EMERGENCY AND DISASTER NURSING

TERMS USE:
Trauma - Intentional or unintentional
wounds/injuries on the human body from
particular mechanical mechanism that exceeds
the bodys ability to protect itself from injury
Emergency Management - traditionally
refers to care given to patients with urgent and
critical needs.

Disaster - Any catastrophic situation in which

the normal patterns of life (or ecosystems)
have been disrupted and extraordinary,
emergency interventions are required to save
and preserve human lives and/or the
environment.
Mass Casualty Incident - situation in which
the number of casualties exceeds the number
of resources.

Triage - process of assessing patients to

determine management priorities.

Post Traumatic Stress Syndrome characteristic of symptoms after a

psychologically stressful event was out of
range of an normal human experience.

First Aid - an immediate or emergency

treatment given to a person who has been
injured before complete medical and surgical
treatment can be secured.

EMERGENCY IT IS WHATEVER THE PATIENT

OR THE FAMILY CONSIDERS IT TO BE.

BLS - level of medical care which is used for

patient with illness or injury until full medical
care can be given.
ACLS ADVANCE CARDIAC LIFE SUPPORTSet of clinical interventions for the urgent
treatment of cardiac arrest and often life
threatening medical emergencies as well as
the knowledge and skills to deploy those
interventions.
Defibrillation - Restoration of normal rhythm
to the heart in ventricular or atrial fibrillation

EMERGENCY NURSING - It is the nursing care

given to patients with urgent and critical needs
EMERGENCY NURSE - has a specialized
education, training, and experience to gain
expertise in assessing and identifying patients
health care problems in crisis situations
establishes priorities, monitors and
continuously assesses acutely ill and
injured patients, supports and attends to
families, supervises allied health
personnel, and teaches patients and

families within a time-limited, highpressured care environment

DISASTER NURSING - a branch of
emergency nursing, it refers to nursing care
given to patients who are victims of disasters,
whether it is manmade or natural phenomena.
INCIDENT COMMAND SYSTEM - It is a
management tool for organizing personnel,
facilities, equipment, and communication for
any emergency situation.
INCIDENT COMMANDER - The head of the
incident command system
He must be continuously informed of all
the activities and informed about any
deviation from the established plan
SCOPE AND PRACTICE OF EMERGENCY
NURSING
The emergency nurse has had
specialized education, training, and
experience.
The emergency nurse establishes
priorities, monitors and continuously
assesses acutely ill and injured patients,
supports and attends to families,
supervises allied health personnel, and
teaches patients and families within a

time-limited, high-pressured care

environment.
Nursing interventions are accomplished
interdependently, in consultation with or
under the direction of a licensed
physician.
Appropriate nursing and medical
interventions are anticipated based on
assessment data.
The emergency health care staff
members work as a team in performing
the highly technical, hands-on skills
required to care for patients in an
emergency situation.
Patients in the ED have a wide variety of
actual or potential problems, and their
condition may change constantly.
Although a patient may have several
diagnosis at a given time, the focus is on
the most life-threatening ones
ISSUES IN EMERGENCY NURSING CARE
Emergency nursing is demanding
because of the diversity of conditions
and situations which are unique in the
ER.

Issues include legal issues, occupational

health and safety risks for ED staff, and
the challenge of providing holistic care in
the context of a fast-paced, technologydriven environment in which serious
illness and death are confronted on a
daily basis.
The emergency nurse must expand his
or her knowledge base to encompass
recognizing and treating patients and
anticipate nursing care in the event of a
mass casualty incident.
Legal Issues Includes:
Actual Consent
Implied Consent
Parental Consent

Golden Rules of Emergency Care

Dos
- Obtain Consent
- Think of the Worst
- Respect Victims Modesty &
Privacy
Donts
- let the patient see his own injury
- Make any unrealistic promises
Guidelines in Giving Emergency Care
A Ask for help
I Intervene
D Do no Further Harm

Good Samaritan Law

Gives legal protection to the
rescuer who act in good faith and
are not guilty of gross negligence
or willful misconduct.
Focus of Emergency Care
Preserve or Prolong Life
Alleviate Suffering
Do No Further Harm
Restore to Optimal Function

Stages of Crisis
1. Anxiety and Denial
encouraged to recognize and talk about
their feelings.
asking questions is encouraged.
honest answers given
prolonged denial is not encouraged or
supported
2. Remorse and Guilt
verbalize their feelings

3.

4.

Core

Anger
way of handling anxiety and fear
allow the anger to be ventilated
Grief
help family members work through their
grief
letting them know that it is normal and
acceptable
Competencies in Emergency Nursing
Assessment
Priority Setting/Critical Thinking Skills
Knowledge of Emergency Care
Technical Skills
Communication

Assess and Intervene

Check for ABCs of life
A Airway
B Breathing
C - Circulation
Team Members
Rescuer
Emergency Medical Technician
Paramedics
Emergency Medicine Physicians
Incident Commander
Support Staff
Inpatient Unit Staff
Emergency Action Principle

I. Survey the Scene

Is the Scene Safe?
What Happened?
Are there any bystanders who can help?
identify as a trained first aider!
II. Do a Primary Survey - organization of
approach so that immediate threats to life are
rapidly identified and effectively manage.
Primary Survey
A - Airway/Cervical Spine
- Establish Patent Airway
- Maintain Alignment
- GCS 8 = Prepare Intubation
B Breathing
- Assess Breath Sounds
- Observe for Chest Wall Trauma
- Prepare for chest decompression
C Circulation
- Monitor VS
- Maintain Vascular Access
- Direct Pressure
Estimated Blood Pressure
SITE

SBP

Radial

80

Femoral

70

Carotid

60

Control of Hemorrhage

D Disability
- Evaluate LOC
- Re-evaluate clients LOC
- Use AVPU mnemonics
E Exposure
- Remove clothing
- Maintain Privacy
- Prevent Hypothermia
III. Activate Medical Assistance
Information to be Relayed:

What Happened?
Number of Persons Injured
Extent of Injury and First Aid given
Telephone number from where youre
calling

IV. Do Secondary Survey

Interview the Patient
S Symptoms
A Allergies
M Medication
P Previous/Present Illness
L Last Meal Taken
E Events Prior to Accident
Check Vital Signs

V. Triage
comes from the French word trier,
meaning to sort
process of assessing patients to
determine management priorities
Categories:
1. Emergent - highest priority,
conditions are life threatening and
need immediate attention
Airway obstruction, sucking chest
wound, shock, unstable chest and

abdominal wounds, open fractures of

long bones
2. Urgent have serious health problems
but not immediately life threatening
ones. Must be seen within 1 hour
Maxillofacial wounds without airway
compromise, eye injuries, stable
abdominal wounds without evidence of
significant hemorrhage, fractures
3. Non-urgent patients have episodic
illness than can be addressed within 24
hours without increased morbidity
Upper extremity fractures, minor burns,
sprains, small lacerations without
significant bleeding, behavioral disorders
or psychological disturbances.
3. Non-urgent patients have episodic
illness than can be addressed within 24
hours without increased morbidity
Upper extremity fractures, minor burns,
sprains, small lacerations without
significant bleeding, behavioral disorders
or psychological disturbances.

