First Aid, Emergency Care, & Disaster Management PDF

Here is the converted Markdown format of the provided document. # XML Nueng thu Disasters, and First Aid # First Aid, Emergency Care, and Disaster Management **Shein Stevens** [http://evolverelsevier.com/Linton/medsund](http://evolverelsevier.com/Linton/medsund) ## Objectives 1. List the prin...

Here is the converted Markdown format of the provided document. # XML Nueng thu Disasters, and First Aid # First Aid, Emergency Care, and Disaster Management **Shein Stevens** [http://evolverelsevier.com/Linton/medsund](http://evolverelsevier.com/Linton/medsund) ## Objectives 1. List the principles of emergency and first-aid care. 2. List the steps of the initial assessment and interventions for the person requiring emergency care. 3. Describe the components of the nursing assessment of the person requiring emergency care. 4. Outline the steps of the nursing process for emergency or first-aid treatment of victims of cardiopulmonary arrest, **Key Terms** avulsion $\text{(ä-VÜL-zhūn)}$ hypothermia $\text{(hī-pô-THER-më-ǎ)}$ cardiac tamponade $\text{(KÄR-dē-äk tăm-pōn-ĀD)}$ poison hemorrhage $\text{(HEM-ör-ij)}$ sprain bemothorax $\text{(hë-mō-THO-räks)}$ strain hyperthermia $\text{(hi-për-THER-më-ǎ)}$ choking, shock, hemorrhage, traumatic injury, burns, heat or cold exposure, poisoning, bites, and stings. 1. Discuss the roles of nurses and nursing students in relation to bioterrorism and natural disasters. 2. Explain the legal implications of administering first aid in emergency situations. 3. Explain the implications of the Good Samaritan doctrine. In the inpatient setting, the nurse is often the first person on the scene when accidents or emergencies occur. Nurses also need to be prepared to act in emergency situations in homes and other community settings. Prompt intervention can make a dramatic difference in patient outcomes. Knowledge of first aid can mean the difference between life and death in many situa- tions. This chapter addresses first-aid interventions for common emergencies seen in homes and community settings. Some emergency conditions that require further medical attention are covered in greater detail elsewhere in this book. ## GENERAL PRINCIPLES OF EMERGENCY CARE When accidents or emergencies occur, the victim and any observers are often anxious and frightened. Knowing that a nurse is present can be very reassuring to them, but you must remember the cardinal rule: Remain calm! Victims react to emergencies in various ways, from stunned silence to hysteria. Your priority is to preserve life and minimize the effects of injuries, but the manner in which you conduct yourself can also soothe and reassure the victim. The nursing process is used in emergencies just as it is in other nursing situations. The important difference is that assessment and intervention must be accom- plished very quickly and efficiently to identify and treat priority needs immediately. ## SURVEY THE SCENE The first step in initiating first aid is to survey the scene. You must determine if the area is safe for you, the victim(s), and any bystander(s) before you proceed. Once you have determined safety, the next steps are to determine how many are injured, how are they injured, and who is around that can help. Identify yourself as a nurse and obtain their consent to provide them with care; then activate, or have a bystander activate, the emergency response system (i.e., call 911). ## PRIMARY AND SECONDARY SURVEYS The focused assessment begins when approaching the victim so that he or she does not have to move his or her head to see you. Ask the victim's name to determine whether the victim can speak, which would reveal airway or neurologic problems. Determine the nature of the emergency; that is, was the injury caused by a motor vehicle accident, a fall, a diving accident, or an electrocution? In addition, look for any hazards to the victim and the rescuer. For example, is the victim in a burning vehicle or lying in the middle of the highway? **1243** ## Failure to recognize such dangers may result in injuries to the rescuer and additional injuries to the victim. A primary survey is performed to detect life- threatening injuries. A primary survey consists of check- ing airway-breathing-circulation, disability, exposure, and facilitation of family. The nurse should intervene immediately if indicated in the following sequence: 1. Evaluate the airway for breathing and immobilize the cervical spine. 2. Initiate cardiopulmonary resuscitation or rescue breathing as needed. Use the jaw thrust maneuver to open the airway on an unconscious patient. 3. Look for uncontrolled bleeding, identify the source, and apply pressure to the source. 4. Assess for disability, which includes the level of consciousness. 5. Assess for exposure by removing clothing and observing for injury. 6. Facilitate the family by allowing them to be close to the patient. 