, nausea, and vomiting



• Heat Injury (continued) Heatstroke (continued)

• Nursing interventions Cool the victim as quickly as possible; use cold packs

around the victim’s neck, under the arms, and around the ankles to cool the blood in the main arteries.

Establish and maintain an airway. Monitor for chilling as the body temperature falls.



• Exposure to Excessive Cold Hypothermia

• Lowering of the body temperature below the normal level; 95° F or below

• Assessment Uncontrollable shivering but ceases when body

temperature drops below 90° F Slurred speech, memory lapses, disorientation and poor

judgment, uncoordinated gait, skin mottled and edematous, weak irregular pulse, decreased respiratory rate, loss of all reflexes



• Exposure to Excessive Cold (continued) Hypothermia

• Nursing interventions Initiate CPR if necessary; must continue until the body is

rewarmed. Place victim in a supine position with the head lower than

the feet. Rewarm slowly: move to a warm area, remove wet

clothing, and wrap with warm blankets.



• Exposure to Excessive Cold (continued) Frostbite

• Freezing and damage of body cells

• Commonly affected area are ears, nose, fingers, and toes.

• Assessment: initially, skin takes on a red flush with numbness, tingling, and pain; progressively, the part becomes hard and loses all sensation; color turns to grayish white; if thawing occurs, may change to blue-purple or black; edema may develop, followed by blisters.



• Exposure to Excessive Cold (continued) Frostbite (continued)

• Nursing interventions Treat the victim for shock and hypothermia; establish and

maintain an airway. Warm part by immersion in warm water at 104 to 110° F

for 20 to 45 minutes. If tub is not available, may use a hot moist towel. Be very careful not to rub the part. The thawed part is wrapped in clean towels or bulky

dressings and elevated.


Bone, Joint, and Muscle InjuriesBone, Joint, and Muscle Injuries

• Fractures A break in the continuity of a bone Types of common fractures

• Open or compound fracture

• Closed fracture

• Comminuted fracture

• Greenstick fracture

• Spiral fracture

• Impacted fracture

• Compressed fracture

• Depression fracture



• Fractures Assessment

• Radiography can determine if a bone is fractured.

• There is pain and tenderness in the area and pain during movement.

• Deformity of the limb may be obvious, with edema and discoloration of the area.

• Fragments of bone may be protruding through the skin.

• Crepitus: grating sound is heard when the affected part is moved.



• Fractures Nursing interventions

• Do not move unless he or she is in danger.

• ABCs of first aid take priority.

• Control bleeding if present.

• Immobilize the fracture but do not attempt to realign the bone.

• Monitor circulation in the limb.

• Apply ice or cold packs to the area.



Immobilization of fractured arm.

(From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2nd ed.]. Philadelphia: Saunders.)



• Dislocations Occurs in joints; usually results from a blow or fall Assessment: complaints of pain and edema; deformity

of the part; part may be rigid, and the victim is unable to move it.

Nursing interventions: never attempt to reduce a dislocation; splint the joint; apply ice or cold packs.


Skill 24-2: Step 4Skill 24-2: Step 4

Applying an arm splint using a triangular (sling and swathe) bandage.



• Strains and Sprains Strains are injuries to muscle tissue from stretching

and tearing due to overexertion. Sprains are injuries to joints resulting from stretched

or torn ligaments due to twisting of the joint beyond the normal range of motion.

Assessment • Strains: spasms of the muscle, acute pain, stiffness,

and weakness on movement; back pain radiating down the leg; discoloration

• Sprains: pain or tenderness around a joint; immobility of the joint; rapid and marked edema



• Strains and Sprains Nursing Interventions

• RICE Rest the affected extremity Ice should be applied to the part Compression with a compression bandage Elevation above the level of the heart



• Spinal Cord Injuries Assessment

• Assess for paralysis.

• Test for sensation.

• Assess for abrasions and ecchymosis on the back. Nursing interventions

• Take spinal cord precautions.

• Maintain airway; keep head in a neutral position.


Skill 24-3: Step 1, A and BSkill 24-3: Step 1, A and B

Moving the victim with a suspected spinal cord injury.


Burn InjuriesBurn Injuries

• Shallow Partial-Thickness Burns Involves the outer layer of the skin Caused by simple sunburns or burns from contact

with hot objects Nursing interventions

• The burn should be cooled immediately by soaking in cold water or applying cold compresses.

• A sterile dressing should be placed over the burn to prevent infection.



• Deep Partial-Thickness Burns Involve the entire first layer of skin (epidermis) as well

as some of the underlying tissue. Severe sunburn, scalding liquids, direct flame, and

chemical substances. Assessment

• Deep erythema of the skin, or mottled skin with blister formation.

• Weeping of fluid through the skin surface and intense pain.



• Full-Thickness Burns These burns involve destruction of the skin and

underlying tissue, including fat, muscle, and bone. Skin may be thick and leathery, with black or dark

brown, cherry red, or dry and milky white colors. The victim may not complain of pain, because nerve

endings may be severed. Wounds weep a great deal of fluid and blood. Causes: direct flame, explosions, and gasoline or oil

fires


• Deep Partial-Thickness Burns and Full-Thickness Burns Nursing interventions

• Establish airway.

• Assess respiratory and cardiac function.

• Remove all of victim’s clothing, shoes, and jewelry.

• Administer CPR if necessary.

• Treat for shock.

• Cool the burn with cool compresses for partial-thickness burns.

• Avoid touching the burn with anything but sterile dressings.



Nursing ProcessNursing Process

• Nursing Diagnoses Confusion, acute Tissue perfusion, ineffective Anxiety Cardiac output, decreased Hyperthermia or hypothermia Skin integrity, impaired Airway clearance, ineffective Pain, acute and chronic Posttrauma syndrome Infection, risk for


Terrorism and BioterrorismTerrorism and Bioterrorism

• Terrorism: Violent or dangerous used to coerce or intimidate

• Bioterrorism: Use of biological agents

• High-risk syndromes

• OSHA guidelines

• Chemical terrorism

• Nuclear terrorism

Emergency First Aid Nursing Chapter 24 Mosby items and derived items © 2011, 2006, 2003, 1999,...

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