TRIAGE
CATEGOR
Y

PRIORIT
Y

IMMEDIA
TE
DELAYE
D
MINIMAL

RED

YELLO
W
GREEN

COLOR

Field TRIAGE
1. Immediate:
Injuries are life-threatening but
survivable with minimal intervention.
Individuals in this group can progress
rapidly to expectant if treatment is
delayed.
2. Delayed:
Injuries are significant and require
medical care, but can wait hours without
threat to life or limb. Individuals in this
group receive treatment only after
immediate casualties are treated.
3. Minimal:
Injuries are minor and treatment can be
delayed hours to days. Individuals in this
group should be moved away from the
main triage area.
4. Expectant:
Injuries are extensive and chances of
survival are unlikely even with definitive
care.
5. Fast-Track:
Psychological support needed

FIRST AID
Role of First Aid
Bridge the Gap Between the Victim and
the Physician
Immediately start giving interventions
in pre-hospital setting
Value of First Aid Training
Self-help
Health for Others
Preparation for Disaster
Safety Awareness

BASIC LIFE SUPPORT - an emergency

procedure that consists of recognizing
respiratory or cardiac arrest or both the proper
application of CPR to maintain life until a victim
recovers or advance life support is available.
Artificial Respiration
a way of breathing air to persons lungs
when breathing ceased or stopped
function.

Respiratory Arrest
a condition when the respiration or
breathing pattern of an individual stops

to function, while the pulse and

circulation may continue.
Causes: Choking, Electrocution, strangulation,
drowning and suffocation.

Table of Cardiopulmonary Resuscitation

for Adult, Child & Infant
Compressi
on Area

WAYS TO VENTILATE THE LUNGS

1. MOUTH-TO-MOUTH = a quick, effective
way to provide O2 and ventilation to the
victim.
2. MOUTH-TO-NOSE = recommended when
it is impossible to ventilate through the
victims mouth. (Trismus, mouth injury)
3. MOUTH-TO-NOSE and MOUTH = if the pt.
is an infant
4. MOUTH-TO-STOMA = used if the pt. has
a stoma; a permanent opening that
connects the trachea directly to the front
of the neck.
For Rescue Breathing Alone:
Rate is 10-12 breaths in ADULT
(1.5 - 2 sec/breath) ( 1 breath every 4 to
5 secs)
Rate is 20 breaths for a CHILD and
INFANT
(1 1.5 sec/breath) ( 1 breath every 3
secs)

Depth
How to
compress
Compressi
onventilation
ratio
Number of
cycles per
minute

Adult
Lower half of
the sternum
but not hitting
the xiphoid
process:
measure up to
2 fingers from
substernal
notch.
Approximately
1 to 2
inches
Heel of 1
hand, other
hand on top.

Child
Lower half
of the
sternum but
not hitting
the xiphoid
process:
measure up
to 1 finger
from
substernal
notch.
Approximate
ly 1 to 1
inches
Heel of 1
hand.

Infant
Lower half
of the
sternum but
not hitting
the xiphoid
process: 1
finger width
below the
imaginary
nipple line.

30:2 (1 or 2
rescuers)

30:2 (1 or 2
rescuers)

Approximate
ly to 1
inch
2 fingers
(middle &
ring
fingertips)
30:2 (1 or 2
rescuers)

5 cycles in 2
minutes

5 cycles in 2
minutes

5 cycles in 2
minutes

Child(1
-8 yrs)

Adult

Procedur
e

Infant(0-1yr)

Safe
Approach
Assess for
Response

Approach and assess situation

Shout and gently pinch

Gently
shouting
are you

Positionin
g
Open the
Airway

ok? then
shake
the
victim
Placed Supine on a firm and flat
surface

Assess for
Breathing

The Casualty is
Go for
Help

Give
Rescue
Breaths

look for
chest rising

rising

look for
chest rising

Check for foreign bodies then

remove using finger sweep
Head-tilt-chin-lift maneuver
Jaw-thrust Maneuver

Bring cheek over the mouth and

nose of the casualty
Look for chest movement
Listen for breath sounds
Feel for breathing on your
cheek
NOT Breathing:

if someone responds to your

shout for help send that person
to phone for ambulance
if youre on your own, leave the
casualty and make the phone
call for yourself
* never leave if the patient has
collapsed as a result of trauma or
drowning or if the casualty is a child
5 rescue breaths
2 rescue
breaths
Place
mouth over
the nose
and mouth
of the
infant

pinch
nose and
ventilate
via mouth
look for
chest

seal lips
around the
mouth and
blow
steadily for
1.5 2
seconds

The Casualty is Breathing:

Place in recovery position
Before moving casualty remove any
objects safely from her pockets

Kneel beside casualty, place arm nearest

at right angles, and then bend elbow
keeping the palm uppermost.
Bring far arm across the casualtys chest
and hold back of the casualtys hand
against the nearest cheek
With your other hand grasp the far thigh
just above the knee, then pull the
casualty towards you and on to his or
her side

CRITERIA FOR NOT STARTING CPR

- All patients in cardiac arrest receive
resuscitation unless:
1. The pt. has a valid DNR order
2. The pt. has signs of irreversible death:
rigor mortis, livor mortis, algor mortis,
decapitation
3. No physiological benefit can be expected
because the vital functions have
deteriorated despite maximal therapy
4. Witholding attempts to resuscitate in the
DR is appropriate for newly born infants
with:
- Confirmed gestation less than 23
weeks or birthweight less than
400 grams
- Anencephaly
When to Stop
when the patient has spontaneous
breathing

 when the first aider is too exhausted to

continue
when another first aider takes over
when EMS arrives and takes over

EARLY DEFIBRILLATION - 7-10%

decrease per minute without
defibrillation
EARLY ACLS technique that attempts
to stabilize patient