7. Look for a medical alert tag, usually a necklace or a bracelet. After the primary survey, once again conduct a system- atic head-to-toe inspection (called the secondary survey) to detect significant changes and other findings that might have been missed initially. ## GUIDELINES FOR FIRST AID TREATMENT General guidelines for first-aid treatment of emergency patients are as follows: 1. Protect the airway. 2. Splint injured parts in the position they are found. 3. Prevent chilling but do not add excessive heat. 4. Do not remove penetrating objects. 5. Do not give anything by mouth to an unconscious person or to one with potentially serious injuries. 6. Stay with the injured person until medical care or transportation arrives. ## NURSING ASSESSMENT IN EMERGENCIES Patient emergencies can occur in every setting. In some situations, nurses observe the events and know what has happened, but at other times evidence at the scene is needed to determine the circumstances. Intervening appropriately in emergencies whose cause cannot be immediately determined can be difficult. Be prepared to make a quick appraisal and then act promptly to provide appropriate care that may save a life. The health history and physical examination are presented sepa- rately here but, in fact, may be conducted almost simultaneously in emergencies. Depending on the nature of the injury outside the health care setting, the assess- ment focuses on the specific injury. The more complete assessment described next would be conducted in the health care setting where the licensed vocational nurse/ licensed practical nurse (LVN/LPN) may assist with data collection. ## HEALTH HISTORY If the victim is able to speak or a witness is available, obtain a brief health history of the victim. Data collection is limited in emergency situations and should include the chief complaint, any treatment given, and the rel- evant medical history. The acronym SAMPLE may help you to remember to inquire about Symptoms, Allergies, current Medications, Past illness/Pregnancy, Last oral intake, and Events related to injury. ## Reason for Seeking Care Determine the nature of the problem, the signs and symptoms, and the circumstances under which the injury or illness occurred. If the victim is or has been uncon- scious, note the length of time that the person has been unconscious if possible. ## Medical Treatment Determine whether any treatment has been given and, if so, the effect of the treatment. In the presence of an injury, note whether the victim has been moved. ## Past Health History If possible, determine known health problems, including diabetes and cardiac or pulmonary disease, which may provide important clues to the immediate problem or influence the care provided. Check for a medical alert tag, which may provide essential information if the patient cannot. If possible, identify current medications and known allergies. Note any evidence of alcohol or other drugs. ## Pharmacology Capknip The medical alert tag can provide clues about medical emergencies and alert rescuers to known allergies and chronic conditions. ## PHYSICAL EXAMINATION Determine if the patient is responsive, then begin col- lecting objective data. The first assessment priorities must be the ABCs: Airway, Breathing, and Circulation followed by D (Disability) and E (Exposure). Watch the victim's chest for rhythmic breathing and listen near the patient's mouth and nose for air movement. Palpate the carotid and peripheral pulses. Once the adequacy of respiration and circulation has been established, assess for uncontrolled bleeding and shock. Note the level of consciousness, pupil response, and gross sensory and motor function to determine disability. Exposure refers to the removal of clothing to permit a more complete inspection for injuries. If no evidence of uncontrolled bleeding or shock is noted, the next step is a systematic head-to-toe examination. At each step, look for obvious injury, bleeding, swelling, bruising, and drainage. Note circulation, mobility, sensation, symmetry, and alignment. ### Box 63.1 ## First Aid, Emergency Care, and Disaster Management CHAPTER 63 ## Assessment of the Patient Who Requires First Aid or Emergency Care **HEALTH HISTORY** **Reason for Seeking Care** * Nature of illness or injury, signs and symptoms, circumstances of illness or injury, how long unconscious **Treatment:** * Efforts that have been made, effects, whether moved after injury **Past Health History** * Current health problems, current medications, allergies **PHYSICAL EXAMINATION** * **ABCs:** Airway, breathing, circulation * **Skin:** Color, temperature, obvious injury * **Head:** Level of consciousness * **Eyes:** Opening, pupil size, equality, response to light * **Neck:** Stiffness, pain, ability to swallow * **Chest:** Symmetry of movement, dyspnea, respiratory rate and effort * **Abdomen:** Contour, rigidity, distention, pain, tenderness * **Extremities:** Deformity, movement, sensation, peripheral