diagnoses.

EMERGENCY NURSING  Identifies expected outcomes, and evaluates

the care provided against these.
• Care given to patients with urgent and  Proactively modifies plans of care to ensure it
critical needs continually meets a patient's needs.
• Also for non-urgent cases or  Recognises their learning needs, and engages
whatever the patient or family in professional development.
considers an emergency  Ensures open and timely communication
• Serious life-threatening cardiac with patients, families and other staff.
conditions (Myocardial infarction,  Provides care which is patient-centred and
Acute heart failure, Pulmonary collaborative, wherever possible.
edema Cardiac dysrhythmias)  Adheres to accepted, established and
relevant practice standards and legislation.
 Engages, at all times, in professional activities
• Emergency nursing involves the episodic and behaviours.
care of people with physical and / or  Values life, dignity, worth, autonomy and
psychological health problems. These health individuality, etc.
problems:
Legal and ethical considerations in emergency
(1) may result from injury and / or illness, nursing
(2) are usually acute, and
(3) require further, often immediate, investigation Consent
and / or intervention. • Consent is the agreement of a patient to
submit to proposed investigation or
• Emergency nurses care for people of all treatment.
ages, and work with conditions which may • it is a fundamental requirement in all nursing
affect any - or, indeed, all - of the body's settings
systems. • may be provided in written, verbal or non-
• emergency nursing care is provided in a way verbal form
that is patient centred • may also be refused or withdrawn at any
• Emergency nursing care may be delivered in time, if a patient considers this in their best
a variety of settings - including in accident interest - even if this places their wellbeing at
and emergency (A&E) departments, minor risk
injury units, ambulance or other acute • it must be given voluntarily by an
transport services, out-of-hours walk-in appropriately informed person who has the
centres and in the armed forces. capacity to consent to the intervention in
• These settings usually allow for the question" (Department of Health, 2009: p. 9).
unplanned or unscheduled presentation of a Duty of Care
patient, often without prior warning, either • owed by a nurse to any person - and
via self-referral or referral from another particularly patients - who may be affected
service. by their actions, advice or admissions.
• As with general nursing, emergency nurses • breach of duty of care occurs when a nurse
work within the assessment → planning → fails to do what a 'reasonable' person would
intervention → evaluation (APIE) do in a similar situation, or does what a
framework. 'reasonable' person would not do.
• To maintain your duty of care, you must
Values of emergency nursing practice within your scope.
The emergency nurse… • A nurse may be found legally negligent if
 Provides care which is comprehensive, they work outside their scope of practice,
accurate and ongoing. breach their duty of care, and cause damage
 Utilises clinical judgement to analyse to the patient
assessment data and make nursing • To avoid breaching your duty of care and
practicing negligently, you must be familiar
 with, and work within, your own scope of problem solving in this
practice at all times. environment
▪ Nursing assessment must be
Restraint continuous, and nursing diagnoses
• restricting a patient's movement, change with the patient’s condition
with the intention of protecting ▪ Although a patient may have several
their own and / or others' safety - diagnoses at a given time, the focus
can be used in managing patients is on the most life-threatening ones
who are violent or aggressive, and ▪ Both independent and
particularly those who are mentally interdependent nursing
ill, intoxicated or otherwise interventions are required
incapacitated.
There are two types of restraint: Emergency Nursing in Disasters
(1) physical restraint, or the restriction of • The emergency nurse must expand his
movement by physical or mechanical or her knowledge base to encompass
means, and recognizing & treating patients
(2) chemical restraint, usually via the exposed to biologic and other terror
administration of sedative medication. weapons
• The emergency nurse must
Privacy and confidentiality anticipate nursing care in the
• understand with whom, and under event of a mass casualty
what circumstances, they are incident.
permitted to share a patient's
confidential information Documentation of Consent
• Nurses must also ensure they are • Consent to examine and treat the
familiar with their organisation's patient is part of the ER record.
systems for the collection, recording • The patient must consent to invasive
and storage of a patient's procedures unless he or she is
confidential information in the busy, unconscious or in critical condition and
fast-paced emergency care settings. unable to make decisions.
• If the patient is unconscious and
The Emergency Nurse brought to the ER without family or
• Applies the ADPIE on the human friends, this fact should be
responses of individuals in all age documented
groups whose care is made difficult by • After treatment, a notation is made on
the limited access to past medical the record about the patient’s
history and the episodic nature of condition on discharge or transfer and
their health care about instructions given to the patient
• Triage and prioritization. and family for follow-up care.
• Emergency operations preparedness.
• Stabilization and resuscitation. Exposure to Health Risks
• Crisis intervention for unique • All emergency health care providers
patient populations, such as should adhere strictly to standard
sexual assault survivors. precautions for minimizing exposure.
• Provision of care in • Early identification and adherence
uncontrolled and to transmission-based precautions
unpredictable environments. for patients who are potentially
• Consistency as much as possible infectious is crucial.
across the continuum of care • ER nurses are usually fitted with a
personal high-efficiency particulate air
The Nursing Process (HEPA)-filter mask apparatus to use
▪ Provides logical framework for when treating patients with airborne
 diseases. treated as if conscious (i.e. touching,
calling by name, explaining
Providing Holistic Care procedures)
• Sudden illness or trauma is a stress • As the patient regains
to physiologic and psychosocial consciousness, the nurse should
homeostasis that requires orient the patient by stating his or
physiologic & psychological healing. her name, the date, and the location.
• When confronted with trauma, severe
disfigurement, severe illness, or Family-Focused Interventions
sudden death, the family experiences • The family is kept informed about
several stages of crisis beginning with where the patient is, how he or she
anxiety, and progress through denial, is doing, and the care that is being
remorse & guilt, anger, grief & given.
reconciliation. • Allowing the family to stay with the
• The initial goal for the patient and patient, when possible, also helps
family is anxiety reduction, a allay their anxieties.
prerequisite to recovering the ability • Additional interventions are based
to cope. on the assessment of the stage of
• Assessment of the patient and crisis that the family is experiencing
family’s psychological function • Helping Cope With Sudden Death
includes evaluating emotional • Take the family to a private place.
expression, degree of anxiety, and • Talk to the family together, so
cognitive functioning. they can mourn together.
• Reassure the family that
Nursing Diagnoses everything possible was done;
• Possible nursing diagnoses include: inform them of the treatment
Anxiety related to uncertain potential rendered.
outcomes of the illness or trauma and • Show the family that you care by
ineffective individual coping related to touching, offering coffee, and offering
acute situational crises the services of the chaplain.
• Possible diagnoses for the family
include: Anticipatory grieving and
alterations in family processes related Helping Them Cope With Sudden Death
to acute situational crises
• Encourage family members to support
each other & to express emotions
Patient-Focused Interventions
freely.
• Those caring for the patient
• Avoid giving sedation to family
should act confidently and
members; this may mask or delay
competently to relieve anxiety.
the grieving process, which is
• Reacting and responding to the necessary to achieve emotional
patient in a warm manner promotes equilibrium and to prevent
a sense of security. prolonged depression.
• Explanations should be given on a • Encourage the family to view the
level that the patient can body if they wish; this action helps
understand, because an informed integrate the loss.
patient is better able to cope
• Spend time with the family, listening
positively with stress.
to them and identifying any needs
• Human contact & reassuring words that they may have.
reduce the panic of the severely
• Allow family members to talk about
injured person and aid in dispelling
the deceased and what he or she
the fear of the unknown.
meant to them; this permits
• The unconscious patient should be
 ventilation of feelings of loss. 5. Black – Patient is dead or
• Avoid volunteering progressing rapidly towards
unnecessary information. death