When to STOP CPR:

S SPONTANEOUS BREATH RESTORED
T TURNED OVER THE MEDICAL SERVICES
O OPERATOR IS EXHAUSTED TO CONTINUE
P PHYSICIAN ASSUMES RESPONSIBILITY
COMPLICATIONS OF CPR:

RIB FRACTURE
STERNUM FRACTURE
LACERATION OF THE LIVER OR SPLEEN
PNEUMOTHORAX, HEMOTHORAX

CHAIN OF SURVIVAL
EARLY ACCESS early recognition of
cardiac arrest, prompt activation of
emergency services
EARLY BLS prevent brain damage, buy
time for the arrival of defibrillator

MANAGEMENT FOR AIRWAY OBSTRUCTION

HEIMLICH MANEUVER
(Subdiaphragmatic Abdominal Thrusts)
For Standing or sitting conscious patient:

Stand behind the patient; wrap your

arms around the patients waist

Make a FIST, placing thumb side of the

fist against the pts abdomen, in the
midline SLIGHTLY ABOVE the UMBILICUS
and WELL BELOW the XIPHOID PROCESS

Make a quick INWARD and UPWARD

thrust. Each thrust is separated.

AIRWAY OBSTRUCTION
KINDS OF AIRWAY OBSTRUCTION:
1. Anatomic Airway Obstruction
2. Mechanical Airway Obstruction
TYPES OF AIRWAY OBSTRUCTION
1. Partial Airway Obstruction with Good Air
Exchange
2. Partial Airway Obstruction with Poor Air
Exchange
3. Complete Airway Obstruction
Clinical Manifestations: UNIVERSAL DISTRESS
SIGNAL
(patient may clutch the neck between the
thumb and fingers), choking, stridor,
apprehensive appearance, restlessness.
CYANOSIS and LOSS of CONSCIOUSNESS
develop as hypoxia worsens.

For patient lying (unconscious):

position patient at the back (supine);

kneel astride the patients thigh

Place HEEL of one HAND against the

pts abdomen, place the second hand
directly on the top of the fist.

Make a quick UPWARD thrust

FINGER SWEEP: used only in unconscious adult
client

Make a TONGUE-JAW LIFT. Opening the

pts mouth by grasping both tongue and
lower jaw between the thumb and
fingers, and lifting the mandible.

Insert index finger of other hand to

scrape across the back of the throat

Use a hooking action

CHEST THRUST: used only in patients in

advanced stages of pregnancy or in markedly
obese clients
a. Conscious Patient standing or sitting
Stand behind the client with arms under
patients axilla to encircle patients chest
Place thumb side of fist on the MIDDLE
of STERNUM, grasp with the other hand
and perform BACKWARD thrust until
foreign body is expelled.
MEASURES TO ESTABLISH AIRWAY
A. HEAD-TILT-CHIN-LIFT MANEUVER
B. JAW-THRUST MANEUVER
C. OROPAHRYNGEAL AIRWAY

D. ENDOTRACHEAL INTUBATION
Indications:
To establish an airway for patients
cannot be adequately ventilated with an
oropharyngeal airway
To bypass upper airway obstruction
To permit connection to ambubag or
mechanical ventilator
To prevent aspiration
To facilitate removal of tracheobronchial
secretions
E. CRICOTHYROIDOTOMY

a puncture or incision of the cricothyroid

membrane to establish an emergency
airway in certain emergency situations

where endotracheal intubation or

tracheostomy is not possible.
indicated to pts. with trauma to head
and neck, and in allergic reaction
causing laryngeal edema
use of gauge 11 needle or scalpel blade

Nursing Actions:

Extend the neck. Place towel roll

beneath the shoulders

Insert the needle at a 10 to 30 degree

caudal direction in the midline jest
above the upper part of the cricoid
cartilage

Listen for air passing back and forth

Direct the needle downward and

posteriorly, and tape it.

INJURIES TO HEAD, SPINE, AND FACE

A.
1.
2.
3.

HEAD INJURIES
OPEN HEAD INJURY skull is fractured
CLOSED HEAD INJURY skull is intact
CONCUSSION temporary loss of
consciousness that results in transient
interruption if the brains normal
functioning
4. CONTUSSSION bruising of the brain
tissue
5. INTRACRANIAL HEMORRHAGE
significant bleeding into a space or
potential space between the skull and
the brain

a. Epidural hematoma
the most serious type of
hematoma; forms rapidly and
results from arterial bleeding
forms between the dura and the
skull from a tear int the meningeal
area
b. Subdural hematoma
forms slowly and results from a
venous bleed

a surgical emergency
c. Intracerebral hemorrhage
bleeding directly into the brain
matter

ALERT: Assume cervical spine fracture for

any patient with a significant head injury,
until proven otherwise.
PRIMARY ASSESSMENT: Assess for ABC
SECONDARY ASSESSMENT:
Change in LOC most sensitive
indicator in the pts condition
CUSHINGS TRIAD ( bradypnea,
bradycardia, widened pulse pressure)
indicating increased intracranial
pressure
unequal or unresponsive pupils;
impaired vision
Battles sign bluish discoloration of the
mastoid, indicating a possible BASAL
SKULL FRACTURE
Rhinorrhea or otorrhea indicative of
CSF leak

Periorbital Ecchymosis indicates

anterior basilar fracture

ALERT: If basilar skull fracture or severe

midface fractures are suspected, a
nasogastric tube(NGT) is CONTRAINDICATED!

MANAGEMENT:
Open airway by Jaw-Thrust Manuever,
suction orally if needed
Administer high flow oxygen: most
common death is CEREBRAL ANOXIA
In general, hyperventilate the patient to
20-25 bpm, causing cerebral
vasoconstriction and minimizing cerebral
edema
Apply a bulky, loose dressing; dont
apply pressure
IV line of PNSS or Plain LR
prepare to manage seizures
maintain normothermia
Medications:
a. Diazepam
b. Steroids
c. Mannitol
Prepare of immediate surgery if pt.
shows evidence of neurologic
deterioration

B. SKULL FRACTURES
SIMPLE closed

COMPOUND open

LINEAR Fx common hairline break, w/o

displacement of structure

COMMINUTED Fx splinters or crushes

the bone in several fragments

DEPRESSED Fx pushes the bone

toward the brain

CRANIAL VAULT Fx top of the head

BASILAR Fx base of the skull and
frontal sinuses
ALERT:

