chapter 016 [read-only] - napa valley college€¦ · 8/23/2016 3 cardiopulmonary resuscitation...

8/23/2016

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Chapter 16

Care of Patients Experiencing Urgent Alterations in Health

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Moral and Legal Responsibilities of the Nurse

Good Samaritan laws Enacted in most states 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


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Assessment of the Emergency Situation

Primary assessment Airway

Breathing

Circulation (pulse and severe bleeding)

Life-threatening situations

Arrested or abnormal breathing or pulse


Assessment of the Emergency Situation (Cont.)

Fractures, dislocations, and superficial ecchymoses or wounds require attention after the more serious conditions are treated


Cardiopulmonary Resuscitation (CPR)

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


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Cardiopulmonary Resuscitation (CPR) (Cont.)

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



Events necessitating CPR CPR is indicated in any syndrome where

respiration or 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



Events necessitating CPR Clinical death

• The heartbeat and respirations have ceased

Biologic 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


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Events necessitating 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



Initial assessment and response Determine responsiveness

• Gently shake and loudly ask “Are you OK?”

Call for help or direct another person to make a telephone call if available

• Vitally important to obtain an automatic external defibrillator (AED)

For most successful treatment of cardiac arrest, CPR and use of an AED should be initiated within the first 3-5 minutes



The CABs of CPR Circulation

Airway

Breathing

Health care providers and lay persons establish unresponsiveness, activate the EMS, and retrieve the AED Both determine if there is no breathing or abnormal

breathing

Only health care providers assess for the carotid pulse; take no more than 10 seconds to palpate the pulse


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Circulation Determine pulselessness

• Carotid pulse is the most reliable Maintain the head tilt method for assessing the carotid

pulse

Absence of pulse confirms cardiac arrest

Perform external cardiac compressions



Circulation Proper compression technique

• Lock elbows in place with arms straight and shoulders positioned over hands

• Lean forward and push, depressing sternum at least 2 inches in adult

• Release external chest compression pressure completely to allow chest to return to position

• Maintain hand position at all times

• Complications of external chest compressions



Airway Confirm absence of breathing and establish patent airway

If no evidence of neck trauma, use head-tilt/chin-lift maneuver to open airway

Initiate rescue breathing if pulse present

Preserve open airway

Kneel at shoulders of patient

Use thumb and index finger to maintain the head-tilt position

Gently pinch nostrils

Nurse takes deep breath

Seal lips around outside of victim’s mouth

Give two full breaths 1 second each


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Airway First attempt unsuccessful, reposition head and

attempt to ventilate again

Second attempt unsuccessful, proceed with foreign body airway obstruction



Steps for adult one-rescuer CPR Determine unresponsiveness

Determine breathlessness

Call for help

Activate the EMS system



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


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Circulation Perform 30 chest compressions at a rate of at

least 100 per minute

Follow compressions with two slow breaths

Continue 30 compressions and two slow breaths until an AED becomes available or help arrives



Airway Open airway using head tilt/chin-lift maneuver

If suspected neck injury, use jaw thrust (chin-lift) without head tilt

Breathing Not breathing – two slow breaths 1 second each,

allowing exhalation between breaths

Unable to give breaths – reposition head and reattempt to ventilate

Still unable – proceed with foreign body airway obstruction management procedures



Adult two-rescuer CPR If EMS not activated – direct second rescuer to

activate EMS

The ventilator – person at victim’s head• Determines responsiveness

• Assesses breathlessness for 5-10 seconds

• Determine pulselessness

• Pulse present – initiate rescue breathing 1 breath every 6-8 seconds (8-10 per minute)


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Adult two-rescuer CPR Compressor – person at victim’s chest

• Activates EMS and calls for AED

• Pulseless – initiate compressions 30 chest compressions for every 2 breaths

Compression rate 100 per minute

• More likely to become fatigued



Adult two-rescuer CPR Compressor

• Switch positions every 5 cycles of 2 minutes for effective CPR Initiated by rescuer performing chest compressions

Checks the pulse for 5-10 seconds– No pulse – “RESUME CPR”



Pediatric CPR 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 year to puberty


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Pediatric CPR Determine unresponsiveness

• Child – shake gently

• Infant – gently tap infant’s heels

Position victim on firm, flat surface

May have to carry small child/infant while performing CPR



Pediatric CPR Open airway

• Use head-tilt/chin-lift or jaw thrust technique

• Be careful not to hyperextend the infant’s neck

• Look for chest movement

• Listen for breath sounds

• Feel exhaled airflow

• Not breathing – begin the CAB sequence



Pediatric CPR Circulation

• Assess carotid artery – child

• Assess brachial artery – infant

• Pulse present – rescue breathing 1 breath every 6-8 seconds

• No pulse (or fewer than 60 beats per minute) Begin external cardiac compressions


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• Technique for external cardiac compressions for infant Use two fingers to perform chest compressions

Compress breastbone at least 1/3 diameter of chest (1½ inches)

Rate 100 times per minute

Ratio of compressions to ventilation is 30 : 2




• Technique for cardiac compression in the child Compress heel of one hand at nipple line at depth of at

least 1/3 diameter of chest (2 inches)

Rate 100 times per minute

Be sure fingers do not touch ribs

Keep compression smooth

Sequence is 30 compressions to 2 breaths



Pediatric CPR Airway

• Use head-tilt/chin-lift or jaw thrust technique to open airway of child

Breathing• Give 2 breaths (1 second per breath)

Use the amount of air for the infant that an adult is able to hold in the cheeks


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Hands-only CPR 2010 – American Heart Association recommends

that bystanders not trained in conventional CPR use only their hands without rescue breathing in crucial moments after witnessing out-of-hospital sudden cardiac arrest

Call 911

Start chest compressions “hard and fast”

Continue until EMS arrives or AED available


Question 1

In two-rescuer CPR of the adult victim, the standard ratio of compressions to breaths is:

1. 15 : 2.