Discharge Planning • Triage Tags should be used on all

• Instructions for continuing care are calls involving 3 or more
given to the patient and the family or patients.
significant others. • The general placement location should
• All instructions should be given be on one of the patient’s arms.
not only verbally but also in • When a triage tag has been utilized,
writing, so that the patient can remember to document the tag number in
refer to them later. the history portion of your run report.
• Instructions should include
information about prescribed “E”– Cart
medications, treatments, diet, • Located in designated areas where
activity, and contact info as well as medical emergencies and
follow-up appointments. resuscitation is needed
• Purpose: to maximize the efficiency in
Principles of Emergency Room Care locating medications/supplies needed for
emergency situations.
Triage: comes from the French word trier, • Drawer 5: Contains respiratory
which means "to sort;” A method to quickly supplies such as oxygen tubing, a
evaluate and categorize the patients requiring flow meter, a face shield, and a bag-
the most emergent medical attention. valve-mask device for delivering
artificial respirations
ER Triage • Drawer 4: Contains suction supplies &
• Emergent (immediate): patients gloves
have the highest priority; must be • Drawer 3: Contains intravenous fluids
seen immediately • Drawer 2: Contains equipment for
• Urgent (delayed or minor): patients establishing IV access, tubes for
have serious health problems, but not laboratory tests, and syringes to flush
immediately life-threatening ones; medication lines.
seen w/in 1 hour • Drawer 1: Contains medications
• Non-urgent (minor or support): needed during a code such as
patients have episodic illnesses epinephrine, atropine, lidocaine, CaCl2
addressed within 24 hours. and NaHCO3
• The back of the cart usually houses the
cardiac board.
Determination of Priority in ER Triage:
Classified based on principle to benefit the
largest number of people Assessment and Intervention in the ER
The Primary Survey: Focuses on stabilizing
Determination of Priority in Field Triage life- threatening conditions; employs the ABCD
• Critical clients are given lowest priority Method
Victims who require minimal care and can
be of help to others are treated first. The ABCD Method
1. Red – Emergent (immediate) Airway - Establish the airway
2. Yellow – Immediate (delayed) Breathing - Provide adequate ventilation
3. Green – Urgent (minor) Circulation - Evaluate & restore cardiac output by
4. Blue – Fast track or psychological controlling hemorrhage, preventing & treating
support needed shock, and maintaining or restoring effective
circulation
Disability - Determine neurologic disability by o In adults, aspiration of a bolus of
assessing neuro function using the Glasgow meat is the most common cause.
Coma Scale o In children, small toys, buttons,
coins, and other objects are
Eye opening response commonly aspired in addition to
Spontaneous 4 food.
To voice 3
To pain 2
None 1 Clinical Manifestations
1. Choking
Verbal response 2. Apprehensive appearance
3. Inspiratory & expiratory stridor
4. Labored breathing
Oriented 5 5. Flaring of nostrils
Confused 4 6. Use of accessory muscles
Inappropriate words 3 (suprasternal & intercostal
Incomprehensible sounds 2 retractions)
None 1 7. ñ anxiety, restlessness, confusion
8. Cyanosis & loss of consciousness
Motor response develops as hypoxia worsens.
Obeys command 6
Assessment and Diagnostics
Localizes pain 5
• Involves simply asking whether the
Withdraws 4
patient is choking & requires help
Flexion 3
Extension 2 • If unconscious, inspection of the
None 1 oropharynx may reveal the object.
• X-rays, laryngoscopy, or bronchoscopy
may also be performed.
Assess and Intervene: The Secondary • For elderly patients, sedatives &
Survey hypnotic medications, diseases
includes: affecting motor coordination, &
• A complete health history & head- mental dysfunction are risk factors for
to-toe assessment asphyxiation of food.
• Diagnostic & laboratory testing • Victims cannot speak, breath or cough.
• Application of monitoring devices • If victim can breathe spontaneously,
• Splinting of suspected fractures partial obstruction should be suspected;
• Cleaning & dressing of wounds the victim is encouraged to cough it out.
• Performance of other necessary • If the patient has a weak cough, stridor,
interventions based on the patient’s DOB & cyanosis, do the Heimlich.
condition. After the obstruction is removed, rescue
breathing is initiated; if the patient has no
Airway Obstruction pulse, start cardiac compressions.

• An acute upper airway obstruction is a Head-Tilt-Chin-Lift Maneuver

blockage of the upper airway, which can 1. Place the patient on a firm, flat surface.
be in the trachea, laryngeal (voice box), 2. Open the airway by placing one hand
or bronchi areas on the victim’s forehead, and apply
• Causes: Viral and bacterial infections, fire firm backward pressure with the palm
or inhalation burns, chemical burns and to tilt the head back.
reactions, allergic reactions, foreign 3. Place the fingers of the other hand
bodies, and trauma. under the bony part of the lower jaw
near the chin & lift up
 4. Bring the chin and teeth forward to both
support the jaw • External: Laceration, avulsion, GSW,
Jaw-Thrust Maneuver stab wound
1. Place the patient on a firm, flat surface. • Internal: Bleeding in body cavities and
2. Open the airway by placing one internal organs
hand on each side of the victim’s
jaw, followed by grasping and
lifting the angles, thus displacing Assessment
the mandible forward. • Results in reduction of circulating
blood vol., w/c is the principal
Oropharyngeal Airway Insertion cause of shock
A semicircular tube or tube-like plastic device • Signs and symptoms of shock:
inserted over the back of the tongue into the 1. Cool, moist skin
lower pharynx 2. Hypotension
Used in a patient who is breathing 3. Tachycardia
spontaneously but unconscious. 4. Delayed Capillary Refill
5. Oliguria