Damage to the brain is the first concern,

it is considered a neurosurgical condition

In children, skulls thinness and

elasticity allows a depression w/o a
break in the bone

CAUSES: Traumatic blows to the head, VA,

severe beatings
S/Sx: scalp wounds, agitation and
irritability, loss of consciousness, labored
breathing, abnormal deep tendon
reflexes, altered pupillary and moor
response
IF CONSCIOUS: complains of persistent
localized headache
IF JAGGED BONE FRAGMENTS: may cause
cerebral
bleeding
HALO SIGN blood-tinged spot surrounded
by lighter
ring
IF SPHENOIDAL Fx: damages the optic nerve
and may
cause BLINDNESS
IF TEMPORAL Fx: may cause unilateral
deafness or
facial paralysis

TREATMENT:
For LINEAR FRACTURES:
supporative (mild analgesics)
cleaning and debridement of wounds
If conscious: observed for 4 hours; if not,
admit for evaluation
if VS stable, may go home with
instruction sheet
For VAULT and BASILAR FRACTURES:
Craniotomy to remove fragemnts
anti-biotics
Dexamethasone
Osmotic Diuretics (MANNITOL) if
increased ICP is present
NURSING CONSIDERATIONS:
maintain patent airway; nasal airway
contraindicated to basilar fx
support with O2 administration
suction pt. through mouth not nose if
CSF leak is present
RHINORRHEA wipe it, dont let him
blow it!
OTORRHEA cover it lightly with sterile
gauze, dont pack it!
Position head on side
Maintain a supine position with bed
elevated to 30 degrees
dont give narcotics or sedative
assist in surgery, maintaining sterile
technique
C. CERVICAL SPINE INJURIES
PRIMARY ASSESSMENT:

immediate immobilization of the spine

A B C ( Intercoastal paralysis w/
diapragmatic breathing)

SUBSEQUENT ASSESSMENT:

Hypotension, bradycardia, hypothermia

- suggests SPINAL SHOCK

Total sensory loss and motor paralysis

below the level of injury
MANAGEMENT:
Nasotracheal intubation
initaite IV access, monitor blood gas
indwelling urinary catheterization
prepare to manage seizures
Meds: High dose steroids and diazepam
D. MAXILLOFACIAL TRAUMA
PRIMARY ASSESSMENT:

Immobilization of spine while

performing assessment

ABC (tongue swelling, bleeding,

broken or missed teeth)
SUBSEQUENT ASSESSMENT:

Paralysis if the upward gaze indicative

of INFERIOR ORBIT FX

Crepitus on nose indicates nasal

fracture

Flattening of the cheek and loss of

sensation below the orbit indicates
ZYGOMA (cheekbone) FX
Malocclussion of teeth, trismus
indicative of MAXILLA FX
PRIMARY INTERVENTIONS:
Insertion of oral airway or intubation
Nasopharyngeal airway should only be
used if no evidence of nasal fracture or
rhinorrhea

Apply bulky, loose dressing; apply ice to

areas of swelling

INJURIES TO SOFT TISSUES, BONES AND

JOINTS
A. SOFT TISSUE INJURIES
1. CLOSED WOUND
A. CONTUSION bleeding beneath the skin into
the soft tissue
B. HEMATOMA well-defined pocket of blood
and fluid beneath the skin
2. OPEN WOUND
A. ABRASION superficial loss of skin from
rubbing or scraping
B. LACERATION tear in the skin, can be
insicional or jagged
C. PUNCTURE penetration of a pointed object,
can be penetrating or perforating
D. AVULSION tearing off or loss of a flap of
skin
E. AMPUTATION traumatic cutting or tearing
off of a finger, toe, arm or leg
PRIMARY MANAGEMENT
D- IRECT PRESSURE
E- LEVATION
P- RESSURE POINTS
S- OAK, SOAP, SCRUB, SURGERY
A- NTI-TETANUS, ANTIBIOTICS
I- RRIGATE
D- RESS
B. INJURIES TO BONES AND JOINTS
1. FRACTURE a break in he continuity of
the bone; occurs when stress is placed

on a bone is greater than the bone can

absorb
ALERT: fractured cervical spine, pelvis and
femur may produce life threatening injuries;
posterior dislocations of the hip are life- and
limb-threatening emergencies due to potential
blood loss.
Clinical Manifestations:
Pain and tenderness over fracture site
Crepitus or grating over fracture site

swelling and edema

Deformity, shortening of an extremity or
rotation of extremity
EMERGENCY Management: IMMOBILIZE,
INITIATE IV
MANAGEMENT PROCESS OF FRACTURES
REDUCTION
setting the bone; refers to the
restoration of the fracture fragments into
anatomic position and alignment
IMMOBILIZATION
maintains reduction until bone healing
occurs
REHABILITATION
Regaining normal function of the
affected part
use of cast and splint to immobilize
extremity and maintain reduction

Skin Traction force applied to the skin

using foam rubber, tapes
Skeletal Traction force applied to the
bony skeleton directly, using wires, pins,
tongs placed in the bone
ORIF operative intervention to achieve
reduction, alignment and stabilization
Endoprosthetic Replacement
implantation of metal device
NURSING CONSIDERATIONS:
Elevate to prevent or limit swelling
Apply ice packs or cold compress; not
place directly in skin
Splint and maintain in good alignment,
immobilize the joint above and below
the fracture
Give pain medications as ordered
Assist in casting; use the palm of your
hands in holding a wet cast
Avoid resting cast on hard surfaces or
sharp edges
Do neurovascular checks hourly for the
first 24 hours
Assess for COMPARTMENT SYNDROME
check for 6 Ps
If Compartment syndrome is suspected,
do not elevate limb above the level of
the cast
Notify the physician
Bivalve the cast

ALERT: this is a medical emergency because of

associated disruption of surrounding blood and
nerve supplies
* Subluxation partial disruption of the
articulating surfaces
Clinical Manifestations:

Pain and deformity

Loss of normal movement

X-ray confirmation of dislocation w/o

assoc. fracture
Management: Immobilize part, Secure
reduction of dislocations manually (usually
preferred under anesthesia)
Nursing Considerations:
Assess neurovascular status before and
after reduction of dislocation
Administer pain medications (NSAIDs)
Ensure proper use of immobilization
device (elastic bandage, splints)

