1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 16 First...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 16

First Aid,Emergency Care, and Disaster Management


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.


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



• 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



• 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


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


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


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


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



• 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


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


Figure 16-3



• 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



• 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


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


Figure 16-4



• 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


Figure 16-5A



• 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


Figure 16-5B


Shock

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


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


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


Figure 16-6


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


Figure 16-7


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


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


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


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


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


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


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


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


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


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



• 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


Figure 16-8


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



• 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


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


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


Figure 16-9



• 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


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


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


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


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


Burns: Interventions

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


Hyperthermia

• Body temperature >37.2° C (99° F) • Heat edema and heat cramps are mild degrees of

hyperthermia • Can be treated by moving individual into cool place and

providing fluids with electrolytes

• Heat exhaustion and heat stroke more serious • See Table 16-5, p. 236


Hypothermia

• Decrease in body core temperature to <36° C (95° F) • Caused by prolonged exposure to cold, extremely

cold temperatures, or immersion in cold water• Causes depression of vital functions, and if not

corrected, death results from cardiac dysrhythmias


Hypothermia

• Mild stage• Patient shivers in an effort to generate body heat • Blood vessels in the extremities are constricted, and

performing complex motor tasks is impaired

• Moderate hypothermia • Appears dazed, poor motor coordination, slurred

speech, and violent shivering • May behave irrationally

• Severe hypothermia • Waves of shivering, rigid muscles, and pale skin • Pulse rate is slow and the pupils are dilated


Carbon Monoxide Poisoning

• Assessment• Early signs and symptoms: headache and shortness

of breath with mild exertion • Then dizziness, nausea, vomiting, and mental

changes • As carbon monoxide in bloodstream rises, victim

loses consciousness and develops cardiac and respiratory irregularities

• Cherry-red skin clear indicator of carbon monoxide poisoning, but skin color often found to be pale or bluish with reddish mucous membranes



• Impaired gas exchange related to carbon monoxide poisoning • The goal of nursing care for the emergency

treatment of the victim of carbon monoxide poisoning is normal oxygenation


Interventions

• Immediately move the victim to fresh air • If person not breathing, start rescue breathing • Seek emergency medical assistance

immediately • Give oxygen as soon as it is available • At the hospital the patient may be placed in a

hyperbaric oxygen chamber


Drug or Chemical Poisoning

• Assessment • History: data about relevant signs and symptoms

• Name of drug or chemical. If the victim cannot provide the information, look for clues and save the container

• Amount consumed• Length of time since substance was taken• Last food consumed: amount, time• Signs and symptoms that may be caused by poisons• Victim’s age and approximate weight• Other medications, drugs, or alcohol ingested


Nursing Diagnosis, Goal, and Outcome Criterion

• Risk for injury related to poison • Decrease or minimize risk for injury caused by the

poison


Drug or Chemical Poisoning

• Interventions • Immediately call your poison center• Some poisonings can be treated at home, others

require a physician or a hospital • Treatment of poisoning in an emergency facility may

be with activated charcoal, total bowel lavage, and/or cathartics


Food Poisoning

• Assessment • Symptoms: nausea, vomiting, abdominal cramps,

and diarrhea • Botulism caused by Clostridium botulinum has

neurotoxic effects: difficulty breathing, seeing, and swallowing

• Clue that food poisoning is causing victim’s symptoms is that all who consumed a certain food become ill

• To assist in identifying poisons, collect samples of stool or vomited materials for possible lab analysis


Nursing Diagnosis, Goal, and Outcome Criterion

• Risk for Injury related to poisoning • Type of injury depends on the action of the

contaminant • In general the treatment of food poisoning aims to

identify the poison and decrease the symptoms • The goal of nursing care for the victim of food

poisoning is the absence or reduction of ill effects from the poison


Food Poisoning: Interventions

• Medical care necessary if symptoms are severe or persistent

• The physician may order antiemetics and antidiarrheals

• Intravenous fluids may be prescribed with severe vomiting and diarrhea


Bites and Stings

• Assessment• Try to determine the type of bite • Inspect bite to identify characteristics of bite site and

any changes in surrounding tissue • Ask about any symptoms that developed after the

bite: pain, edema, numbness, tingling, nausea, fever, dizziness, and dyspnea

• Interventions: see Table 16-7, p. 239


Acts of Bioterrorism

• Deliberate release of pathogens to kill people • Anthrax, botulism, plague, smallpox, tularemia:

most common biologic agents in terrorist attack

• Easily spread; potential to cause many deaths• Health care providers must know how to

protect themselves and others • Staff should know where to obtain personal

protective equipment and what types of precautions (i.e., patient isolation) should be taken


Disaster Planning

• A challenge for the health care system is to be ready for natural disasters that often occur with short warning

• American Red Cross and the Salvation Army are experienced in handling these situations and quickly move in to help

• A call for nurse volunteers usually follows • Regardless of the area of clinical expertise,

there is certain to be a way each nurse can contribute


Legal Aspects of Emergency Care

• Emergency doctrine • In emergencies, person may be unable to consent

to care• Treatment can be provided under the assumption

that the patient would have consented if able

• Good Samaritan laws• Limit liability and provide protection against

malpractice claims when health care providers render first aid at the scene of an emergency

• These laws do not protect the nurse in the event of gross negligence or willful misconduct

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 16 First...

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