1. Emergency First Aid Nursing Chapter 24 Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Obtaining Medical Emergency Aid The nurse’s ability to recognize the need for medical assistance and knowledge of how to obtain medical emergency aid can mean the difference between life and death to an injured or ill person. Health care providers must be prepared to provide cardiopulmonary resuscitation (CPR) if needed until emergency medical assistance arrives.

3. Slide 3Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Moral and Legal Responsibilities of the Nurse Good Samaritan Laws  Enacted in most state to protect health professionals from legal liability when providing emergency first aid  Follow a reasonable and prudent course of action Victim must give verbal permission. The law assumes that an unconscious person would give consent if he or she were able. Once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training.

4. Slide 4Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of the Emergency Situation Primary Assessment  Airway  Breathing  Circulation (pulse and severe bleeding) Life-threatening Situations  Arrested or abnormal breathing or pulse Observe for indications of skull injury and brain or spinal cord damage. Fractures, dislocations, and superficial ecchymoses or wounds require attention after the more serious conditions are treated.

5. Slide 5Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Ethical Implications Reasons why individuals choose not to perform CPR  Lack of motivation  Fear of doing harm  Lack of knowledge  Fear of contracting communicable diseases

6. Slide 6Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Ethical Implications Once CPR is started, it may not be discontinued except for the following reasons.  The victim recovers.  The rescuer is exhausted and cannot continue CPR.  Trained medical personnel arrive on the scene and take over CPR.  A licensed physician arrives on the scene, pronounces the victim dead, and orders CPR to be discontinued.

7. Slide 7Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Events Requiring CPR CPR is indicated in any syndrome where respiration or respiration and circulation are absent. Two Purposes of CPR  To keep the lungs supplied with oxygen when breathing has stopped  To keep the blood circulating and carrying oxygen to the brain, heart, and other parts of the body

8. Slide 8Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Events Requiring CPR Clinical Death  The heartbeat and respirations have ceased. Biological Death  This results from permanent cellular damage caused by lack of oxygen.  The brain is the first organ to suffer from lack of oxygen.  In many cases, CPR can reverse clinical death if initiated before 4 minutes of cardiopulmonary arrest.  After 10 minutes without CPR, brain death is certain.

9. Slide 9Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Events Requiring CPR Brain Death  This is an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat.  The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration; pupils that are fixed and dilated; and absent electric activity of the brain on two electroencephalograms (EEGs) performed 12 to 24 hours apart.

10. Slide 10Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult One-Rescuer CPR Airway  Determine responsiveness. Gently shake and shout, “Are you OK?”  Call for help.  Open the airway.  To determine breathlessness Look for the rise and fall of the chest. Listen for sounds of breathing. Feel for the warmth of the victim’s mouth against the cheek.

11. Slide 11Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult One-Rescuer CPR Breathing  Mouth-to-mouth ventilation is the quickest method of supplying oxygen to the victim’s lungs.  Rescuer takes a deep breath, seals the lips around the outside of the victim’s mouth, and gives two full breaths lasting 1.5 to 2 seconds.  If the initial attempt to ventilate the victim is unsuccessful, the rescuer should reposition the head and attempt to ventilate again.  If the second attempt is also unsuccessful, proceed to foreign body airway obstruction management.

12. Slide 12Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult One-Rescuer CPR Circulation  Assess for the presence of the pulse.  Cardiac compressions on a person with a pulse may result in severe damage.  If pulse is present, initiate rescue breathing.  Pulselessness indicates the need for external cardiac compressions.  To determine pulselessness, palpate the carotid pulse.  External cardiac compressions will circulate blood to the heart, lungs, brain, and the rest of the body.

13. Slide 13Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult One-Rescuer CPR Circulation (continued)  External cardiac compressions are performed on the lower half of the sternum with the heel of both hands; elbows are locked, arms straight; the rescuer leans forward, creating pressure to depress the sternum.  Perform 15 compressions and 2 slow breaths for 4 cycles; check the pulse; if no pulse, continue.