2. TRAUMATIC JOINT DISLOCATION - occurs

when the surfaces of the bones forming the
joint no longer in anatomic position

4. STRAIN a microscopic tearing of the muscle

cause by excessive force, stretching, or
overuse

3. SPRAIN an injury to the ligamentous

structure surrounding a joint; usually caused by
a wrench or twist resulting in a decrease joint
stability
Clinical Manifestations:

Rapid swelling due to extravasation of

blood w/n tissues

Pain on passive movement of joint

discoloration, and limited use or

movement

Clinical Manifestations:

Pain with isometric contractions

Swelling and tenderness

Hemorrhage in muscle

MANAGEMENT OF SPRAINS AND STRAINS

COMPRESSION (Elastic Bandage)

REST
ICE (for the first 24 hrs; 1 hr on, 2 hrs off
during waking hours)
MEDICATIONS ( NSAIDs)
ELEVATION
SUPPORT (Use of crutches, splints)
NURSING CONSIDERATIONS:
Apply ice compress for the first 24 hrs
to produce vasoconstriction, decrease
edema, and reduce discomfort
Apply warm compress after 24 hrs to
promote circulation and absorption (20
to 30 minutes at a time)
Educate to rest injured part for a month
to allow healing
Educate to resume activities gradually
and to warm up

SHOCK AND INTERNAL INJURIES

A. SHOCK
- Inadequate tissue perfusion, resulting in
failure of one or more of the ff:
a. pump failure of the heart
b. Blood volume
c. arterial resistance levels
d. capacity of venous beds

- Can be classified as:

A. HYPOVOLEMIC - occurs when
significant amount of fluid is lost in the
intravascular space (Ex. Hemorrhage,
burns, fluid shifts)
B. CARDIOGENIC occurs when the heart
fails as a pump. Primary causes includes
MI, dysrhythmias; Secondary causes
includes mechanical restriction of
cardiac function or venous obstruction
like in Cardiac Tamponade, tension
pneumothrorax, VCO
C. SEPTIC SHOCK from bacteria and
their products circulating in the blood
PRIMARY INTERVENTIONS:
Assess for ABC
Resuscitate as necessary
Administer O2 to augment O2-carrying
capacity of arterial blood
Start cardiac monitoring
Control hemorrhage
SUBSEQUENT ASSESSMENT:

Assess LOC, decreasing LOC indicates

progression of shock
o Monitor arterial blood pressure
(narrowing pulse pressure, fall in systolic
pressure)
o Assess pulse quality and rate change
(tachycardia, weak and thready)
o Assess urinary output (25ml/hr may
indicate shock)
o Assess capillary perfusion
o Assess for metabolic acidosis due to
anaerobic metabolism of cells
o Assess for excessive thirst,
hyperthermia on septic shock
MANAGEMENT:
Administer O2 via ET or nonrebreather
face mask (if intubated, may be
hyperventilated to control acidosis)
Fluid resuscitation (2 large-bore IV lines,
Ringers Lactate, BT)
Insertion of an indwelling catheter
Maintain patient in a supine position
with legs elevated
Continue to monitor VS, ECG, CVP, ABG,
UO, HCT, Hgb,and electrolytes; refer
changes on the following
Maintain normothermia (high fever will
increase the cellular metabolism effects
of shock
Medications: Inotropics, Vasopressor,
and Anti-biotics
o

ELECTROCARDIOGRAM
- It is a useful tool in the diagnosis of
those conditions that may cause
abberations in the electrical activity

WAVE INTERPRETATIONS:
P WAVE : Atrial Depolarization; first positive
deflection
Q WAVE: first negative deflection
R WAVE: first positive deflection
S WAVE: negative deflection, after R wave
QRS COMPLEX: Ventricular Depolarization
T WAVE: Ventricular Repolarization

Nursing Responsibilities during ECG

Check order for ECG, in cases of arrest,
prepare the machine at the bedside at
ER
Provide Privacy
Instruct patient to lie still and avoid
movement
Remove metal objects on the patients
(jewelries)
Place Chest leads as labeled:
Lead 1: Red, Right Arm
Lead 2: Yellow, Left Arm
Lead 3: Green, Left Foot
Neutralizer: Black, Right foot
V1: Red, 4th ICS, Right Sternal
Border
V2: Yellow, 4th ICS, Left sternal
border
V3: Green, midway between V2
and V4
V4: Brown, 5th ICS, Left MCL
V5: Black, 5th ICS, LAAL

V6: Violet, 5th ICS, LMAL

B. BLUNT CHEST INJURIES
- It is a trauma in the chest without an
open wound
usually cause by VA, blast injuries
SIGNS/SYMPTOMS:
RIB FRACTURES: tenderness, slight
edema, pain that worsens with deep
breathing and movement, shallow and
splinted respirations
STERNAL FRACTURES: persistent chest
pain
MULTIPLE RIB FRACTURES:
- FLAIL CHEST (loss of chest wall
integrity)
decreased lung inflation,
paradoxical chest movements
extreme pain
rapid and shallow respirations
hypotension, cyanosis
respiratory acidosis
COMPLICATIONS:
1. TENSION PNEUMOTHORAX
a condition in which air enters the chest
but cant be ejected during exhalation
There is lung collapse and mediastinal
shift
S/Sx: tracheal deviation, cyanosis and
severe dyspnea, absent breath sound on
the affected side, agitation, JVD
2. HEMOTHORAX
collection of blood in the pleural cavity,
usually results from ribs, lacerating lung
tisssue or an intercoastal artery

It is the most common cause of shock

following chest trauma
2. LACERATION or RUPTURE of AORTA
immediately fatal
3. DIAPHRAGMATIC RUPTURE
causes severe respi. Distress; if
untreated abdominal viscera may
herniate, compromising both circulation
and vital capacity of lungs
4. CARDIAC TAMPONADE
rapid unchecked rise in intrapericardia
pressure that impairs diastolic filling of
the heart
results from blood or fluid accumulation
in the pericardial sac
ASSESSMENT AND DIAGNOSIS:

Percussion:
- Hemothorax: Dullness
- Tension Pnuemothorax: tymphany

Auscultation:
- Tension Pnemothorax: PMI is deviated
- Cardiac tamponade: muffled heart
tones

X-ray

Thoracentesis yeilds blood and

serosanguinous fluid

ECG

Retrograde aortography reveals aortic

laceration

Echocardiography

Computed Tomography
TREATMENT:
Simple Rib Fractures

mild analgesics, bed rest, apply heat

incentive spirometry
deep breathing, coughing and splinting
Severe Rib Fractures
intercoastal nerve blocks
position for semi-fowlers, administer O2
Hemothorax
Chest tube insertion at 5th-6th ICS
anterior to MAL
administer IV fuids, O2, Blood
Transfusion
Thoracotomy
Thoracentesis