ET Intubation: Indications Management

1. To establish an airway for patients  Fluid Replacement
who cannot be adequately  Two large-bore intravenous cannulae are
intubated with an oropharyngeal inserted to provide a means for fluid and
airway. blood replacement, and blood samples are
2. To bypass an upper airway obstruction obtained for analysis, typing, & cross-
3. To prevent aspiration matching.
4. To permit connection of the  Replacement fluids may include
patient to a resuscitation bag or isotonic solutions (LRS, NSS), colloid,
mech. ventilator and blood component therapy.
5. To facilitate removal of • Packed RBCs are infused when
tracheobronchial secretions there is massive hemorrhage
• In emergencies, O(-) blood is used for
women of child-bearing age.
Cricothyroidotomy • O(+) blood is used for
• Used in the following emergencies in men and postmenopausal
w/c ET intubation is contraindicated: women.
1. Extensive maxillofacial trauma • Additional platelets and clotting factors
2. Cervical spine injuries are give when large amounts of blood is
3. Laryngospasm needed.
4. Laryngeal edema
5. Hemorrhage into neck tissue
6. Laryngeal obstruction Control of External Hemorrhage
▪ Physical assessment is done to identify
Nursing Diagnoses For Airway Obstruction area of the hemorrhage.
1. Ineffective airway clearance due to ▪ Direct, firm pressure is applied
obstruction of the tongue, object, or over the bleeding area or the
fluids (blood, saliva) involved artery.
2. Ineffective breathing pattern ▪ A firm pressure dressing is applied, and
due to obstruction or injury the injured part is elevated to stop
venous & capillary bleeding if possible.
Hemorrhage ▪ If the injured area is an extremity,
it is immobilized to control blood
• Bleeding that may be external, internal or loss.
Control of Bleeding: Tourniquets
 Applied only as a last resort just proximal Hypovolemic Shock: Management
to the wound and tied tightly enough to 1. Rapid blood and fluid replacement; blood
control arterial blood flow; tag the client component therapy optimizes cardiac
with a “T” stating the location and the preload, correct hypotension, & maintain
time applied tissue perfusion
 Loosened periodically to prevent 2. Large-bore intravenous needles or
irreparable vascular on neuro damage catheters are inserted into peripheral
 If still with arterial bleeding, remove vv.
tourniquet and apply pressure dressing 3. A central venous pressure catheter may
 If traumatically amputated, the also be inserted in or near the RA.
tourniquet remains in place until the 4. LRS approximates plasma
OR. electrolyte composition and
osmolarity
Control of Internal Bleeding 5. A Foley catheter is inserted to
• Watch out for tachycardia, hypotension, record urinary output every
thirst, apprehension, cool and moist skin, hour; urine volume indicates
or delayed capillary refill. adequacy of kidney perfusion
• Packed RBC are administered at a rapid 6. Ongoing nursing surveillance of the total
rate, and the patient is prepped for OR. patient is maintained to assess the
• Arterial blood is obtained to evaluate patient’s response to treatment; a flow
pulmonary perfusion & to establish sheet is used to document parameters
baseline hemodynamic parameters 7. Lactic acidosis is a common side
• Patient is maintained in a supine position effect & causes poor cardiac
and closely monitored. performance

Hypovolemic Shock Wounds

 A condition where there is loss of effective • A type of physical trauma wherein the
circulating blood volume due to rapid fluid skin is torn, cut or punctured (open
loss that can result to multi-organ failure wound), or where blunt force trauma
 Causes causes a contusion (closed wound).
1. Massive external or internal bleeding • Specifically refers to a sharp injury which
2. Traumatic, vascular, GI and damages the dermis of the skin.
pregnancy related • Types of Wounds
3. Burns o Open (Incised wound,
Nursing Diagnoses for Hypovolemic Shock Laceration, Abrasion, Puncture
1. Altered tissue perfusion related to wound, Gunshot wound)
failing circulation o Closed (Contusion, Hematoma,
2. Impaired gas exchange related to Crushing injury)
a V-P imbalance
3. Decreased cardiac output Incised Wound
related to decreased • A clean cut by a sharp edged object
circulating blood volume such as glass or metal.
• As the blood vessels at the wound
Clinical Manifestations edges are cut straight across, there may
1. Weakness, lightheadedness, and be profuse bleeding
confusion
2. Tachycardia
3. Tachypnea Laceration
4. Decrease in pulse pressure • Ripping forces or rough brushing
5. Cool clammy skin against a surface which can cause
6. Delayed capillary refill
 rough tears in the skin or lacerations.
• Laceration wounds are usually bigger Wound Management
and can cause more tissue damage due 1. Use of antibiotics depends on how the
to the size of the wound. injury occurred, the age of the wound, &
the risk for contamination
2. Site is immobilized & elevated to
Abrasion limit accumulation of fluid
3. Tetanus prophylaxis is administered based
• Superficial wounds that occur at the on the condition of the wound and the
surface of the skin. immunization status
• Friction burns and slides can cause
abrasion Wound Healing: By First Intention
• Characteristic in the way that only
• Occurs when tissue is cleanly incised and
the top most layer of the skin is
re- approximated and healing occurs
scrapped off.
without complications.
• Bleeding is not profuse though wounds
• The incisional defect re-epithelizes rapidly
and matrix deposition seals the defect.
Puncture Wound
• Small entry site
Wound Healing: By Second Intention
• Though not large in surface area, wounds
• Healing occurs in open wounds.
are deep and can cause great internal
• When the wound edges are not
damage.
approximated and it heals with formation
of granulation tissue, contraction and
Gunshot Wound (GSW)
eventual spontaneous migration of
• Caused by firing bullets or any other
epithelial cells.
small arms.
• Have a clean entry site but a large and Wound Healing: By Third Intention
ragged exit site.
• Occurs when a wound is allowed to heal
open for a few days and then closed as if
Contusion a.k.a. bruise: Caused by blunt
primarily.
force trauma that damages tissue under the
• Such wounds are left open initially
skin
because of gross contamination.
Hematoma: Also called a blood tumor
Trauma
• Caused by damage to a blood vessel
that in turn causes blood to collect
• The unintentional or intentional wound or
under the skin
injury inflicted on the body from a
• Caused by a great or extreme amount of
mechanism against w/c the body cannot
force applied over a long period of time
protect itself
Patterned Wound: Wound representing the
• Leading cause of death in children
outline of the object (e.g. steering wheel)
and in adults younger than 44 y/o
causing the wound
• Alcohol & drug abuse are implicated in
Management: Wound Cleansing both blunt & penetrating trauma
1. Hair around wound may be shaved. • Collection of Forensic Evidence: Included
2. NSS is used to irrigate the wound. in documentation are the ff:
3. Betadine & hydrogen peroxide are only 1. Descriptions of all wounds
used for initial cleaning & aren’t allowed 2. Mechanism of injury
to get deep into the wound without 3. Time of events
thorough rinsing. 4. Collection of evidence
4. Use local or regional block 5. Statements made by the patient
anesthetics if indicated.
• If suicide or homicide is suspected in a
 deceased patient, the medical examiner 3. WBC count to detect elevation
will examine the body on site or have it associated with trauma
moved to the medico-legal office for 4. Serum amylase to detect
autopsy. pancreatic or GIT injury
• All tubes & lines are left in place.
• Patient’s hands are covered with paper
bags to protect evidence. PE for Internal Bleeding
 Inspect body for bluish
Injury Prevention Components discoloration, asymmetry,
1. Education: Provide information and abrasion, & contusion
materials to help prevent violence,  FAST (Focused Assessment for
and to maintain safety at home and Sonographic Examination of the
in vehicles. Trauma Patient) exam through CT
2. Legislation: Provide universal scan to assess hemodynamically
safety measures without unstable patients and detect
infringing on rights (Seatbelt intraperitoneal bleeding
Law).  Pain in the left shoulder is common
3. Automatic Protection: Provide in a patient with bleeding from a
safety without requiring personal ruptured spleen.
intervention (Airbags, seatbelts).  Pain in the right shoulder can result
High incidence of injury to from a laceration of the liver.
hollow organs, particularly the  Administration of opioids is avoided
small intestines during the observation period.
The liver is the most frequently
injured solid organ.
High velocity missiles create extensive
tissue damage. Trauma: Genitourinary Injury
• A rectal or vaginal exam is done to
Intra-abdominal Injuries: Blunt (MVA, falls, determine any injury to the pelvis,
blows) bladder, and intestinal wall.
Associated with extra-abdominal injuries to • To decompress the bladder & monitor
chest, head, extremity urine output, a Foley catheter is inserted
Incidence of delayed & trauma-related AFTER DRE.
complications is higher • A high-riding prostate gland
Leads to massive blood loss into the indicates a potential urethral
peritoneal cavity injury.