14. Slide 14Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult Two-Rescuer CPR When One-Rescuer CPR Is Already in Progress  The most logical time for entrance of the second rescuer is after a completed cycle of 15 compressions and 2 slow breaths.  The second rescuer identifies himself by saying, “I know CPR”; moves to the head; opens the airway; and checks a carotid pulse.  The other rescuer takes position at the chest and finds the proper hand placement for chest compressions.

15. Slide 15Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult Two-Rescuer CPR When No CPR Is in Progress  One rescuer activates EMS while the other initiates one-rescuer CPR.  If the EMS can be activated by another person, the two rescuers should proceed as follows.

16. Slide 16Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. First Rescuer  Determine unresponsiveness.  Position the victim.  Open the airway.  Assess for breathing.  If breathing is absent, say “No breathing” and give 2 ventilations.  Assess for pulse; if pulse is absent, say “No pulse.” Adult Two-Rescuer CPR

17. Slide 17Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult Two-Rescuer CPR Second Rescuer, at the Same Time, Does the Following  Finds the location for external cardiac compressions  Assumes proper hand position  Begins external cardiac compressions after the “No pulse” statement is made by the first rescuer

18. Slide 18Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adult Two-Rescuer CPR Switching Procedures  Switching the positions of the ventilator and the compressor prevents fatigue of both rescuers and allows time for the ventilator to evaluate the effectiveness of CPR.  The switch is initiated by the rescuer performing chest compressions at the end of the 15:2 sequence.  After giving a breath, the ventilator moves to the chest and gets into position to give compressions.  The compressor moves to the head and checks the pulse. If no pulse, state, “Resume CPR.”

19. Slide 19Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant The basic steps of CPR and foreign body airway obstruction management are the same whether the victim is an infant, a child, or an adult. For the purpose of life support  Infant: younger than 1 year  Child: between the ages of 1 and 8 years

20. Slide 20Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant Airway  Unresponsiveness should be determined Gently shake the child; tap the heels of an infant.  Call for help If the rescuer cannot immediately activate EMS, perform BLS for 1 minute before going to activate EMS. Position victim on a firm, flat surface for effectiveness of CPR. Open the airway; do not hyperextend in infants.

21. Slide 21Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant Breathing  Look for movement of the chest, listen for breath sounds, and feel for exhaled airflow.  If there is no breathing, inhale and seal the mouth and nose of the infant.  Two breaths are given, with a pause between each breath; the volume of air in the infant’s lungs is smaller than that in an adult’s; adjust to allow for appropriate rise and fall of the chest.

22. Slide 22Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant Circulation  Assessment of pulse Carotid artery of the child Brachial artery of the infant  If there is a pulse, rescue breathing should be continued at a rate of 1 breath every 3 seconds.  If there is no pulse, external cardiac compressions must be performed.

23. Slide 23Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant Circulation  Infant CPR (two health care providers) Visualize an imaginary line between the nipples. Use a two-thumb, encircling-hands compression technique, performing compressions with the thumbs. The breastbone is compressed to a depth of 0.5 to 1 inch at a rate of at least 100 times per minute. At the end of each compression, pressure is released and the sternum is allowed to return to normal position. The sequence is 5 compressions to 1 breath.

24. Slide 24Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Pediatric CPR Child/Infant Circulation  Child CPR The lower margin of the child’s rib cage is palpated with the middle and index fingers while the head tilt is maintained. Place the heel of the hand on the sternum, avoiding the xiphoid process. The chest is compressed 1 to 1.5 inches, 100 times per minute. The sequence is 5 compressions to 1 breath.

25. Slide 25Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Foreign Body Airway Obstruction Management Food is the most common cause of choking or airway obstruction in the adult. Foreign objects are the most common cause of airway obstruction in children. If the air exchange is good and the victim is able to cough forcibly, do not interfere. The victim should be monitored closely, because he or she may regress to a state of poor exchange.

