local anesthetics: overview - drexel university college of medicine

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1Elsevier items and derived items © 2005 by Elsevier Inc. Slide 1Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1

Chapter 24Emergency First Aid NursingChapter 24Emergency First Aid Nursing

Elsevier items and derived items © 2005 by Elsevier Inc. Slide 2Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2

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.


Moral and Legal Responsibilities• Good Samaritan Laws

– Enacted in most state to protect health professionals from legal liability when providing emergency first aid.

– Follow a reasonable and prudent course of action.• Victim must give verbal permission• The law assumes that an unconscious person

would give consent if he or she were able.• Once first aid is initiated, the nurse has the moral

and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training.

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Assessment of the Emergency• Primary Assessment

– Airway– Breathing– Circulation (pulse and severe bleeding)

• Life-threatening Situations– Arrested or abnormal breathing or pulse

• Observe for indications of skull injury and brain or spinal cord damage.

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


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


Events Requiring CPR• Clinical Death

– The heartbeat and respirations have ceased.• Biological Death

– This results from permanent cellular damage caused by lack of oxygen.

– The brain is the first organ to suffer from lack of oxygen.

– In many cases, CPR can reverse clinical death if initiated before 4 minutes of cardiopulmonary arrest.

– After 10 minutes without CPR, brain death is certain.

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Events Requiring CPR

• Brain Death– This is an irreversible form of

unconsciousness characterized by a complete loss of brain function while the heart continues to beat.

– The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration; pupils that are fixed and dilated; and absent electric activity of the brain on two electroencephalograms (EEGs) performed 12 to 24 hours apart.


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

• http://www.wonderhowto.com/how-to/video/how-to-diagnose-septic-shock-symptoms-254886/

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Shock

• Classification of Shock– Classified according to cause

• Severe blood loss• Intense pain• Extensive trauma; burns• Poisons• Emotional stress or intense emotions• Extremes of heat and cold• Electrical shock• Allergic reactions• Sudden or severe illness


Shock

• Assessment– Level of consciousness– Skin changes– Blood pressure– Pulse– Respirations– Urinary output– Neuromuscular changes– Gastrointestinal effects


Shock• Nursing Interventions

– Establish airway.– Control bleeding.– Reduce pain.– Position the victim flat with the head slightly

lower than the rest of the body (elevate the feet and legs).

– If victim is unconscious or is vomiting or bleeding around the nose or mouth, position on the side.

– If victim is having breathing problems, elevate head and shoulders.

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Figure 24-9, A

Body positions for shock. A, Modified Trendelenburg.


Figure 24-9, B

Body positions for shock. B, If head, neck, or spinal injuries are suspected.


Figure 24-9, C

Body positions for shock. C, Breathing problems.

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Shock

• Nursing Interventions (continued)– Cover victim with a blanket or other covering

to keep warm.– Do not give anything to eat or drink.– Relieve pain: support injury; avoid rough

handling; adjust tight or uncomfortable clothes.

– Do not give analgesics unless directed by a physician.

– Provide emotional support and reassurance.


Bleeding/Hemorrhage• Effects of Blood Loss

– Blood loss from internal or external bleeding causes a decrease in oxygen supply to the body.

– Blood pressure drops.– Heart pumps faster to compensate for the

decreased volume and blood pressure.– The body will attempt to clot the blood to halt

bleeding; usually requiring 6 to 7 minutes.– Uncontrolled, bleeding can result in shock and

death.


Bleeding/Hemorrhage

• Types of Bleeding– Capillary

• Most common; results from damaged or broken capillaries and causes oozing of minor cuts, scratches, and abrasions

– Venous• Occurs when the vein is severed or punctured • Results in a slow, even flow of dark red blood• Embolism may occur if air enters the severed vein.

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Bleeding/Hemorrhage

• Types of Bleeding (continued)– Arterial

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

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


Bleeding/Hemorrhage

• Nursing Interventions– Direct Pressure

• The most effective general treatment of bleeding is to apply direct pressure over the bleeding site.

• Raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body’s ability to clot at this site.


Figure 24-10

Applying pressure to wound site.

(From Sorrentino, S.A. [1996]. Mosby’s textbook for nursing assistants. [4th ed.]. St. Louis: Mosby.)

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Bleeding/Hemorrhage• Nursing Interventions (continued)

– Indirect Pressure• If direct pressure and elevation do not control

bleeding, indirect pressure may be applied to any of the pressure points situated along main arteries.

– Application of a Tourniquet• A tourniquet must be used only when the other

methods have failed and the victim’s life is in danger.

• It can cause extensive damage to the body part.


Figure 24-11

Applying pressure to wound site.

(From Kidd, P.S., Stuart, P.A. [1996]. Mosby’s emergency nursing reference. St. Louis: Mosby.)


Skill 24-1: Step 7

Applying a tourniquet.