TREATMENT:
Tension Pneumothorax
insertion of spinal, 14G or 16G needle
into the 2nd ICS at MCL to release
pressure
Chest Tubes
Surgical Repair
Aortic Rupture/Laceration
immediate surgery
- synthetic grafts
- aortic anastomosis
O2, BT, IV
NURSING CONSIDEARTIONS:
monitor VS, (q 15, first hour post
thoracentesis and post CTT)
After CTT insertion, encourage cough
and breathing exersises
Chest tubes should have continuous
FLUCTUATIONS
if BUBBLING, air leak is suspected

if FLUCTUATION STOPS, mechanical

blockage or lung has already expanded
have an extra bottle with PNSS, clamps
and sterile gauze at bedside
in case of dislodgment, cover the
opening with sterile/petroleum gauze to
prevent rapid lung collapse
Assist with proper positioning
Bed Rest

C. ABDOMINAL INJURIES
1. PENETRATING ABDOMINAL INJURY
usually the result of gunshot wound or
stab wounds; may cross the diaphragm
and enters the chest
2. BLUNT ABDOMINAL INJURY caused by
vehicular accidents or falls
PRIMARY ASSESSMENT AND
INTERVENTIONS:
ASSESS ABC
INITITATE RESUSCITATION AS NEEDED
CONTROL BLEEDING AND PREPARE TO
TREAT SHOCK
IF THERE IS AN IMPALED OBJECT IN THE
ABDOMEN, LEAVE IT THERE AND
STABILIZE THE OBJECT WITH BULKY
DRESSINGS
GENERAL INTERVENTIONS:
Keep pt. quiet in the stretcher, any
movement may dislodge a clot
Cut the clothing, count the number of
wounds, look for entrance and exit
wounds

Apply compression to external bleeding

wounds
double IV line and infuse Ringers
Lactate
Insert NGT to decompress the abdomen
Cover protruding abdominal viscera w/
sterile saline dressings; dont attempt to
place back the protruding organs
Cover open wounds with dry dressings
Insert indwelling catheter; if pelvic
fracture is suspected, catheter should
not be placed until integrity of urethra is
ensured.
Meds: Tetanus Prophylaxis, Antibiotics
Assist in peritoneal lavage
Prepare pt. for surgery if the condition
persists. (Exploratory Laparotomy)

ENVIROMENTAL EMERGENCIES
1. HEAT EXHAUSTION - It is the inadequacy
or the collapse of peripheral circulation due to
volume and electrolyte depletion
ASSESSMENT: temperature may be normal or
slightly elevated, hypotension, tachycardia,
tachypnea, pale and moist skin, fatigue,
headache, dizziness, syncope
DIAGNOSTICS: hemoconcentration,
hyponatremia or hypernatremia, ECG may
show dysrhythmias
MANAGEMENT:
Move patient to a cool environment,
remove all clothing
Position the patient supine with the feet
slightly elevated

Monitor VS every 15 mins and cardiac

rhythm
Educate to avoid immediate reexposure
to high temperatures
2. HEATSTROKE - It is a combination of
hyperpyrexia and neurologic symptoms. It
caused by a shutdown or failure of the heatregulating mechanisms of the body.
CLINICAL MANIFESTATIONS:

bizarre behavior or irritability,

progressing to confusion, delirium and
coma

40.6 degrees Celcius, hypotension,

tachycardia, tachypnea

skin may appear flushed and hot; at

start it maybe moist progressing to
dryness (Anhidrosis)
NURSING ALERT:

Elderly clients are high-risk to develop

heat-stroke

Once diagnosis is confirmed, it is

imperative to reduce patients
temperature
MANAGEMENT:
EVAPORATIVE COOLING, most effective,
by spraying tepid water on skin while
fans are used to blow
Apply ice packs to necks, groin, axillae,
and scalp
Soak sheets/towels in ice water and
place on patient
If temp. fails to decrease, initiate core
cooling: iced saline lavage, cool fluid

peritoneal dialysis, cool fluid bladder

irrigation
Discontinue active cooling when the
temp. reaches 39 degrees Celcius
Oxygenate the pt. via ET or
nonrebreather mask
Monitor VS, ECG, and neurologic status
Start IV infusion using Ringers Lactate
Anti-pyretics are not useful
Indwelling catheterization
WOF hypokalemia, metabolic acidosis,
seizures

3. HYPOTHERMIA
- It is a condition where the core temp. is
less than 35 degrees Celcius as a result
in the exposure to cold.
3 compensatory mechanisms:
a. shivering produces heat thru
muscular activity
b. peripheral vasoconstriction to
decrease heat loss
c. raising basal metabolic rate
NURSING ALERT:

Elderly are greater risk for hypothermia

due to altered compensatory
mechanisms

Extreme caution should be used in

moving or transporting hypothermic pts.,
because the heart is near fibrillation
threshold
CLINICAL MANIFESTIONS:

slow, spontaneous respirations

heart sounds may not be audible even if

its beating

BP is extremely difficult to hear

fixed dilated pupils, no pulse, no BP;

initiate CPR

drowsiness progressing to coma

shivering is suppressed on temp. below

32.3 degrees

ataxia

cold diuresis

fruity or acetone odor of breath

GOAL of MANAGEMENT: Rewarm
without precipitating cardiac
dysrhythmias.

MANAGEMENT:
Passive External Rewarming (temp
above 28 degrees)
- Remove all wet clothing, and replace
with warm clothing
Provide insulation by wrapping the
patient in several blankets
Provide warm fluids
Disadvantage: slow process
Active External Rewarming (temp above
28 degrees)
- Provide external heat for patient- warm
hot water bottles to the armpits, neck, or
groin
Warm water immersion
- Disadvantages:
1. causes peripheral vasodilation, returning
cool blood to the core, causing an initial
lowering of the core temp.
2. Acidosis due to washing out of lactic acid
from the peripheral tissue