26. Slide 26Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poor Air Exchange  Weak, ineffective cough  High-pitched, “crowing” noise while inhaling  Increased respiratory difficulty  Cyanosis  Complete airway obstruction: cannot speak, breathe, or cough and may clutch the neck Ask the victim, “Are you choking?” Foreign Body Airway Obstruction Management

27. Slide 27Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Conscious Victim  Abdominal thrusts Abdominal thrusts given below the diaphragm This is an emergency procedure for dislodging a bolus of food or other obstruction from the trachea to prevent asphyxiation. Thrusts put pressure on the diaphragm, forcing air from the lungs to move and expel the foreign object. Foreign Body Airway Obstruction Management

28. Slide 28Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Conscious Victim (continued)  Abdominal thrusts (continued) Stand behind the victim. Wrap your arms around the victim’s waist. Make a fist with one hand and place the thumb of the fist against the middle of the victim’s abdomen slightly above the navel and well below the xiphoid process. Wrap the other hand over the fist into the victim’s abdomen with a quick upward thrust. Repeat thrusts until the foreign body is expelled or the victim becomes unconscious. Foreign Body Airway Obstruction Management

29. Slide 29Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Unconscious Victim  Place victim in a supine position with the face up.  Perform a finger sweep.  Open the airway and attempt to ventilate.  If unsuccessful, perform abdominal thrusts by kneeling astride the victim’s thighs and place the heel of one hand against the victim’s abdomen, in the midline slightly above the navel but well below the xiphoid process; second hand remains on top of the first hand for additional force.  Press into the abdomen with a quick, upward thrust.  Open the mouth and perform a finger sweep. Foreign Body Airway Obstruction Management

30. Slide 30Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Unconscious Victim (continued)  Infant (continued) The infant is straddled over the rescuer’s arm with head lower than the trunk, with the face down. With this arm resting on the rescuer’s thigh, the other arm delivers five back blows between the shoulder with the heel of the hand. The rescuer places his or her free hand on the infant’s back so that the victim is sandwiched between the two hands. Foreign Body Airway Obstruction Management

31. Slide 31Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Unconscious Victim (continued)  Infant (continued) The rescuer turns the infant and places the infant on the rescuer’s thigh with the head lower that than the trunk. Five chest thrusts are performed with the hands in the same position as when performing external cardiac compressions. Foreign Body Airway Obstruction Management

32. Slide 32Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Shock Shock is an abnormal condition of inadequate blood flow to the body’s peripheral tissues, with life- threatening cellular dysfunction, hypotension, and oliguria. It results from failure of the cardiovascular system to provide sufficient blood circulation to the body’s tissues and decreased metabolic waste removal. To maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient volume of blood.

33. Slide 33Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Shock Classification of Shock  Classified according to cause Severe blood loss Intense pain Extensive trauma; burns Poisons Emotional stress or intense emotions Extremes of heat and cold Electrical shock Allergic reactions Sudden or severe illness

34. Slide 34Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Shock Assessment  Level of consciousness  Skin changes  Blood pressure  Pulse  Respirations  Urinary output  Neuromuscular changes  Gastrointestinal effects

35. Slide 35Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Shock Nursing Interventions  Establish airway.  Control bleeding.  Reduce pain.  Position the victim flat with the head slightly lower than the rest of the body (elevate the feet and legs).  If victim is unconscious or is vomiting or bleeding around the nose or mouth, position on the side.  If victim is having breathing problems, elevate head and shoulders.

36. Slide 36Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-10, A Body positions for shock. A, Modified Trendelenburg.

37. Slide 37Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-10, B Body positions for shock. B, If head, neck, or spinal injuries are suspected.

38. Slide 38Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-10, C Body positions for shock. C, Breathing problems.

39. Slide 39Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Shock Nursing Interventions (continued)  Cover victim with a blanket or other covering to keep warm.  Do not give anything to eat or drink.  Relieve pain: support injury; avoid rough handling; adjust tight or uncomfortable clothes.  Do not give analgesics unless directed by a physician.  Provide emotional support and reassurance.