Trauma: Assessment Trauma: Management of Intra-abdominal

1. Inspection of abdomen for signs of Injuries
injury (bruises, abrasions) 1. A patent airway is maintained.
2. Auscultation of bowel sounds 2. Bleeding is controlled by applying direct
3. Watch out for signs of pressure to any external bleeding wounds
peritoneal irritation like & by occlusion of any chest wounds.
distention, involuntary guarding, 3. Circulating blood vol. is maintained with
tenderness, pain, muscular intravenous fluid replacement including
rigidity, or rebound tenderness blood component therapy.
together with absent BS. 4. In blunt trauma, cervical spine
immobilization is maintained until cervical
Trauma: Diagnostic Findings x-rays have been obtained & injury is
1. Urinalysis to detect hematuria ruled out.
5. All wounds are located,
2. Serial hematocrit to detect
counted & documented.
presence or absence of bleeding
 6. If abdominal viscera protrude, the area person responsible for coordinating
is covered with sterile, moist saline the treatment
dressing to prevent drying. • Immediately after injury, the
7. Oral fluids are withheld and stomach body is hypermetabolic,
contents are aspirated with an NGT in hypercoagulable, and severely
anticipation of surgery. stressed.
Tetanus and broad-spectrum antibiotics • Mortality is related to the severity
are given as prescribed. & the number of systems
8. If still with evidence of shock, blood loss, involved.
free air under the diaphragm,
evisceration, hematuria or suspected Multiple Injuries: Nursing Responsibilities
abdominal injury, transport to OR. 1. Assessing & monitoring the patient
2. Ensuring venous access
Trauma: Crushing Injuries 3. Administering prescribed meds
 Occur when a person is caught 4. Collecting laboratory specimens
between objects, run over by a 5. Documenting activities and the
moving vehicle, or compressed by patient’s response
machinery 6. Gross evidence may be slight or absent;
 Watch out for hypovolemic shock from the injury regarded as the least significant
extravasation of blood & plasma into may be the most lethal.
injured tissues after compression has 7. Determine the extent of injuries &
been released. establish priorities of treatment
(ABC’s)
Crushing Injuries: Assessment 8. Establish airway & ventilation.
• Watch out for paralysis of a body part, 9. Control hemorrhage.
erythema & blistering of skin, damaged 10. Prevent & treat hypovolemic shock &
part appearing swollen, tense & hard. monitor intake & output.
• Renal dysfunction is secondary to 11. Assess for head & neck injuries.
prolonged hypotension. 12. Evaluate for other injuries – reassess
head & neck, chest; assess abdomen,
back & extremities.
• Myoglobinuria is secondary to muscle
13. Splint fractures.
damage causing ARF.
14. Carry out a more thorough and
• In conjunction with ABC’s, the
ongoing examination &
patient is observed for acute
assessment.
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
 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
FRACTURES fracture & some traction is applied
while the other hand is placed
• When a client is being examined for a beneath the fracture for support.
fracture, the body part is handled gently 2. The splint should extend beyond the
& as little as possible. joints adjacent to the fracture.
• Clothing is cut off to visualize the 3. Upper extremities must be
body & assessment is done for pain splinted in a functional position.
over or near a bone, swelling, & 4. If a fracture is open, moist, sterile
circulatory disturbance, ecchymosis, dressing is applied.
tenderness & crepitation. 5. Check the vascular status by assessing
color, temperature, pulse, and
Management of Fractures blanching of the nail bed.
6. If there is neurovascular
• ABCD Method & evaluation for
compromise, the splint is removed
abdominal injuries is performed
and reapplied.
BEFORE an extremity is treated unless
7. Investigate complaints of pain or
a pulseless extremity is seen.
pressure.
• If the extremity is pulseless,
repositioning of the extremity to proper
People at Risk:
alignment is required.
 those not acclimatized to heat
 elderly and very young people
 those unable to care for themselves
Pulseless Extremities
 those w/ chronic & debilitating dse
• If the pulseless extremity involves a  those taking tranquilizers,
fractured hip or femur, a Hare traction diuretics, anticholinergics, and
may be applied to assist w/ alignment. beta blockers.
• If repositioning is ineffective in restoring  exertional heat stroke occurs in healthy
 individuals during sports or work cooling blankets
activities. 3. Iced saline lavage of
stomach or colon if
Heat Stroke temperature does not
• An acute medical emergency caused by decrease
failure of the heat-regulating mechanisms. 4. Immersion in cold water
• Usually occurs during extended heat bath
waves, especially when accompanied by
high humidity • During cooling, the patient is massaged
to promote circulation and maintain
Pathophysiology cutaneous vasodilation.
• Hyperthermia results because of • An electric fan is positioned so that it
inadequate heat loss, which can also blows on the patient to augment heat
cause death. dissipation by convection and
• Most heat-related deaths occur in the evaporation.
elderly, because their circulatory • Client’s core temperature is
systems are unable to compensate for constantly monitored w/ a
the stress imposed by heat thermometer placed in the rectum,
• Elderly people have ò ability to bladder, or esophagus
perspire as well as a ò thirst • Avoid hypothermia; prevent
mechanism to compensate for heat. spontaneous recurrence of
hyperthermia

