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First Aid, Emergency Care, and Disaster Management

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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?

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