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Bleeding/Hemorrhage

• Epistaxis– Nosebleed– Common but seldom a serious emergency– Causes

• Trauma• Epistaxis digitorum (trauma from nasal picking)• Infections• Hypertension• Strenuous activity• Low humidity


Bleeding/Hemorrhage• Epistaxis

– Nursing Interventions• Keep the victim’s head tilted slightly forward.• Apply steady pressure to both nostrils for 10 to 15

minutes.• Remind the victim to breathe through the mouth

and to expectorate any accumulated blood.• Apply ice compresses over the nose at the same

time.• Look in the victim’s mouth at the back of the throat

to assess for bleeding from a posterior site.


Bleeding/Hemorrhage• Internal Bleeding

– This is a potentially life-threatening situation.– Common causes are fractures, knife or bullet

wounds, crushing injuries, organ injuries, and medical conditions such as ruptured aneurysms.

– Assessment• Signs and symptoms of shock.• Vertigo• Hemoptysis or hematemesis• Melena• Hematuria

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Bleeding/Hemorrhage

• Internal Bleeding– Nursing Interventions

• This is a priority medical emergency.• Place on a flat surface with legs elevated.• Establish an airway.• Cold compress or ice is placed on the area of

injury.• Maintain body temperature with blankets.• Assess vital signs.• Oxygen may be ordered by the physician.


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

• 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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Wounds and Trauma• Dressings and Bandages

– General Principles of Bandaging• Bleeding should be controlled before bandage is

applied.• Use sterile material if possible; if not use, the

cleanest material possible.• Dressing should never cover the entire wound.• Wounds should be bandaged firmly but not too

tightly.• Bandage in alignment is desired.• Tips of fingers and toes should remain exposed if

possible.


Wounds and Trauma• Application of Common Types of

Bandages– Bandage Compress

• Most common type of dressing; consists of several thicknesses of gauze, covered with tape or gauze.

– Triangular Bandage• Made of a piece of cloth that is folded diagonally

and cut along the fold; used as a sling to support injured bones.

– Roller Bandage• Used to support an injured part apply pressure to a

dressing, or secure a splint to immobilize a part.


Figure 24-13

Use of roller bandage.

(From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2nd ed.]. Philadelphia: Saunders.)

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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.


Poisons

• Ingested Poisons– Poisoning by mouth is the most common type

of poisoning, especially in children.– Common substances include household

cleaning products, garden and garage supplies, drugs, medications, food, and plants.


Poisons

• Ingested Poisons– Nursing Interventions

• Immediately call the poison control center.• Maintain airway.• Possible instructions by the poison control center

– Dilute the poison by giving one or two glasses of water.– Induce vomiting if gag reflex is present and poison is not

a corrosive.

• Treat for shock and administer CPR if needed.

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Poisons

• Inhaled Poisons– Common Sources

• Carbon monoxide, carbon dioxide, and refrigeration gases; poisonous fumes from chlorine and other liquid chemical sprays

– Nursing Interventions• Remove victim from the dangerous area only if

there is no danger to the rescuer.• Maintain airway; perform CPR if needed.• Victim should remain quite and inactive while

being transported to the nearest medical facility.


Poisons• Absorbed Poisons

– Poisons, caustic chemicals, and poisonous plants that come in contact with the skin

– Causes burning, skin irritation, allergic responses, or severe system reactions

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

pupils, cardiovascular abnormalities, and CNS reactions


Poisons

• Absorbed Poisons– Nursing Interventions

• Quickly remove the source of the irritation; wash with soap and water.

• Skin preparations include baking soda, Burow’ssolution, and oatmeal.

• Calamine lotion and hydrocortisone cream are effective to relieve pruritus.

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Poisons• Injected Poisons

– Minor reactions to insect bites• Remove stinger, if present, by scraping.• Wash the bite with soap and water.• Apply cold packs; baking soda paste.

– Severe reactions to insect bites• Urticaria, wheezing, edema of the lips and tongue,

generalized pruritus, and respiratory arrest• Nursing interventions

– Apply a wide constricting band proximal to the wound; keep affected part in dependent position; transport to the hospital immediately.


Drug and Alcohol Emergencies– 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

• 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• 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 of

hallucination.– Carefully assess mental status and vital signs

frequently.


Thermal and Cold Emergencies

• Heat Injury– Heat Exhaustion

• The most common type of heat injury, this results from prolonged perspiration and the loss of large quantities of salt and water.

• Observe for signs and symptoms of headache, vertigo, nausea, weakness, and diaphoresis.

• Mental disorientation and brief loss of consciousness may occur.



• Heat Injury (continued)– Heat Exhaustion (continued)

• Nursing interventions– Cool the victim as quickly as possible; use cold, wet

compresses and fan or air conditioner.– Have victim lie down with feet elevated.– If alert, give one-half glass of water every 15 minutes for

1 hour.– In the clinical setting, IV fluids are given.