Assessment Nursing Interventions

• Causes thermal injury at the cellular • Monitor vital signs, ECG, CVP and
level, resulting to widespread damage level of responsiveness
to the heart, liver, kidney, and blood • Administer 100% oxygen to meet tissue
coagulation needs exaggerated by the
• Watch out for profound CNS hypermetabolic condition.
dysfunction (confusion, delirium, bizarre • NSS or LRS is initiated to replace fluid
behavior, coma), ñ body temperature losses and maintain circulation
(>40.6°C), hot, dry skin, anhidrosis, • Urine output is monitored to detect
tachypnea, hypotension, and acute tubular necrosis from
tachycardia. rhabdomyolysis.
• Blood specimens are obtained to detect
Management DIC and to estimate thermal hypoxic
• The primary goal is to reduce the high injury to the liver, heart, and muscle
temperature as quickly as possible, tissue
because mortality is directly related to • Dialysis is done for renal failure.
the duration of hyperthermia. • Give benzodiazepines or
• Simultaneous treatment focuses on chlorpromazine for seizures; K for
stabilizing oxygenation using the ABC’s hypokalemia; Na bicarbonate for
of basic life support. metabolic acidosis
• After clothing is removed, core
temperature is reduced to 39°C ASAP by
one or more of the ff methods: Nurse Teaching
1. Cool sheets & towels or
continuous sponging with • Advise client to avoid immediate
cool H2O exposure to high temperature (10am –
2. Ice applied to neck, groin, 2pm)
chest, & axillae while • Emphasize importance of adequate
spraying with tepid water; fluid intake, wearing loose
 clothing, and reducing activity in affected fingers or toes to prevent
hot weather. maceration.
• Monitor weight and fluid losses • A foot cradle is used to prevent contact
during workouts; replace fluids with bedclothes.
• Use a gradual approach to physical • Blebs are left intact and not
conditioning; allow acclimatization ruptured, especially if they are
hemorrhagic.
• Risk for infection is great; strict aseptic
FROSTBITE technique is used during dressing
• Trauma from exposure to freezing changes, and tetanus prophylaxis & anti-
temperatures that results to actual inflammatory medications are given
freezing of the tissue fluids in the cell and • Whirlpool bath for affected extremity to
intracellular spaces aid circulation, debride necrotic tissue and
• Results in cellular and vascular damage prevent infection
• Body parts most frequently affected • Escharotomy to prevent further tissue
are the feet, hands, nose and ears damage, allow normal circulation and
• Ranges from 1st (erythema) to 4th degree permit joint motion; fasciotomy
(full- depth tissue destruction) • After rewarming, hourly active motion
of affected digits is done to promote
Assessment maximal restoration of function and to
• Frozen extremity may be cold, prevent contractures.
hard, and insensitive to touch • Refreezing is avoided
• Appears white or mottled blue-white • Avoid tobacco, alcohol, and caffeine
• Extent of injury from exposure to cold is because of vasoconstrictive effects
not initially known; assess for which further reduce the already
concomitant injury deficient blood supply to injured
• History includes environmental tissues.
temperature duration of exposure,
humidity, and presence of wet
conditions Hypothermia
• A condition in which core temperature is
Management 35°C or less as a result of exposure to
• The goal is to restore normal body cold
temperature; controlled yet rapid • Occurs when patient loses ability to
rewarming is instituted maintain body temperature
• Constrictive clothing and jewelry that • Urban hypothermia is associated with a
could impair circulation are removed. high mortality rate affected are the
• Patient should NOT be allowed to elderly, infants, patients with concurrent
ambulate if the lower extremities are illnesses, and the homeless.
involved. • Alcohol ingestion ñ susceptibility
• Place extremity in a 37° to 40°C due to systemic vasodilation.
circulating bath for 30- to 40-min. • Trauma victims are at risk resulting from
• Repeat treatment until circulation is treatment with cold fluids, unwarmed
effectively restored. oxygen, and exposure during
• Early rewarming ò amount of tissue loss. examination.
• Analgesic is given during rewarming • Hypothermia takes precedence in
since process may be very painful. treatment over frostbite.
• Avoid handling of body part to prevent
further injury. Assessment
• ELEVATE to prevent further swelling. • Watch out for progressive
• Sterile gauze or cotton is placed between deterioration, with apathy, poor
 judgment, ataxia, dysarthria, and maintain urine output and core
drowsiness, pulmonary edema, acid- rewarming
base abnormalities, coagulopathy & • Sodium bicarbonate to correct
coma metabolic acidosis if necessary
• Shivering may be suppressed below • Antiarrhythmic medications
32.2°C due to ineffective • Insertion of Foley catheter to monitor
mechanism fluid status
• Peripheral pulses are weak and become
undetectable; cardiac irregularities,
hypoxemia and acidosis may occur. Near-Drowning
• Survival for at least 24 hours after
Management: Monitoring submersion
• VS, CVP, urine output, arterial blood gas • Most common consequence is hypoxemia
levels, blood chemistry and chest xray are
• One of the leading causes of death in
frequently evaluated.
children younger than 14 y/o; children
• Body temp is monitored with a younger than 4 y/o account for 40% of all
rectal, esophageal, or bladder drownings
thermometer.
• Continuous ECG monitoring is done Risk Factors
because cold-induced myocardial 1. Alcohol ingestion
irritability can lead to 2. Inability to swim
v. fibrillation. 3. Diving injuries
4. Hypothermia
5. Exhaustion
Management: Core Rewarming
• Include cardiopulmonary bypass, Rescue
warm fluid administration, warm • Successful resuscitation with full
humidified oxygen by ventilator, and neurologic recovery has occurred in
warm peritoneal lavage drowning victims after prolonged
• Done for severe hypothermia submersion in cold water.
• Monitoring for ventricular fibrillation • After surviving submersion, ARDS
as the patient passes through 31° to resulting in hypoxia, hypercarbia, &
32°C is essential. respiratory or metabolic acidosis can
occur.
Management: Passive External Rewarming
• Includes the use of warm blankets or Pathophysiology
over-the- bed heaters • Fresh water aspiration results in loss of
• Increases blood flow to the acidotic, surfactant, hence the inability to expand
anaerobic extremities the lungs.
• Cold blood returning to the core can • Salt water aspiration leads to
cause cardiac dysrhythmias & electrolyte pulmonary edema from the osmotic
imbalances effects of the salt within the lungs.
• Treatment Goals
• Maintaining cerebral perfusion and
Supportive Care adequate oxygenation to prevent further
• External cardiac compression damage to vital organs
• Defibrillation of v. fibrillation (ineffective if • Immediate CPR is the factor with the
core temp is <31°C) greatest influence on survival
• Mechanical ventilation and heated, • Prevention of hypoxia by ensuring an
humidified oxygen adequate airway and respiration, thus
• Warmed IVF to correct hypotension improving ventilation and oxygenation
 • A rapid history & recompression is done
Management ASAP & may necessitate a low altitude
• ABG analyses are performed to flight to the nearest hyperbaric
evaluate O2, CO2, HCO3 and pH chamber.
• If the patient is not breathing
spontaneously, ET intubation with Assessment
positive-pressure ventilation improves  Evidence of rapid ascent, loss of air in the
oxygenation, prevents aspiration, and tank, buddy breathing, recent alcohol
corrects intrapulmonary shunting and V-P intake or lack of sleep, or a flight within 24
abnormalities hours after diving are risk factors.
• If the patient is breathing  Signs and symptoms:
spontaneously, supplemental O2 1. Joint/extremity pain
may be given by mask 2. numbness, hypesthesia
• Because of submersion, the patient is 3. loss of ROM
usually hypothermic; use a rectal probe 4. neuro Sx mimicking CVA
to assess 5. CP arrest in severe cases
• Prescribed warming procedures such as
Management
corporeal rewarming, warmed PD, inhalation
 A patient airway and adequate
of warmed aerosolized O2, and torso
ventilation are established & 100% O2 is
warming depends on the severity & duration
given throughout treatment & transport
of hypothermia.
 A CXR is obtained to identify aspiration,
• Intravascular volume expansion & and at least 1 IV line is started with LRS or
inotropic agents are used to manage NSS.
hypotension & impaired tissue  If a head injury is suspected, the head of
perfusion; ECG monitoring is done to the bed is lowered.
monitor dysrhythmias.  Wet clothing is removed and the
• A Foley catheter is used to measure patient is kept warm.
output; NGT intubation is used to  Transfer to the closest hyperbaric
decompress the stomach & prevent chamber is done.
aspiration of gastric contents.  Antibiotics may be prescribed if
• Close monitoring continues with serial VS, aspiration is suspected.
serial ABG’s, ECG monitoring, ICP
assessments, serum electrolyte levels, I & Animal and Human Bite
O, & serial CXR. • Dog bites constitute 80% to 90% of these
• Complications include hypoxic or bites and are responsible for the majority of
ischemic cerebral injury, ARDS, deaths from bites by a nonvenomous animal
pulmonary damage 2° to aspiration, & (Tintinalli et al., 2020)
cardiac arrest. • Cat bites have a high risk of infection because
of the presence of Pasteurella in their saliva
• Human bites are frequently associated with
Decompression Sickness (DCS) rapes, sexual assaults, or other forms of
• Occurs in patients who have engaged in battery. The human mouth contains more
diving, high-altitude flying, or flying in a bacteria than that of most other animals, so
commercial aircraft 24 hrs after diving a high risk of bite-related infection exists.
Depending on the circumstances surrounding
• Results from nitrogen bubbles trapped in
the event, the victim may delay seeking
joint or muscle spaces, resulting in
treatment.
musculoskeletal pain, numbness, &
hyperesthesia • Cleansing with soap and water is then
necessary, followed by the administration of
• Bubbles can become emboli in the
antibiotics and tetanus toxoid as prescribed
bloodstream & cause stroke,
(Tintinalli et al., 2020).
paralysis, or death.
