EMERGENCY NURSING-1

• 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 patient’s
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 patient’s 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 transmission-based precautions for patients who are
potentially infectious is crucial.
• ER nurses are usually fitted with a personal high-efficiency particulate air (HEPA)-filter
mask apparatus to use when treating patients with airborne diseases.

Providing Holistic Care

• 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 family’s 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.

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 patient’s 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 bag-valve-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

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

Eye Spontaneous 4
opening To voice 3
response To pain 2
None 1
Verbal Oriented 5
response Confused 4
Inappropriate words 3
Incomprehensible 2
sounds 1
None
Motor Obeys command 6
response Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 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 patient’s 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. ñ 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 victim’s 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 victim’s 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.

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

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

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:
1. Cool, moist skin
2. Hypotension
3. Tachycardia
4. Delayed capillary refill
5. 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, & cross-matching.
 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 child-bearing 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.

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.

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.

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 patient’s
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

• 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 & aren’t 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 re-approximated 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.
• Patient’s 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.
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 ABC’s, the patient is observed for acute renal insufficiency
• Major soft tissue injuries are splinted early to control bleeding and pain.
• A ò 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 patient’s 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 (ABC’s)
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-to-toe 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.

Emergency Nursing -2

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 ò ability to perspire as well as a ò 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
• Watch out for profound CNS dysfunction (confusion, delirium, bizarre behavior, coma), ñ body
temperature (>40.6°C), 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 ABC’s of basic life
support.
• After clothing is removed, core temperature is reduced to 39°C 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.
• Client’s 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 40°C circulating bath for 30- to 40-min.
• Repeat treatment until circulation is effectively restored.

• Early rewarming ò 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 & anti-inflammatory 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 35°C 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 ñ 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 32.2°C due to ineffective mechanism
• Peripheral pulses are weak and become undetectable; cardiac irregularities, hypoxemia and
acidosis may occur.

Management: Monitoring
• 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 cold-induced 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 32°C 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 <31°C)
• 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 ABG’s, 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, high-altitude 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
 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, ò 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 ò 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 ò
circulating blood volume due to ñ 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).
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.
9. Elevate funnel above patient’s head and 150-200mL of solution into it.
10.Lower funnel and siphon the gastric contents, or connect to suction.
11.Save the samples of the first two washings.
12.Repeat the lavage until the returns are clear and no particulate matter is seen.
13.The stomach may be left empty, and an absorbent or saline cathartic is instilled and
allowed to remain inside.
14.Pinch out the tube during removal or suction while withdrawing and keep head lower than
the body.
15.Warn patient that stools will turn black from the charcoal.

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 poison-proofing 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 doesn’t 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

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

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)

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 client’s appearance?
Management
 Determine the source and type of food poisoning.
 Food, gastric contents, vomitus, serum and feces are collected for examination.
 Patient’s VS, sensorium and muscular activity are closely monitored.
 Support the respiratory system and assess fluid and electrolyte balance; watch out for
lethargy, ñPR, 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

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.

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

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 Ringer’s Solution: 4 mL x body weight (kg) x % BSA burned
 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 Curling’s 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 patient’s 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
 The patient is instructed to have the affected area re-examined at 24 & 72 hours and in 7
days because of the risk of under-estimating the extent & depth of these types of injuries.