40. Slide 40Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Effects of Blood Loss  Blood loss from internal or external bleeding causes a decrease in oxygen supply to the body.  Blood pressure drops.  Heart pumps faster to compensate for the decreased volume and blood pressure.  The body will attempt to clot the blood to halt bleeding, usually requiring 6 to 7 minutes.  Uncontrolled, bleeding can result in shock and death.

41. Slide 41Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Types of Bleeding  Capillary Most common; results from damaged or broken capillaries and causes oozing of minor cuts, scratches, and abrasions  Venous Occurs when the vein is severed or punctured Results in a slow, even flow of dark red blood Embolism may occur if air enters the severed vein.

42. Slide 42Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Types of Bleeding (continued)  Arterial Least common; usually protected by bones, fat, and other structures Heavy spurting of bright red blood in the rhythm of the heartbeat

43. Slide 43Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Nursing Interventions  Direct pressure The most effective general treatment of bleeding is to apply direct pressure over the bleeding site. Raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body’s ability to clot at this site.

44. Slide 44Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-11 Applying pressure to wound site. (From Sorrentino, S.A. [1996]. Mosby’s textbook for nursing assistants. [4 th ed.]. St. Louis: Mosby.)

45. Slide 45Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Nursing Interventions (continued)  Indirect pressure If direct pressure and elevation do not control bleeding, indirect pressure may be applied to any of the pressure points situated along main arteries.  Application of a tourniquet A tourniquet must be used only when the other methods have failed and the victim’s life is in danger. It can cause extensive damage to the body part.

46. Slide 46Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-12 Applying pressure to wound site. (From Kidd, P.S., Stuart, P.A. [1996]. Mosby’s emergency nursing reference. St. Louis: Mosby.)

47. Slide 47Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Skill 24-1: Step 7 Applying a tourniquet.

48. Slide 48Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Epistaxis  Nosebleed  Common but seldom a serious emergency  Causes Trauma Epistaxis digitorum (trauma from nasal picking) Infections Hypertension Strenuous activity Low humidity

49. Slide 49Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Epistaxis  Nursing interventions Keep the victim’s head tilted slightly forward. Apply steady pressure to both nostrils for 10 to 15 minutes. Remind the victim to breathe through the mouth and to expectorate any accumulated blood. Apply ice compresses over the nose at the same time. Look in the victim’s mouth at the back of the throat to assess for bleeding from a posterior site.

50. Slide 50Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Internal Bleeding  This is a potentially life-threatening situation.  Common causes are fractures, knife or bullet wounds, crushing injuries, organ injuries, and medical conditions such as ruptured aneurysms.  Assessment Signs and symptoms of shock Vertigo Hemoptysis or hematemesis Melena Hematuria

51. Slide 51Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bleeding/Hemorrhage Internal Bleeding  Nursing interventions This is a priority medical emergency. Place on a flat surface with legs elevated. Establish an airway. Cold compress or ice is placed on the area of injury. Maintain body temperature with blankets. Assess vital signs. Oxygen may be ordered by the physician.

52. Slide 52Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Wounds and Trauma Closed Wounds  The underlying tissue of the body is involved; the top layer of skin is not broken.  Ecchymoses (bruises) and contusions occur.  Signs and symptoms Edema, discoloration, deformity, shock, pain and tenderness, and signs of internal bleeding  Nursing interventions Small wound: ice packs and elastic bandage Large wound: treat for shock; cold compresses and pressure bandage

53. Slide 53Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Wounds and Trauma Open Wounds  Openings or breaks in the mucous membrane or skin  Always danger of bleeding or infection  Types Abrasions Puncture wounds Incisions Lacerations Avulsions Chest injuries

54. Slide 54Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-13 Flail chest. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6 th ed.]. St. Louis: Mosby.)