pulses of the entire body. Also note skin color, warmth, and temperature at each step of the head-to-toe assessment. The systematic assessment, or secondary survey, will be a more thorough assessment of the injured person. It begins with a head-to-toe assessment. Speak to the victim and evaluate the response to determine level of consciousness (alert, disoriented, unresponsive). Evaluate comprehension by asking the patient to follow simple commands such as opening and closing the eyes. Inspect the eyes for pupil size, equality, and reaction to light. Ask the alert victim about neck pain or stiffness and the ability to swallow. Inspect the chest for symmetry of the chest wall movement. Next, assess respiratory effort, dyspnea, and abnormal sounds associated with respirations. Examine the contour of the abdomen to detect distention. Use light palpation to detect areas of pain or tenderness. Inspect the extremities for deformity or injury and evaluate movement. Then assess peripheral pulses and warmth and sensation in the extremities. Box 63.1 summarizes the focused assessment of the patient who requires first aid or emergency care. ## SPECIFIC EMERGENCIES ### CARDIOPULMONARY ARREST When the heart stops beating, a person is in cardiac arrest. When respirations cease, the person is in respira- tory, or pulmonary, arrest. Cardiopulmonary arrest is the absence of a heartbeat and respirations. The cardiac and respiratory systems are so dependent on each other that when one fails, the other quickly fails as well. Nerve tissue is susceptible to hypoxia (low levels of oxygen), and brain cells begin to die after 4 minutes without oxygen. Unless circulation and oxygenation are restored very quickly after cardiopulmonary arrest, permanent brain damage or death results. Prompt recognition and treatment of cardiopulmonary arrest can maintain the oxygen supply to the brain until circula- tion and respiration are restored. Cardiopulmonary resuscitation (CPR) can be part of basic life support or advanced life support. Basic life support is the immediate care given to maintain oxy- genation of the brain until advanced life support is available. To obtain the latest recommended interven- tions, see materials published by the American Heart Association (AHA) and the American Red Cross. All nurses should be familiar with the automated external defibrillator (AED), which is available in many public places. **Causes** Among the causes of cardiopulmonary arrest are myo- cardial infarction, heart failure, electrocution, drowning, drug overdose, anaphylaxis, and asphyxiation. **Signs and Symptoms** Victims of cardiopulmonary arrest collapse and quickly lose consciousness. They have no pulse or respiration. ### Focused Assessment In cardiopulmonary arrest, assessment and interventions are quickly interwoven. Only patient problems and goals are provided here. Patient Problems, Goals, and Outcome Criteria: Cardiopulmonary Arrest | Patient Problems | Goals and Outcome Criteria | | :-------------------------------------------------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Inadequate circulation related to cessation of heartbeat | Adequate oxygenation until heartbeat and respirations are restored: improving skin color, palpable pulse, spontaneous respirations | | Decreased cardiac output related to cessation of heartbeat | | | Inadequate oxygenation related to inadequate or absent respirations | Effective ventilation: spontaneous respirations, improving skin color | ### Interventions Refer to the latest AHA guidelines for CPR because the guidelines are revised at intervals. ### CHOKING OR AIRWAY OBSTRUCTION Choking is airway obstruction caused by a foreign body that enters the airway. ### Focused Assessment The initial response when a person appears to be choking depends on the severity of the airway obstruction. **1246 UNIT XVIII** Nursing in Disasters and First Aid *Image showing the Heimlich maneuver, both standing and lying down.* ## Mild Airway Obstruction If the victim has good air exchange, is responsive, and can cough forcefully, do not interfere. 1. Encourage the victim's efforts to breathe and cough. 2. If symptoms persist, activate the emergency response system. ### Severe Airway Obstruction Signs of severe airway obstruction are poor or no air exchange, poor or no cough, high-pitched noise known as stridor on inhala- tion, respiratory distress, cyanosis, inability to speak, inability to move air, and clutching the neck (the uni- versal choking sign, depicted in Fig. 63.1). Patient Problems, Goals, and Outcome Criteria: Choking | Patient Problems | Goals and Outcome Criteria | | :--------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------- | | Airway obstruction related to inability to expel an aspirated foreign object | Patent airway with normal respirations: expulsion of foreign object, audible respirations, improving skin color, decreased coughing, reduced anxiety, normal pulse | ### Interventions Perform abdominal thrusts for the conscious or uncon- scious choking victim per the latest AHA guidelines for choking (Fig. 63.2). Adaptive measures should be taken for obese or pregnant individuals. ### Complications From Abdominal Thrusts Because of the risk for damage to internal organs, a person who has received abdominal thrusts should subsequently be examined by a health care provider. ### Prevention Most choking deaths could be prevented if people would do the following: 1. Cut food into small pieces, eat slowly, and chew food thoroughly before swallowing. 