Snakebites • There are two venomous spiders found in
• Venomous (poisonous) snakes caused the United States that may interact with
more than 2000 of the 6000 snakebites in humans: the brown recluse and the black
the United States annually (Tintinalli et al., widow
2020) • Both are usually found in dark places such
• The most frequent poisonous snakebite in as closets, woodpiles, and attics, as well as
the United States occurs from Crotalidae, in shoes (ENA, 2020a).
otherwise called pit vipers, such as water • Brown recluse spider bites are painless.
moccasins, copperheads, and rattlesnakes. Systemic effects such as fever and chills,
The most common site is the upper nausea and vomiting, malaise, and joint
extremity (ENA, 2020a). pain develop within 24 to 72 hours. The site
• Of pit viper bites, 75% to 80% result in of the bite may appear reddish to purple in
envenomation (injection of a poisonous color within 2 to 8 hours after the bite.
material by sting, spine, bite, or other Necrosis occurs in the next 2 to 4 days in
means); the rest result in what are called approximately 10% of cases.
dry bites (Tintinalli et al., 2020) • Black widow spider bites feel like pinpricks.
Clinical Manifestations: Systemic effects usually occur within 30
• edema, ecchymosis, and hemorrhagic minutes—much more rapidly than with
bullae, leading to necrosis at the site of brown recluse spider bites. Signs and
envenomation symptoms include abdominal rigidity,
Symptoms: nausea and vomiting, hypertension,
• lymph node tenderness, nausea, vomiting, tachycardia, and paresthesias. Severe pain
numbness, and a metallic taste in the also develops within 60 minutes and
mouth increases over 1 to 2 days. Treatment
• Without decisive treatment, these clinical involves application of ice to the site to
manifestations may progress to include decrease swelling and discomfort, along
fasciculations, hypotension, paresthesias, with elevation and assessment of tetanus
seizures, and coma (ENA, 2020a) immunization status
Initial First Aid: TICK BITES:
• having the person lie down, removing • The tick bite itself is not usually the problem;
constrictive items such as rings, rather, it is the pathogen transmitted by the
providing warmth, cleansing the tick that can cause serious disease. Ticks can
wound, covering the wound with a carry diseases such as Rocky Mountain
light sterile dressing, and immobilizing spotted fever, tularemia, west Nile virus, and
the injured body part below the level Lyme disease.
of the heart • Ticks transmit pathogens through their
• CABs are the priorities of care. saliva; therefore, the earlier the tick is
• Ice, incision and suction, or a removed, the better the prognosis. The tick
tourniquet is not applied. should be removed with tweezers using a
• Tetanus and analgesia should be given straight upward pull
as necessary • Lyme disease has three stages:
Administration of Antivenin  Stage I may present with erythema
• The most readily available antivenin in the migrans (a classic “bull’s-eye” rash)
United States is Crotalidae polyvalent that typically can be found in the
immune Fab antivenom (FabAV or CroFab). axilla, groin, or thigh area
The dose depends on the type of snake and  stage II Lyme disease may present
the estimated severity of the bite. within 4 to 10 weeks following the
Indications for antivenin depend on the tick bite and may manifest with joint
progression of symptoms, including pain, memory loss, poor motor
coagulopathy and systemic reaction (ENA, coordination, adenopathy, and
2020a). cardiac abnormalities
Spider Bites  Stage III can begin anywhere from
 weeks to more than a year after the edema)
bite and has serious long-term
sequelae, including arthritis, Cardiovascular:
neuropathy, myalgia, and ➢ Tachycardia or bradycardia
myocarditis. ➢ Peripheral vascular
collapse indicated by pallor,
imperceptible pulse, ò BP,
Anaphylaxis circulatory failure, coma &
 An acute systemic hypersensitivity death
reaction that occurs w/in seconds or
min. after exposure to foreign GIT:
substances such as medications &  nausea & vomiting
other agents  colicky abdominal pains, diarrhea
 Repeated administration of oral &
parenteral therapeutic agents may cause this Anaphylaxis Management
when initially only a mild allergic response  Establish an airway & ventilation while
occurred. another gives epinephrine.
 Early ET intubation avoids loss of the
airway, & oropharyngeal suction removes
secretions.
 If glottal edema occurs, a crico-
Pathophysiology thyroidotomy is used to provide an airway.
• Antigen-antibody interaction
• Antigen – allergen Anaphylaxis: Epinephrine Administration
• Antibody – IgE previously sensitized  Subcutaneous injection for mild,
basophils and mast cells generalized symptoms
• Release of mediators like histamine  IM injection for more severe &
and prostaglandin cause the progressive reactions with the
systemic reactions possibility of vascular collapse
 IV route for rare instances where there is
Causes LOC & severe cardiovascular collapse; may
•  Penicillins – most common cause dysrhythmias
•  Contrast media
•  Bee stings Anaphylaxis: Additional Treatments
•  Food •  Antihistamines are given
to block further histamine release
•  Aminophylline by slow IV
Anaphylaxis Signs and Symptoms trans-fusion for severe bronchospasm
Respiratory Signs: & wheezing refractory to treatment
 nasal congestion •  Albuterol inhalers or humidified
 itching, sneezing, coughing treatment to ò bronchoconstriction
 bronchospasm & laryngeal edema • Crystalloids, colloids, or
 chest tightness, dyspnea vasopressors for prolonged
 wheezing & cyanosis hypotension
•  Isoproterenol or dopamine for
Skin: reduced cardiac output; O2 to
 flushing with sense of warmth & enhance tissue perfusion
diffuse erythema; •  IV benzodiazepines for
 generalized itching over entire seizure control; corticosteroids for
body (systemic reaction) prolonged reaction with persistent
 urticaria (hives); hypotension or bronchospasm
 massive facial angioedema (with
accompanying upper respiratory
 esophageal burn or perforation.
 The following procedures may be done:
Anaphylaxis Prevention  Ipecac syrup to induce vomiting in the
 Be aware of the danger signs of alert patient
anaphylaxis.  Gastric lavage for the obtunded
 Ask the patient about previous allergies patient; aspirate is tested
(e.g. allergies to eggs)  Activated charcoal administration if poison
 Before giving antigenic agents, ask can be absorbed by it
caregiver whether agent was received at  Cathartic, when appropriate
an earlier time.  Ingested Poison Warnings
 Avoid giving medications to patients  Vomiting is NEVER induced after
with allergic disorders unless ingestion of caustic substances or
necessary. petroleum distillates.
 Perform a skin test before  The area poison control center should be
administration of certain agents; have called if an unknown toxic agent has been
epinephrine readily available. taken or if
 If dealing with outpatients, keep them in
it is necessary to identify an antidote for a
the clinic for at least 30 min after
known toxic agent.
injection of any agent.
 Caution patients who are highly
sensitive to carry medical kits.
 Encourage wearing of medical IDs. Gastric Lavage Guidelines
1. Remove dentures and inspect for
Poisoning: Ingested Poisons loose teeth.
 May be corrosive (alkaline and acid agents 2. Measure the distance between the
that cause tissue destruction) bridge of the nose and the xiphoid
 Alkaline products: Lye, drain and toilet process and mark tube with indelible
bowl cleaners, bleach, non-phosphate pencil or tape.
detergents, button batteries 3. Lubricate tube with KY-Jelly.
 Acid products: toilet bowl and metal 4. If comatose, patient is intubated
cleaners, battery acid with cuffed nasotracheal or
endotracheal tube before placement
Poisoning Management of NGT.
 Control the airway, ventilation 5. Place patient in a left lateral position
and oxygenation. with head lowered 15°.
 ECG, VS, and neurologic status are 6. Pass the tube orally while keeping the
monitored for changes. head in neutral position. Pass tube to
 Shock resulting from the cardio- marking (50 cm).
depressant action of the ingested 7. Aspirate gastric contents with the
substance, or from ò circulating syringe attached to the tube before
blood volume due to ñ capillary instilling water/antidote & save
permeability, is treated. specimen.
 A Foley catheter is inserted to monitor
renal function and blood examinations 8. Remove syringe and attach funnel to
are done to test for poison the end of the tube or use a 50mL
concentration. syringe to instill solution into tube.
 The amount, time since ingestion, signs 9. Elevate funnel above patient’s head
and symptoms, age and weight and and 150-200mL of solution into it.
health history are determined. 10. Lower funnel and siphon the
 Patient who ingested a corrosive gastric contents, or connect to
poison is given water or milk to drink suction.
for dilution (not attempted if patient 11. Save the samples of the first two
has acute airway obstruction, or if washings.
with evidence of gastric or 12. Repeat the lavage until the returns
 are clear and no particulate 5. Keep patient as quiet as possible.
matter is seen. 6. Do NOT give alcohol in any form.
13. The stomach may be left empty, and 7. Upon arrival at the ER, analyze
an absorbent or saline cathartic is carboxyhemoglobin levels and give
instilled and allowed to remain inside. 100% O2 until level is <5%.
14. Pinch out the tube during removal 8. Watch out for psychoses, spastic
or suction while withdrawing and paralysis, ataxia, visual disturbances,
keep head lower than the body. and deterioration in mental status and
15. Warn patient that stools will turn behavior which may be symptoms of
black from the charcoal. brain damage.
9. If accidental poisoning occurs, the
Management DOH should be informed so that
 The specific chemical is given as early the dwelling could be inspected.
as possible to reverse effects.
 Procedures include administration of Food Poisoning
charcoal, diuresis, dialysis, and  A sudden illness that occurs after
hemoperfusion. ingestion of contaminated food or drink
 If poisoning is due to a suicide attempt,  Some of the most common diseases
psychiatric evaluation is requested; if are infections caused by bacteria, such
accidental, home poison-proofing as Campylobacter, Salmonella, Shigella,
directions are given E. coli O157:H7, Listeria, and botulism

