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

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

3. General Principles of Emergency Care
Cardinal rule: Remain Calm!
Priority is to preserve life and minimize effects of injuries; manner in which you conduct yourself also can soothe and reassure the victim
Assessment and intervention must be done quickly and efficiently to identify and treat priority needs immediately
The nursing process is used in emergencies just as it is in other nursing situations.
When does your assessment of the victim begin?
Failure to recognize such hazards may result in injuries to the rescuer and additional injuries to the victim.

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

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

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

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

8. Physical Examination The first priority: ABCs
Airway, breathing, and circulation
Watch chest for rhythmic breathing; listen near mouth and nose for air movement
Palpate the carotid and peripheral pulses
Once respiration and circulation established, assess for uncontrolled bleeding and shock
If none, assess systematic head-to-toe
Begin collecting objective data as soon as the victim is seen, and quickly determine whether the patient is responsive.

9. Systematic Head-to-Toe Assessment

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

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

12. Cardiopulmonary Arrest
Absence of a heartbeat and respirations
Causes
Myocardial infarction, heart failure, electrocution, drowning, drug overdose, anaphylaxis, and asphyxiation
Signs and symptoms
Collapse and quickly lose consciousness
No pulse or respiration
The cardiac and respiratory systems are so dependent on each other that when one fails, the other quickly fails as well.
How long can the brain go without oxygen before brain cells begin to die?

13. Figure 16-3

14. Cardiopulmonary Arrest
Interventions
Determine responsiveness
Open airway
Check for breathing (look, listen, feel)
If nonresponsive and not breathing, palpate for a pulse
If no pulse in 10 seconds, begin compression:ventilation cycles of 30:2
If a pulse, deliver 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
American Heart Association guidelines for CPR are revised at intervals.
What changes were made in the 2005 Guidelines?

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

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

17. Figure 16-4

18. Choking or Airway Obstruction
Victim is conscious
Perform the Heimlich maneuver
If effective, air expels foreign body from the airway
If not, repeat maneuver until the object is expelled or victim loses consciousness
The Heimlich maneuver is a “bear hug” procedure named for the physician who first described it.
Stand behind the victim and reach around the victim slightly above the umbilicus and below the xiphoid process.
Make a fist with one hand and use the other to press the fist against the victim.
Tighten your arms around the victim and perform quick upward thrusts into the victim’s abdomen.
How does the Heimlich maneuver help to expel the object?

19. Figure 16-5A

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

21. Figure 16-5B

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

23. Hemorrhage The loss of a large amount of blood
Loss of more than 1 liter (L) of blood in an adult may lead to hypovolemic shock
Death from continued uncontrolled bleeding
Bleeding may be external or internal
Internal bleeding is suspected if signs of shock but no external bleeding is evident
Assess for signs and symptoms of hemorrhage, which may include obvious bleeding; cool, sweaty, pale skin; thready pulse; rapid respirations; and decreasing alertness.
What are the symptoms of internal bleeding?

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

25. Figure 16-6

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

27. Figure 16-7

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

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

30. Nursing Diagnoses, Goals, and Outcome Criteria
Risk for Trauma related to movement of unstable fractures
Immobilize the injured part
Apply direct pressure to the artery above the injury to stop bleeding
What is the key to emergency management of fractures?
Do not attempt to straighten a broken bone; splint the bone in the position in which it was found, with as little movement as possible.
Severe bleeding may be present with compound fractures.

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

32. Head Injury
Suspected with any type of blow to the head or any unexplained loss of consciousness
Assessment
Inspection and palpation of the head
Evaluate for signs and symptoms of increased intracranial pressure
Be alert for the leakage of cerebrospinal fluid that occurs with basilar skull fractures
What is a critical complication of a head injury?
Older adults are at special risk for head injuries because they are more likely to have sensory deficits, unstable gait, or circulatory disorders.
What are signs of increased intracranial pressure?

33. Head Injury Must be assessed by a physician as soon as possible
Immobilize neck and keep victim flat with proper alignment of the neck and head
Backboard used for transporting victim
Always treat the victim as if there were a spinal injury until it is ruled out.
Why should a victim see a physician even if the head injury seems to be minor?

34. Neck and Spinal Injuries
Assessment
Assess breathing and circulation and then begin resuscitation if needed
Remember to use the jaw-thrust method to open the airway!
Assess movement and sensation in all extremities
Suspect neck and spinal injuries along with head injuries, especially if the victim has had a diving or motor vehicle accident.
What is the priority nursing diagnosis for the person with a neck or spinal injury?

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

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

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

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

39. Figure 16-8

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

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

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

43. Chest Injury
Critical injuries: open pneumothorax, flail chest, massive hemothorax, and cardiac tamponade
Assessment
Note rate and character of respirations, skin color, pulse rate and rhythm, symmetry of the chest wall movement, and the presence of any apparent injuries to the chest
Signs and symptoms of chest injuries that impair respirations are dyspnea, tachycardia, restlessness, cyanosis, asymmetric or other abnormal chest wall movement, abnormal sounds of breathing
Note mental state and level of consciousness
Injuries to the chest can result in serious impairment of respiratory function.
What is the difference between an open and a closed chest injury?

44. Figure 16-9

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

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

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

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

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

50. Burns: Interventions
Ensure a patent airway and respirations for burn victims
Rescue breathing, if needed
See Table 16-4, p. 235
If the burns have been caused by flames, fumes, or chemicals, the victim may have inhaled substances that cause respiratory impairment.

51. 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
Should victims of heat hyperthermia take salt tablets?

52. 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

53. Hypothermia Mild stage Moderate hypothermia Severe hypothermia
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
Hypothermia is classified on the basis of core body temperature as mild (32-35 C), moderate (28-32 C) or severe (<28 C).
Why are older adults susceptible to hyopthermia?

54. 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
Carbon monoxide is an odorless, invisible gas emitted by automobile engines, gas stoves and furnaces, and burning charcoal and other combustible materials.
What happens when carbon monoxide is inhaled?

55. 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
What is the criteria for evaluating the effects of nursing interventions?

56. 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
A hyperbaric chamber uses pressure to force oxygen into the blood and tissues.

57. 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

58. Nursing Diagnosis, Goal, and Outcome Criterion
Risk for injury related to poison
Decrease or minimize risk for injury caused by the poison
What is the criterion for evaluating successful intervention for drug or chemical poisoning?

59. 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
It is helpful to have the product container with you because specific interventions depend on knowing exactly what poison was consumed.
When should syrup of ipecac be used?

60. 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
Victims of food poisoning often recognize the relationship between their symptoms and the ingestion of food.
What are the most common symptoms of food poisoning?

61. 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

62. 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
Most cases of food poisoning can be attributed to improper storage or preparation of perishable foods.
How can food poisonings be prevented?

63. Bites and Stings Assessment Interventions: see Table 16-7, p. 239
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
Snakes, ticks, bees, wasps, household pets, and even humans are capable of causing serious harm by their bites or stings.
What are the most serious affects of bites?

64. 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
A major problem in the United States is the lack of experience in recognizing and treating these infections.
Health care facilities should have readily available information on resources, including the local health department and the Centers for Disease Control and Prevention (CDC).
What events have made us aware that we are vulnerable to attacks using various means?

65. 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
The Red Cross offers courses in disaster training for nurses and nursing students.
What are the competencies for nurses in relation to emergency and disaster preparedness?

66. 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
In the first aid treatment of emergencies outside the hospital, the nurse is expected to demonstrate the same skill, knowledge, and care that would be provided by other nurses in the same community with the same credentials.
What evidence should be preserved in cases involving possible criminal activity?