2. Avoid laughing and talking while chewing and swallowing. 3. Perform abdominal thrusts promptly when a person is in distress because of an obstructed airway. ## SHOCK Shock results from acute circulatory failure caused by inadequate blood volume, heart failure, overwhelming infection, severe allergic reactions, or extreme pain or fright. Because of the complexity of the topic, shock is covered in detail in Chapter 9. ## HEMORRHAGE Hemorrhage is the loss of a large amount of blood. The loss of more than 1 liter of blood in an adult may lead to hypovolemic shock. Continued uncontrolled bleeding results in death. Bleeding may be external or internal. Internal bleeding is suspected if a trauma victim shows signs of shock but no external bleeding is evident. #### First Aid, Emergency Care, and Disaster Management CHAPTER 63 ### Focused Assessment Assess for signs and symptoms of hemorrhage, which may include obvious bleeding; cool, sweaty, pale skin; weak, thready pulse; rapid respirations; and decreasing alertness. The victim who is bleeding internally may also have abdominal distention, pain, hematemesis, or dyspnea, depending on the site of the bleeding. Ask if the patient has a bleeding disorder or takes any drugs that affect blood coagulation. Patient Problems, Goals, and Outcome Criteria: Hemorrhage |Patient Problems | Goals and Outcome Criteria| | -------- | -----| |Decreased cardiac output related to hypovolemia | Increased cardiac output: pulse and blood pressure within normal range, skin warm and dry, no visible bleeding | | Fear related to possible impending death| Decreased fear: patient appears more relaxed, states is less fearful| **1247** #### Interventions The immediate treatment for external bleeding is direct, continuous pressure with or without gauze. Ideally, a sterile dressing is placed over the wound. If sterile supplies are unavailable, use a clean cloth. Place the patient in a supine position. To provide stabilization, immobilize an injured part. Elevation of the feet 6 to 12 inches is permitted unless it causes pain. Elevation decreases blood flow to the area. After the bleeding stops, secure a large dressing, if available, over the wound. Reinforce the dressing but do not change it. ***See the original document for supporting image here)*** If direct wound pressure and elevation fail to control bleeding, apply indirect pressure, that is, pressure to the main artery that supplies the area (Fig. 63.3). The use of a tourniquet to control severe bleeding in an extremity is an option. However, tourniquets that are inappropriately placed or left in place too long may result in complications such as amputations. Therefore tourniquets should be applied only by people with advanced training in first aid. Some sources do not recommend a tourniquet under any circumstances; others indicate that it should be used only as a last resort when a limb is mangled, crushed, or amputated. The least dangerous tourniquet is a pneumatic one, such as a blood pressure cuff, that allows control of pressure. If a blood pressure cuff is used, inflate the cuff above the victim's systolic blood pressure. If the victim's blood pressure cannot be measured, the cuff should be inflated until the bleeding stops. Once the cuff is inflated, only a physician should remove it. When a victim with a tourniquet is transferred, the receiving caregiver must be informed that a tourniquet is in place. Major arterial pressure points. #### Epistaxis One type of bleeding that requires special intervention is epistaxis (nosebleed). Blood may come from the anterior or the posterior portion of the nose. Most anterior nosebleeds respond to pressure. Instruct the patient to sit down and lean the head forward to prevent aspiration of blood. Pinch the nostrils of the patient shut for at least 10 minutes (Fig. 63.4). Pinching the nostrils provides pressure that decreases bleeding. In most cases, this action stops the bleeding. Afterward, advise the patient not to blow or pick at the nose for several hours. Continued bleeding or bleeding from the posterior area of the nose requires medical treatment (see Chapter 60). #### TRAUMATIC INJURY Traumatic injuries result from a variety of events. Sports injuries, motor vehicle accidents, falls, and acts of violence often require emergency treatment at the scene of the injury. #### Fractures A fracture is a