Inhaled Poisons: CO Poisoning Campylobacter

 A result of industrial or household  A bacterium that causes acute diarrhea
incidents, or attempted suicide  Transmitted through ingestion of
 Implicated in more deaths than any contaminated food, water, or
other toxins, except alcohol. unpasteurized milk, or through contact
 CO exerts its toxic effects by binding to with infected infants, pets or wild animals.
circulating hemoglobin, reducing its
oxygen- carrying capacity. Hemoglobin Salmonella
absorbs CO 200x more readily than O2.  Transmitted by drinking unpasteurized
 Carboxyhemoglobin doesn’t have O2 milk or by eating undercooked poultry
 CNS symptoms predominate with CO and poultry products such as eggs
toxicity.  Any food prepared on surfaces
Watch out for headache, muscle contaminated by raw chicken or turkey
weakness, palpitation, dizziness, and can also become tainted
confusion, which rapidly leads to  May also stem from food contaminated
coma. by a food worker
 Skin color ranges from cherry-red to pale
and is not a reliable sign. Shigella
 Pulse oximetry will record false (+)’s.  Transmitted through feces. It causes
dysentery, an infection of the intestines
CO Poisoning Management causing severe diarrhea. The disease
 Goal: to reverse cerebral and generally occurs in tropical or temperate
myocardial hypoxia and hasten climates, especially under conditions of
elimination of CO by: crowding, where personal hygiene is poor
1. Carrying the patient to fresh
air immediately and opening E. Coli O157:H7
doors and windows  Associated with eating undercooked,
2. Loosening all tight clothing contaminated ground beef. Drinking
3. Initiate CPR if required; give O2. unpasteurized milk and swimming in or
4. Prevent chilling; wrap in blankets. drinking sewage-contaminated water can
also cause infection
 Management
Listeria  Determine the source and type of
 found in many types of uncooked food poisoning.
foods, such as meats and vegetables,  Food, gastric contents, vomitus, serum
as well as in processed foods that and feces are collected for examination.
become contaminated  Patient’s VS, sensorium and muscular
activity are closely monitored.
after processing, such as soft cheeses (such as
 Support the respiratory system and
feta and crumbled blue cheese) and cold
assess fluid and electrolyte balance;
cuts.
watch out for lethargy, ñPR, fever,
 Unpasteurized milk or foods made from
oliguria, anuria, hypotension, and
unpasteurized milk may also be sources
delirium.
of listeria infection
 Administer IV antiemetic medications for
mild nausea, give sips of weak tea,
Botulism carbonated drinks, or tap water.
 Linked to home-canned foods with a low
 Clear liquids for 12 to 24 hrs after nausea
acid content
and vomiting subside, and then
 Foods include asparagus, green beans,
progressed to a low-residue bland diet.
beets, and corn.
 Other sources include chopped garlic in
Burns
oil, chili peppers, tomatoes, improperly
 Alteration in skin and underlying tissues
handled baked potatoes cooked in
as a result of:
aluminum foil, and home-canned or
 Too much exposure to sun and UV
fermented fish (such as sardines)
 Direct contact with heat and burning
object
Food Poisoning: MC Foods  Hot water and liquids
 Honey should NOT be given to children  Chemicals
younger than 12 months of age, as it can
contain spores of C. botulinum and is  Factors considered when
known to cause infant botulism assessing the severity of a burn:
 Staphylococcus aureus in spaghetti  depth of the burn and size
 Bacillus cereus in fried rice  the part of the body burned
 Toxins in mushrooms, shellfish, including  the age of the client, and the
the puffer fish  client's previous and past medical
history