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Thermal and Cold Emergencies• Heat Injury (continued)

– Heatstroke• This is a more serious heat injury; death can result.• The most common cause is vigorous physical

activity in a hot, humid environment.• The body becomes overheated, but the cooling

mechanism of perspiration does not operate.• Assessment: rapidly rising body temperature; hot, dry,

erythemic skin; no visible perspiration; pulse rapid initially and then slow and blood pressure falls; breathing deep and rapid; victim complains of headache, dry mouth, nausea, and vomiting



• Heat Injury (continued)– Heatstroke (continued)

• Nursing interventions– Cool the victim as quickly as possible; use cold packs

around the victim’s neck, under the arms, and around the ankles to cool the blood in the main arteries.

– Establish and maintain an airway.– Monitor for chilling as the body temperature falls.



• 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 (continued)– Hypothermia

• Nursing interventions– Initiate CPR if necessary; must continue until the body is

rewarmed.– Place victim in a supine position with the head lower than

the feet.– Rewarm slowly: move to a warm area, remove wet

clothing, and wrap with warm blankets.


Thermal and Cold Emergencies• Exposure to Excessive Cold (continued)

– Frostbite• Freezing and damage of body cells• Commonly affected area are ears, nose, fingers,

and toes.• Assessment: initially, skin takes on a red flush with

numbness, tingling, and pain; progressively, the part becomes hard and loses all sensation; color turns to grayish white; if thawing occurs, may change to blue-purple or black; edema may develop, followed by blisters.


Thermal and Cold Emergencies• Exposure to Excessive Cold (continued)

– Frostbite (continued)• Nursing interventions

– Treat the victim for shock and hypothermia; establish and maintain an airway.

– Warm part by immersion in warm water at 104 to 110° F for 20 to 45 minutes.

– If tub is not available, may use a hot moist towel. – Be very careful not to rub the part.– The thawed part is wrapped in clean towels or bulky

dressings and elevated.

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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

• 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.


Bone, Joint, and Muscle Injuries

• Fractures– Nursing Interventions

• Do not move unless he or she is in danger.• ABCs of first aid take priority.• Control bleeding if present.• Immobilize the fracture but do not attempt to

realign the bone.• Monitor circulation in the limb.• Apply ice or cold packs to the area.

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Figure 24-14

Immobilization of fractured arm.

(From Henry, M.C., Stapleton, E.R. [1997]. EMT prehospital care. [2nd ed.]. Philadelphia: Saunders.)


Bone, Joint, and Muscle Injuries• Dislocations

– Occurs in joints; usually results from a blow or fall

– Assessment: complaints of pain and edema; deformity of the part; part may be rigid, and the victim is unable to move it.

– Nursing interventions: never attempt to reduce a dislocation; splint the joint; apply ice or cold packs.


Skill 24-2: Step 4

Applying an arm splint using a triangular (sling and swathe) bandage.

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Bone, Joint, and Muscle Injuries• Strains and Sprains

– Strains are injuries to muscle tissue from stretching and tearing due to overexertion.

– Sprains are injuries to joints resulting from stretched or torn ligaments due to twisting of the joint beyond the normal range of motion.

– Assessment– Sprains: pain or tenderness around a joint; immobility of the

joint; rapid and marked edema

– Strains: spasms of the muscle, acute pain, stiffness, and weakness on movement; back pain radiating down the leg; discoloration


Bone, Joint, and Muscle Injuries• Strains and Sprains

– Nursing Interventions• RICE

– Rest the affected extremity– Ice should be applied to the part– Compression with a compression bandage– Elevation above the level of the heart


Bone, Joint, and Muscle Injuries• Spinal Cord Injuries

– Assessment• Assess for paralysis.• Test for sensation.• Assess for abrasions and ecchymosis on the back.

– Nursing Interventions• Take spinal cord precautions.• Maintain airway; keep head in a neutral position.

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Skill 24-3: Step 1

Moving the victim with a suspected spinal cord injury.


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

• 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.

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Burn Injuries• Full-Thickness Burns

– These burns involve destruction of the skin and underlying tissue, including fat, muscle, and bone.

– Skin may be thick and leathery, with black or dark brown, cherry red, or dry and milky white colors.

– The victim may not complain of pain, because nerve endings may be severed.

– Wounds weep a great deal of fluid and blood.– Causes: direct flame, explosions, and

gasoline or oil fires


• Deep Partial-Thickness Burns and Full-Thickness Burns– Nursing interventions

• Establish airway.• Assess respiratory and cardiac function.• Remove all of victim’s clothing, shoes, and jewelry.• Administer CPR if necessary.• Treat for shock.• Cool the burn with cool compresses for partial-

thickness burns.• Avoid touching the burn with anything but sterile

dressings.

Burn InjuriesBurn Injuries


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

local anesthetics: overview - drexel university college of medicine

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