break in a bone that may be described as simple or compound, open or closed, complete or incomplete. A simple (closed) fracture does not break 1248 UNIT XVIII Nursing in Disasters and First Aid Epistaxis may be controlled by having the patient sit up and lean forward slightly. Then pinch the patient's nostrils closed. the skin. A compound (open) fracture is one in which the ends of the broken bone protrude through the skin. In a complete fracture, the broken ends are separated. The bone ends in an incomplete fracture are not separated. (See Chapter 45 for a discussion of other types of fractures.) ### Focused Assessment. Check the victim of traumatic injury for signs and symptoms of fractures. The primary symptom is pain, although some people, especially older adults, do not always have severe pain with fractures. Numbness and tingling may be present as a result of injury to nerves and blood vessels. Objective signs of fracture include deformity, swelling, discoloration, decreased function, and bone fragments protruding through the skin. Suspected fractures should be treated as such until they are ruled out by the physician. ### Patient Problem, Goal, and Outcome Criterion Fractures. The primary patient problem for the emergency treatment of the person with a suspected fracture is risk for trauma related to movement of unstable fractures. The goal is reduced risk for trauma, and the outcome criterion is stabilization of the fractured bone with minimal tissue damage. ### Interventions. ***The key to emergency management of fractures is immobilization. Immobilize the injured part, including the joints above and below the injury, to prevent further trauma to the bone and surrounding soft tissue. Do not attempt to straighten a broken bone. Instead, splint the bone in the position in which it was found, with as little movement as possible.*** Boards, sticks, magazines, and strips of cloth can all be used to immobilize an injured limb. A cool pack may be applied to reduce swelling. Severe bleeding may be present with compound fractures. In such cases, apply direct pressure to the artery above the injury. Give the victim nothing by mouth and seek transportation to a medical care facility as soon as possible. ### Strains and Sprains Strains are injuries to muscles or to the tendons that attach muscles to bones, or to both. Sprains are injuries to ligaments. Ligaments are bands of tissue that hold bones in position in the joints. These injuries are painful, and swelling may be present. Emergency treatment for both of these injuries is immobilization, elevation, and application of a cool pack. The victim should see a physician for further evaluation. ### Head Injury Head injury is not always apparent immediately after an accident. It should be suspected with any type of blow to the head or any unexplained loss of conscious-ness. A critical complication of head injury is increased intracranial pressure caused by bleeding or swelling associated with trauma. Increased intracranial pressure progressively impairs brain function and may lead to cessation of breathing. Older adults are at special risk for head injuries because they are more likely than younger people to have sensory deficits, unstable gait, or circulatory disorders. Head injury in an older person may be overlooked if a state of confusion is attributed to age without determining the person's usual level of mental function. ### Focused Assessment. When head injury is suspected, the focused assessment includes inspection and palpation of the head and evaluation for signs and symptoms of increased intracranial pressure. Signs of increased intracranial pressure are as follows: * Change in behavior, agitation, confusion * Decreasing level of consciousness * Pupil dilation or constriction, pupillary inequality, slow or no pupillary response to light * Impaired sensory or motor function * Increasing blood pressure with widening pulse pressure * Decreasing pulse and respiratory rates * Projectile vomiting Be alert for the leakage of cerebrospinal fluid (CSF) that occurs with basilar skull fractures. CSF leakage is usually seen as clear, colorless fluid draining from the nose or ear. If the fluid drains onto a white cloth, it appears as a yellowish stain. If blood is in the fluid, a yellow "halo" is produced around the pink (bloody) center. Although other fluids can also produce the "halo" sign, it is one piece of data in assessing for CSF leakage First Aid, Emergency Care, and Disaster Management CHAPTER 63 1249 Patient Problems, Goals, and Outcome Criteria: Head Injury |Patient Problems| Goals and Outcome Criteria| |----------------|--------------------------| |Inadequate oxygenation related to neurologic trauma| Adequate oxygenation: normal respiratory rate and depth, normal pulse, oxygen saturation Of at least 95%| |Potential for injury to brain or spinal column related to increasing intracranial pressure, improper movement after spinal fracture