3. An increased in metabolic demands before

the heart is warmed to meet these needs.
Active Core Rewarming (temp below 28
degrees)
- Inhalation of warm, humidified O2 by
mask or ventilator
warmed IV fluids
Warm gastric lavage
- Peritoneal dialysis with warmed standard
dialysis solution
Cardiopulmonary bypass
Disadvantage: invasiveness of the procedure
4. NEAR-DROWNING
- It is a survival for atleast 24 hours after
submersion, with most common
consequence of hypoxemia.
- Hypoxia and acidosis are common
problems of the victim.
- Resultant pathophysiologic changes and
pulmonary injury depend on type of fluid
and the volume aspirated.
a. Fresh water aspiration- results in loss of
surfactant, hence an inability to expand lungs
b. Saltwater aspiration- leads to pulmonary
edema from the osmotic effect of salt within
the lungs.
Clinical Manifestations:
-difficulty of breathing
-hypothermia
-cyanosis
-chills
MANAGEMENT:
Immediate CPR

Endotracheal intubation with PEEP

VS, check degree of hypothermia
Rewarming procedures
Intravascular volume expansion and
inotropic agents
ECG
Indwelling catheterization
NGT insertion

TOXICOLOGIC EMERGENCIES
ASSESSMENT:

ABC

Identify the poison

Obtain blood and urine tests; gastric
contents may be sent to laboratory

Monitor neurologic status

Monitor fluid and electrolytes

GENERAL INTERVENTIONS:

Initiate large-bore IV access, monitor

shock

Prevent aspiration of gastric contents by

positioning head on side

Maintain seizures precaution

MINIMIZING ABSORPTION
Administration of activated charcoal
with a cathartic to hasten secretion.
Induction of emesis with syrup of
ipecac; done only in patients with good
gag reflex and is conscious.

Adult dose is 30 ml by mouth followed

by 2 glasses of water; Pedia dose is15 ml
followed by 8 16 oz. of water.

NURSING ALERT: Do not induce emesis after

ingestion of caustic substances, hydrocarbons,
iodides, silver nitrates, petroleum distillates; to
a patient having seizure or to pregnant patient.
Gastric lavage for the obtunded patient.
Save gastric aspirate for toxicology
screen.
Procedure to enhance the removal of
ingested substance if the patient is
deteriorating.
1. Forced diuresis with urine pH alteration
to enhance renal clearance.
2. Hemoperfusion (process of passing blood
through an extracorporeal circuit and a
cartridge containing an adsorbent, such
as charcoal, after which the detoxified
blood is returned to the patient)
3. Hemodialysis to purify and accelerate
the elimination of circulating toxins.
4. Repeated dose of charcoal.
5. Providing an antidote antidote is a
chemical or physiologic antagonist that
will neutralize the poison.
GASTRIC LAVAGE
PURPOSES:
1. To remove unabsorbed poison after
ingestion.
2. To diagnose and treat gastric
hemorrhage and for the arrest of
hemorrhage.

3. To cleanse stomach before endoscopic

procedures.
4. To remove liquid or small particles of
material from the stomach.
NURSING CONSIDERATIONS
Insertion of NGT or OGT.
Place patient on left lateral position with
head lower 15 degrees downward.
Elevate funnel and pour approx. 150
200 ml.
Lavage fluid is left in place for about
one minute before allowed to drain
Save samples of first two washings.
Repeat lavage procedure until the
returns are relatively clear and no
particular matter is seen.
At the completion of the lavage:
1. Stomach may be left empty.
2. An Adsorbent may be instilled in the
tube and allowed to remain in the
stomach.
3. A saline cathartic may be instilled in the
tube.
Pinch off the tube during removal or
maintain suction while tubing is being
withdrawn.
Give the patient a cathartic if
prescribed.
Warn patient that stool will turn black
from the charcoal.
2. CARBON MONOXIDE POISONING
- It is an example of inhaled poison and
results in the incomplete hydrocarbon
combustion

Carbon monoxide exerts its toxic effects

by binding to circulating hemoglobin to
reduce the oxygen carrying capacity of
the blood.
Carbon monoxide and hemoglobin is
200 300 times affinity compared to
oxygen and hemoglobin.
Creation of carboxyhemoglobin
resulting to tissue anoxia.
CLINICAL MANIFESTATIONS
Respiratory depression, stridor.
Confusion progressing to coma.
Headache, muscular weakness,
palpitation, and dizziness.
Skin is pink in color, cherry red, or
cyanotic.
ABG: carboxyhemoglobin level is 12%
(Normal), 30 40% severe carbon
monoxide poisoning.
-

MANAGEMENT:
Provide 100% oxygen by tight-fitting
mask (the elimination half life of
carboxyhemoglobin, in serum, for a
person breathing room air is 5 hours and
20 minutes. If patient breaths 100%
oxygen the half life is reduced to 80
minutes
100% oxygen in hyperbaric chamber
reduces halflife to 20 minutes.
Intubate if necessary to protect airway.
Continuous ECG monitoring, treat
dysrhythmias.
Correct acid-base and electrolyte
imbalances.

Continuous observation of psychoses,

spastic paralysis, visual disturbances,
and deterioration of personality may
persist after resuscitation and may be
symptoms of permanent CNS damage.

3. INSECT STINGS
- These are injected poisons that can
produce either local or systemic
reactions.
Local reactions are characterized by
pain, erythema and edema at the site of
injury.
Systemic reactions usually begin within
minutes. (Unconsciousness, laryngeal
edema, bronchospasm, and
cardiovascular collapse.
MANAGEMENT:
ABC
Epinephrine is the drug of choice give
SQ.
Administer bronchodilator.
Initiate IV with Ringers Lactate.
Prepare for CPR.
NURSING CONSIDERATIONS:
Apply ice packs to site to relieve pain.
Elevate extremities with large
edematous local reaction.
Administer anti histamine for local
reaction.
Clean wounds thoroughly with soap and
water or antiseptic solution.
Educate patient.
- Have epinephrine on hand

- Wear emergency medical bracelet

indicating hypersensitivity.
- If sting occurs, remove stinger with one
quick scrape of fingernail.
- Do not squeeze venom sack, because
this may cause additional venom to be
injected.
- Avoid insect feeding areas.
4. SNAKE BITES
CLINICAL MANIFESTATIONS:
- Burning pain, swelling, and numbness of
the site.
Hemorrhagic blisters may occur after
few hours of bite and entire extremity
may become edematous.
WOF signs of systemic reactions
(nausea, sweating, weakness,
lightheadedness, initial euphoria
followed by drowsiness, dysphagia,
paralysis of various muscle groups,
shock, seizures, and coma).
MANAGEMENT:
Wash the site of bite, keep the patient
calm and immobilize extremity.
Administer O2 and start IV line.
Administer anti-venin and be alert to
allergic reaction.
Administer vasopressors in the
treatment of shock.
5. ALCOHOL WITHDRAWAL DELIRIUM
a.k.a Delirium Tremens or Alcoholic
Hallucinosis
An acute toxic state that follows a
prolonged bout of steady drinking or

sudden withdrawal from prolonged

intake of alcohol.
Symptoms begins as early as 4 hours
after reduction of alcohol intake and
peaks at 24 - 48 hours but may last up
to 2 weeks.