“Rule of Nines” Chart Assessment of Damage

Assessment
1. How soon after eating did the  Lund & Browder Method: Assigns
symptoms occur? percentage
2. What was eaten in the previous of BSA for various
meal? Did the food have an unusual anatomic parts; more precise method of
odor or taste? estimating the extent of burn
3. Did anyone else become ill from  Palm Method: The size of
eating the same food? the palm (approximately
4. Did vomiting occur? What 1% of BSA)
was the appearance of the can be used to assess the extent of
vomit? burn injury in patients with scattered
5. Did diarrhea occur? burn.
6. Any other neurologic symptoms?
7. Does the patient have a fever? Factors considered when assessing the
8. What is the client’s appearance? severity of a burn:
 depth of the burn and size
  the part of the body burned A. Assess the airway.
 the age of the client, and the B. Auscultate the trachea, and monitor
 client's previous and past medical history for adventitious breath sounds or
decreased breath sounds.
Depth of Burns: Superficial burn C. If client is dyspneic or if there is
 The epidermal layer is damaged and hurt carbon monoxide poisoning, a high
 Wound is quite painful. liter flow of 8 to 10 liters of oxygen is
 Skin is characteristically red and dry. recommended.
 Redness generally subsides within 24 D. If compromise is suspected, the victim
to 48 hours may be intubated and ventilated.
 Scarring does not occur  Indications for intubation are
airway obstruction and a PaO2
Depth of Burns: Deep partial thickness of less than 60 mm Hg.
 The continuous monitoring
 Burns affect the dermal layer of the skin.
by means of a pulse oximeter
 The injured skin is red or mottled,
assists in assuring adequate
possibly weepy with vesicles
or blisters and considerable swelling. oxygenation.
 When healing is complete, the skin is E. The client's level of consciousness
usually somewhat discolored should be carefully monitored. Burn
Tightening and contracture may develop. victims are most often alert, oriented
and cooperative even with extensive
Depth of Burns: Full thickness burn injuries.
 the injury extends all the way
through the subcutaneous tissue Fluid Resuscitation
 sometimes to muscle and bone  The maximum loss of fluid occurs within 12
 no regeneration can occur to 18 hours after the burn.
 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  The total quantity of fluid required to correct
immunologic response to stress and this volume deficit is replaced in the first 24
trauma is not fully developed, and a burn hours following the burn injury.
injury can be overwhelming.
 In the elderly, these responses are  The amount of fluid required to correct
diminished and the person's general the deficit is calculated to be 2 to 4 mL
health may be compromised by existing per cent burn per kilogram of body
medical problems. weight.
 Administration of the fluids takes place
over a 24-hour period with half the
Burn Management amount given in the first 8 hours and the
Maintenance of Airway Patency remainder over the next 16 hours.
 (Assess peripheral pulse, capillary
refill.)
Fluid Loss Management  Assess for Paralytic Ileus (Auscultate
bowel sounds, abdominal distention.)
1. Consensus Formula: 2-4 mL x body weight  Assess for Curling’s Ulcer (Assess gastric
(kg.) x % body surface area burned. Half pH, occult blood in stools.)
to be given in first 8 hours, remaining
half to be given over next 16 hours. Burn Care: Acute Phase
 Begins 48 to 72 hours post-injury
Evans Formula  Assess for edema, jugular vein
 Colloids: 0.5 mL x body weight (kg.) x distention, crackles, increased arterial
%BSA burned pressure
 Electrolytes: 1.5 mL x body weight (kg)  Use asepsis & reverse isolation.
x % BSA burned  Give high-calorie, high-protein diet
 Glucose: 2000 mL for insensible loss  Assess the graft sites. Report signs of
 Day 1: Half to be given in the first 8 poor healing, graft take or trauma.
hours; remaining half over next 16  Prevent flexed position in burned areas.
hours  Burn Care: Rehabilitation Phase
 Wound healing, psychosocial support,
Parkland Formula and restoring maximal functional
 Lactated Ringer’s Solution: 4 activity remain priorities.
mL x body weight (kg) x % BSA
burned Chemical Burn
 Day 1: Half to be given in first 8 hours;  Most chemicals that cause burns are
half to be given over next 16 hours either strong acids or bases
 Day 2: Varies. Colloid is added  The severity of a chemical burn is
(e.g. albumin, dextran) determined by the mechanism of action,
the penetrating strength and
Burn Management concentration, & the amount and
 Obtain laboratory data duration of exposure of the skin to the
 Monitor urine output and vital signs chemical.
 Administer tetanus antitoxin/toxoid
 Hypertonic Saline Solution Management
 Goal: to increase serum sodium level  The skin should be continuously
and osmolarity to reduce edema and drenched immediately with running
prevent pulmonary complications water from a shower, hose or faucet
 Concentrated solutions of sodium as the patient’s clothing is removed.
chloride (NaCl) and lactate are given  The skin of the health care
sufficiently to maintain a desired professional assisting should also
volume of urinary output. be appropriately protected.

Phases of Burn Care: Emergent Chemical Poison Warnings

1. Airway • Water should NOT be applied on
2. Breathing burns from lye or white phosphorus
3. Circulation because of a potential for an
4. Disability explosion or for deepening of the
5. Exposure burn.
6. Fluid Resuscitation • All evidence of these chemicals
should be brushed off the patient
 Assess for Acute Respiratory Failure before flushing.
 Assess for Acute Renal Failure
 Assess for Distributive Shock
 Assess for Compartment Syndrome 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.