55. Slide 55Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Wounds and Trauma Dressings and Bandages  General principles of bandaging Bleeding should be controlled before bandage is applied. Use sterile material if possible; if not use, the cleanest material possible. Dressing should never cover the entire wound. Wounds should be bandaged firmly but not too tightly. Bandage in alignment is desired. Tips of fingers and toes should remain exposed if possible.

56. Slide 56Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Wounds and Trauma Application of Common Types of Bandages  Bandage compress Most common type of dressing; consists of several thicknesses of gauze, covered with tape or gauze  Triangular bandage Made of a piece of cloth that is folded diagonally and cut along the fold; used as a sling to support injured bones  Roller bandage Used to support an injured part apply pressure to a dressing, or secure a splint to immobilize a part

57. Slide 57Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-14 Use of roller bandage. (From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2 nd ed.]. Philadelphia: Saunders.)

58. Slide 58Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons General Assessment of Poisonings  Signs and symptoms may be delayed for hours.  Indications may be respiratory distress; nausea, vomiting, or diarrhea; seizures; decreased level of consciousness; restlessness, delirium, agitation; color changes; signs of burns; pain on swallowing; unusual urine color; abnormal constriction or dilation of pupils; abnormal eye movement; skin irritation; and shock or cardiac arrest.

59. Slide 59Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Ingested Poisons  Poisoning by mouth is the most common type of poisoning, especially in children.  Common substances include household cleaning products, garden and garage supplies, drugs, medications, food, and plants.

60. Slide 60Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Ingested Poisons  Nursing interventions Immediately call the poison control center. Maintain airway. Possible instructions by the poison control center  Dilute the poison by giving one or two glasses of water.  Induce vomiting if gag reflex is present and poison is not a corrosive. Treat for shock and administer CPR if needed.

61. Slide 61Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Inhaled Poisons  Common sources Carbon monoxide, carbon dioxide, and refrigeration gases; poisonous fumes from chlorine and other liquid chemical sprays  Nursing interventions Remove victim from the dangerous area only if there is no danger to the rescuer. Maintain airway; perform CPR if needed. Victim should remain quiet and inactive while being transported to the nearest medical facility.

62. Slide 62Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Absorbed Poisons  Poisons, caustic chemicals, and poisonous plants that come in contact with the skin  Causes burning, skin irritation, allergic responses, or severe system reactions  Signs and symptoms Nausea, vomiting, diarrhea, flushed skin, dilated pupils, cardiovascular abnormalities, and CNS reactions

63. Slide 63Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Absorbed Poisons  Nursing interventions Quickly remove the source of the irritation; wash with soap and water. Skin preparations include baking soda, Burow’s solution, and oatmeal. Calamine lotion and hydrocortisone cream are effective to relieve pruritus.

64. Slide 64Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Poisons Injected Poisons  Minor reactions to insect bites Remove stinger, if present, by scraping. Wash the bite with soap and water. Apply cold packs; baking soda paste.  Severe reactions to insect bites Urticaria, wheezing, edema of the lips and tongue, generalized pruritus, and respiratory arrest Nursing interventions  Apply a wide constricting band proximal to the wound; keep affected part in dependent position; transport to the hospital immediately.

65. Slide 65Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Drug and Alcohol Emergencies Alcohol  Mild intoxication signs and symptoms Nausea, vomiting, diarrhea, lack of coordination, and poor muscle control, flushing, erythema of the face and eyes, visual disturbances, rapid mood swings, slurred or inappropriate speech, inappropriate behavior and lethargy  Serious intoxication signs and symptoms Drowsiness to coma, rapid weak pulse, depressed, labored breathing or respiratory arrest, loss of control of urinary and bowel functions, disorientation, restlessness, and hallucinations

66. Slide 66Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Drug and Alcohol Emergencies Drugs  Signs and symptoms Loss of reality orientation, hallucinations, and varying degrees of consciousness; slurred speech; extremes in mood swings; inappropriate behavior; anxiety; flushed skin; diaphoresis; lack of coordination; impaired judgment; increased or decreased pulse; pupils constricted or dilated; needle marks on the arms, legs, and neck

67. Slide 67Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Drug and Alcohol Emergencies Nursing Interventions  Obtain information about the substance ingested.  Life-threatening situations are handled first.  Establish airway.  If unconscious, turn on the side.  Loosen clothing.  If fever is present, apply cool, wet compresses.  Protect the victim from injury during a seizure or hallucination.  Carefully assess mental status and vital signs frequently.

