Transcript Chapter 34

Chapter 16
First Aid,
Emergency Care, and
Disaster Management
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
1
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.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
2
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
3
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
4
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
5
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
6
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
7
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
8
Systematic Head-to-Toe Assessment
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
9
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
10
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
11
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
12
Figure 16-3
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
13
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 810 per minute
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
14
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 logrolled to one side if no cervical trauma is suspected
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
15
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
16
Figure 16-4
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
17
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
18
Figure 16-5A
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
19
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
20
Figure 16-5B
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
21
Shock
• Results from acute circulatory failure caused
by inadequate blood volume, heart failure,
overwhelming infection, severe allergic
reactions, or extreme pain or fright
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
22
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
23
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
24
Figure 16-6
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
25
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
26
Figure 16-7
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
27
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
28
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
29
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
30
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
31
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
32
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
33
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
34
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
35
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
36
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
37
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
38
Figure 16-8
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
39
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
40
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
41
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
42
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
43
Figure 16-9
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
44
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
45
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
46
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
47
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
48
Burns: Assessment
• Determine the type of burn
• If patient has a flame burn or was in a closed, smokefilled 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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
49
Burns: Interventions
• Ensure a patent airway and respirations for
burn victims
• Rescue breathing, if needed
• See Table 16-4, p. 235
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
50
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
51
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
52
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
53
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
54
Nursing Diagnosis, Goal, and
Outcome Criteria
• 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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
55
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
56
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
57
Nursing Diagnosis, Goal, and
Outcome Criterion
• Risk for injury related to poison
• Decrease or minimize risk for injury caused by the
poison
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
58
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
59
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
60
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
61
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
62
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
63
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
64
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
65
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
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
66