2. 30 : 2.

3. 15 : 1.

4. 30 : 1.


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


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Foreign Body Airway Obstruction Management (Cont.)

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?”



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



Conscious victim Abdominal thrusts

• 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, thrust into the victim’s abdomen with a quick upward motion

• Repeat thrusts until the foreign body is expelled or the victim becomes unconscious


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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 placing 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



Unconscious victim Infant

• 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 shoulders 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



Unconscious victim Infant

• The rescuer turns the infant and places the infant on the rescuer’s thigh with the head lower than the trunk

• Five chest thrusts are performed with the hands in the same position as when performing external cardiac compressions


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Question 2

A victim is using the universal sign for choking. The rescuer:

1. asks, “Are you OK?”

2. sweeps the mouth with two fingers.

3. places the victim flat and uses the jaw thrust maneuver to open the airway.

4. gives the victim support.


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


Shock (Cont.)

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


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Shock (Cont.)

Assessment Level of consciousness

Skin changes

Blood pressure

Pulse

Respirations

Urinary output

Neuromuscular changes

Gastrointestinal effects


Shock (Cont.)

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


Shock (Cont.)

Nursing interventions 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 health care provider

Provide emotional support and reassurance


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Bleeding and 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 6-7 minutes

Uncontrolled bleeding can result in shock and death


Bleeding and Hemorrhage (Cont.)

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



Types of bleeding Arterial

• Least common; usually protected by bones, fat, and other structures

• Heavy spurting of bright red blood in the rhythm of the heartbeat


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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 the site



Nursing interventions 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



Epistaxis Nosebleed

Common but seldom a serious emergency

Causes Trauma

Epistaxis digitorum (trauma from nasal picking)

Infections

Hypertension

Strenuous activity

Low humidity


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Epistaxis Nursing interventions

• Keep the victim’s head tilted slightly forward

• Apply steady pressure to both nostrils for 10-15 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



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



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 provider


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Question 3

Tourniquets are indicated for control of hemorrhage only when:

1. injuries are so diffuse that maintaining direct pressure is not possible.

2. an extremity is severely mutilated or amputated.

3. application of ice and elevation has not stopped the bleeding.

4. the patient must be transported.


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


Wounds and Trauma (Cont.)

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


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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



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


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


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Poisons (Cont.)

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


Poisons (Cont.)

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


Poisons (Cont.)

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


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Poisons (Cont.)

Absorbed poisons Poisons, caustic chemicals, and poisonous plants

that come in contact with the skin

Cause burning, skin irritation, allergic responses, or severe system reactions

Signs and symptoms • Nausea, vomiting, diarrhea, flushed skin, dilated pupils,

cardiovascular abnormalities, and CNS reactions


Poisons (Cont.)

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


Poisons (Cont.)

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


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Question 4

A hiker is brought to the emergency department after being bitten on this lower leg by a snake. The nurse immobilizes the affected limb and:

1. places it in a dependent position.

2. elevates it on two pillows.

3. places warm, moist packs on it.

4. cleans it vigorously with antimicrobial soap.


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


Drug and Alcohol Emergencies (Cont.)

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


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Drug and Alcohol Emergencies (Cont.)

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


Thermal and Cold Emergencies

Heat injury Heat exhaustion

• The most common type of heat injury, which 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


Thermal and Cold Emergencies (Cont.)

Heat injury Heat exhaustion

• 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


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Heat injury 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



Heat injury Heatstroke

• 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



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


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Exposure to excessive cold 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



Exposure to excessive cold Frostbite

• Freezing and damage of body cells

• Commonly affected areas 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



Exposure to excessive cold Frostbite

• Nursing interventions Treat the victim for shock and hypothermia; establish and

maintain an airway

Warm part by immersion in warm water at 104-110° F for

20-45 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


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Question 5

A hunter is found in the woods with feet that are cold, damp, and shriveled. The rescuer recognizes this condition as:

1. chilblain.

2. frostbite.

3. overdose of stimulants.

4. withdrawal of stimulants.


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


Bone, Joint, and Muscle Injuries (Cont.)

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


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Fractures Nursing interventions

• Do not move unless victim 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



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



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


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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



Spinal cord injuries Assessment

• Assess for paralysis

• Test for sensation

• Assess for abrasions and ecchymoses on the back

Nursing interventions• Take spinal cord precautions

• Maintain airway; keep head in a neutral position


Question 6

A patient arrives in the emergency department with a fractured left wrist. The complaint that is most likely to indicate serious injury and must be addressed first is:

1. pain in the affected wrist.

2. swelling in the fingers.

3. bruising in the hand and arm.

4. numbness in the fingers.


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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


Burn Injuries (Cont.)

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



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 lost

Wounds weep a great deal of fluid and blood

Causes: direct flame, explosions, and gasoline or oil fires


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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


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


Question 7

A factory worker was brought to the emergency department with an injured arm that appears grey at the burn site and does not hurt. He wants to return to work this afternoon. The nurse explains to him:

1. “Since you are not in pain that should not be a problem.”

2. “This is a third-degree burn and will require admission to the hospital.”

3. “We need to observe you for at least an hour to make sure that you are OK.”

4. “You can leave now if you agree to come to the clinic tomorrow for a follow-up visit.”


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