68. Slide 68Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Heat Injury  Heat exhaustion The most common type of heat injury, this results from prolonged perspiration and the loss of large quantities of salt and water. Observe for signs and symptoms of headache, vertigo, nausea, weakness, and diaphoresis. Mental disorientation and brief loss of consciousness may occur.

69. Slide 69Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Heat Injury (continued)  Heat exhaustion (continued) Nursing interventions  Cool the victim as quickly as possible; use cold, wet compresses and fan or air conditioner.  Have victim lie down with feet elevated.  If alert, give one-half glass of water every 15 minutes for 1 hour.  In the clinical setting, IV fluids are given.

70. Slide 70Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Heat Injury (continued)  Heatstroke This is a more serious heat injury; death can result. The most common cause is vigorous physical activity in a hot, humid environment. The body becomes overheated, but the cooling mechanism of perspiration does not operate. Assessment: rapidly rising body temperature; hot, dry, erythemic skin; no visible perspiration; pulse rapid initially and then slow and blood pressure falls; breathing deep and rapid; victim complains of headache, dry mouth, nausea, and vomiting

71. Slide 71Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Heat Injury (continued)  Heatstroke (continued) Nursing interventions  Cool the victim as quickly as possible; use cold packs around the victim’s neck, under the arms, and around the ankles to cool the blood in the main arteries.  Establish and maintain an airway.  Monitor for chilling as the body temperature falls.

72. Slide 72Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Exposure to Excessive Cold  Hypothermia Lowering of the body temperature below the normal level; 95° F or below Assessment  Uncontrollable shivering but ceases when body temperature drops below 90° F  Slurred speech, memory lapses, disorientation and poor judgment, uncoordinated gait, skin mottled and edematous, weak irregular pulse, decreased respiratory rate, loss of all reflexes

73. Slide 73Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Exposure to Excessive Cold (continued)  Hypothermia Nursing interventions  Initiate CPR if necessary; must continue until the body is rewarmed.  Place victim in a supine position with the head lower than the feet.  Rewarm slowly: move to a warm area, remove wet clothing, and wrap with warm blankets.

74. Slide 74Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Exposure to Excessive Cold (continued)  Frostbite Freezing and damage of body cells Commonly affected area are ears, nose, fingers, and toes. Assessment: initially, skin takes on a red flush with numbness, tingling, and pain; progressively, the part becomes hard and loses all sensation; color turns to grayish white; if thawing occurs, may change to blue-purple or black; edema may develop, followed by blisters.

75. Slide 75Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Thermal and Cold Emergencies Exposure to Excessive Cold (continued)  Frostbite (continued) Nursing interventions  Treat the victim for shock and hypothermia; establish and maintain an airway.  Warm part by immersion in warm water at 104 to 110° F for 20 to 45 minutes.  If tub is not available, may use a hot moist towel.  Be very careful not to rub the part.  The thawed part is wrapped in clean towels or bulky dressings and elevated.

76. Slide 76Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Fractures  A break in the continuity of a bone  Types of common fractures Open or compound fracture Closed fracture Comminuted fracture Greenstick fracture Spiral fracture Impacted fracture Compressed fracture Depression fracture

77. Slide 77Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Fractures  Assessment Radiography can determine if a bone is fractured. There is pain and tenderness in the area and pain during movement. Deformity of the limb may be obvious, with edema and discoloration of the area. Fragments of bone may be protruding through the skin. Crepitus: grating sound is heard when the affected part is moved.

78. Slide 78Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Fractures  Nursing interventions Do not move unless he or she is in danger. ABCs of first aid take priority. Control bleeding if present. Immobilize the fracture but do not attempt to realign the bone. Monitor circulation in the limb. Apply ice or cold packs to the area.

79. Slide 79Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 24-15 Immobilization of fractured arm. (From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2 nd ed.]. Philadelphia: Saunders.)

80. Slide 80Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Dislocations  Occurs in joints; usually results from a blow or fall  Assessment: complaints of pain and edema; deformity of the part; part may be rigid, and the victim is unable to move it.  Nursing interventions: never attempt to reduce a dislocation; splint the joint; apply ice or cold packs.

81. Slide 81Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Skill 24-2: Step 4 Applying an arm splint using a triangular (sling and swathe) bandage.

82. Slide 82Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Strains and Sprains  Strains are injuries to muscle tissue from stretching and tearing due to overexertion.  Sprains are injuries to joints resulting from stretched or torn ligaments due to twisting of the joint beyond the normal range of motion.  Assessment Strains: spasms of the muscle, acute pain, stiffness, and weakness on movement; back pain radiating down the leg; discoloration Sprains: pain or tenderness around a joint; immobility of the joint; rapid and marked edema

83. Slide 83Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Strains and Sprains  Nursing Interventions RICE  Rest the affected extremity  Ice should be applied to the part  Compression with a compression bandage  Elevation above the level of the heart

84. Slide 84Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Bone, Joint, and Muscle Injuries Spinal Cord Injuries  Assessment Assess for paralysis. Test for sensation. Assess for abrasions and ecchymosis on the back.  Nursing interventions Take spinal cord precautions. Maintain airway; keep head in a neutral position.

85. Slide 85Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Skill 24-3: Step 1, A and B Moving the victim with a suspected spinal cord injury.

86. Slide 86Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Burn Injuries Shallow Partial-Thickness Burns  Involves the outer layer of the skin  Caused by simple sunburns or burns from contact with hot objects  Nursing interventions The burn should be cooled immediately by soaking in cold water or applying cold compresses. A sterile dressing should be placed over the burn to prevent infection.

87. Slide 87Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Burn Injuries Deep Partial-Thickness Burns  Involve the entire first layer of skin (epidermis) as well as some of the underlying tissue.  Severe sunburn, scalding liquids, direct flame, and chemical substances.  Assessment Deep erythema of the skin, or mottled skin with blister formation. Weeping of fluid through the skin surface and intense pain.

88. Slide 88Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Burn Injuries Full-Thickness Burns  These burns involve destruction of the skin and underlying tissue, including fat, muscle, and bone.  Skin may be thick and leathery, with black or dark brown, cherry red, or dry and milky white colors.  The victim may not complain of pain, because nerve endings may be severed.  Wounds weep a great deal of fluid and blood.  Causes: direct flame, explosions, and gasoline or oil fires

89. Slide 89Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Deep Partial-Thickness Burns and Full-Thickness Burns  Nursing interventions Establish airway. Assess respiratory and cardiac function. Remove all of victim’s clothing, shoes, and jewelry. Administer CPR if necessary. Treat for shock. Cool the burn with cool compresses for partial-thickness burns. Avoid touching the burn with anything but sterile dressings. Burn Injuries

90. Slide 90Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process Nursing Diagnoses  Confusion, acute  Tissue perfusion, ineffective  Anxiety  Cardiac output, decreased  Hyperthermia or hypothermia  Skin integrity, impaired  Airway clearance, ineffective  Pain, acute and chronic  Posttrauma syndrome  Infection, risk for

91. Slide 91Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Terrorism and Bioterrorism Terrorism: Violent or dangerous used to coerce or intimidate Bioterrorism: Use of biological agents High-risk syndromes OSHA guidelines Chemical terrorism Nuclear terrorism