ALCOHOLISM a chronic disease or

disorder characterized by excessive
alcohol intake and interference in the
individuals health, interpersonal
realtionship and economic functioning
-

Considered to be present when

there is .1% or 10 ml for every 1000
ml of blood
At .1 - .2%, there is low
coordination
At .2 - .3%, there is ataxia, tremors,
irritability, and stupor

At .3 and above, there is

unconsciousness
COMMON BEHAVIORAL PROBLEMS: 5 Ds
D-enial
D-ependency
D-emanding
D-estructive
D-omineering
COMMON WITHDRAWAL SIGNS AND
SYMPTOMS:
HALLUCINATIONS (VISUAL AND TACTILE)
INCREASED VITAL SiGNS
TREMORS
SWEATING AND SIEZURE

COMMON DEFENSE MECHANISMS:

DENIAL
RATIONALIZATION
ISOLATION
PROJECTION
PRIORITY NURSING DIAGNOSIS:
- INEFFECTIVE INDIVIDUAL COPING
DRUG OF CHOICE for aversion therapy of
an alcoholic:
- DISULFIRAM (antabuse)
Instruct patient to avoid, when taking
Disulfiram:
MOUTH WASH
OVER THE COUNTER COLD REMIDIES
FOOD SAUCES MADE UP OF WINE
FRUIT FLAVORED EXTRACTS
AFTERSHAVE LOTIONS
VINEGAR
SKIN PRODUCTS
MANAGEMENT:
Protect patient from injury, diazepam or
phenytoin for seizure control as
prescribed.
Monitor VS every 30 minutes.
Use a non-alcohol skin preparation,
draw blood for measurement of ethanol
concentration, toxicologic screen for
other drug abuse.
Maintain electrolyte balance and
hydration.
Observe for hypoglycemia.

Administer thiamine followed by

parenteral dextrose if liver glycogen is
depleted.
Give orange juice, gatorade, or other
carbohydrates to stabilize blood sugar.
Place patient in a private room with
close observation.

BEHAVIORAL EMERGENCIES - It is an urgent,

serious disturbances of behavior, affect, or
thought that makes the patient unable to cope
with his life situation and interpersonal
relationship
1. VIOLENT PATIENTS
- Is usually episodic and is a means of
expressing feelings of anger, fear and
hopelessness about a situation.
Manage through:
a. Establish control, keeping the door open,
and be in clear veiw of staff
b. Ask if he has a weapon, avoid touching an
agitated pt.
c. Adopt a calm, nonconfrontational approach
d. Provide emotional support; CRISIS
INTERVENTION
2. SUICIDE
- Ultimate form of self-destruction; cry for
help
- Major Interventions: PREVENTION and
LISTEN
RISK FACTORS

SEX (female attempts, male commits suicide)

UNSUCCESSFUL PREVIOUS ATTEMPT
IDENTIFICATION with family member
committed suicide
CHRONIC
ILLNESS
DEPRESSION/DEPENDENT PRERSONALITY
AGE (18-25 AND ABOVE 40)/ALCOHOLISM
LETHALITY OF PREVIOUS ATTEMPTS

PRIORITY NURSING DIAGNOSIS:

Risk for Injury, Self-directed
NURSING INTERVENTIONS:
Provide one-on-one monitoring
Have frequent unscheduled rounds
Avoid use of metals and glass utensils
Remove shampoos, perfumes,
medicines at the bedside
Monitor for signs of impending suicide
(giving away of valued possession)
3. RAPE TRAUMA SYNDROME
According to RA 8353, RAPE refers to
the insertion of penis into the mouth,
vagina, anus of a victim

Insertion of any object into the mouth or

anus

It is generally considered as an act of

hostility, anger, or violence
ELEMENTS OF RAPE:

Use of threat/force

lack of consent of the victim

Actual penetration of the penis into the

vagina
DifferentClassification
Kinds of Rape: Affected Part

POWER done to prove ones

1st degree
Epidermis
masculinity
superficial

ANGER done as a means of retaliation

SADISTIC done to express erotic

2nd degree
Pediermis and
feelings
partial thickness part of the
RAPE TRAUMA SYNDROMEdermis

(flames, scald, contact with heat) , electrical,

chemical or radiation

FACTORS DETERMINING SEVERITY OF

BURN:
1. age mortality rates are higher for children
< 4 yrs of age and for clients > 65 yrs of age
2. Patients medical condition debilitating
disorders
such as cardiac,
Description
of Wound
Whatrespiratory,
to Expect
endocrine and renal disorders negatively
influence
the clients response
to last
injury
and48
Pin, painful
sunburn
Discomfort
after
treatment.
Blisters
form after 24
hrs; heals in 3-7 days

mortality rate is higher when the

hours
client has a pre-existing disorder at the
Red, wet blisters,
bullae
time of
the burnHeals
injuryin 2-3 weeks, in no
very painful
complication
3. location
burns on the head, neck and chest
It refers
to a group of signs
andskin
are
with
pulmonary
2nd degree
Only the
Waxy white, difficult
toassociated
Slow to
heal
94-8 weeks)
rdcomplications;
symptoms
experienced
by
a
victim
in
deep partial
appendages in
distinguish from 3
surgical incision and
reaction
to rape
burns ongrafting
the faceunless
are associated
thickness
the hair follicle
degree except hair
has
abrasion;
remain
growth becomes with corneal
complication
4 Phases
days,
burns on the ear are associated
apparent in 7-10
1. ACUTE PHASE characterized by shock, little or no pain
with auricular chondritis;
numbness and disbelief
hands and joints require intensive
3rd degree
2. DENIAL
characterizedEpidermis,
by victims
Dry, leathery,
therapy; Requires excision and
Full thickness
dermis
grafting.
refusal
to talk about the
eventand
may be red
or
the perineal
area is prone to
1014
days
graft
to
3. HEIGHTENED ANXIETY subcutaneous
characterized by
black
autocontamination
byfor
urine
and
tissue . no skin
revascularize
fear, tension, and nightmares
May have feces;
appendages
4. REORGANIZATION victims
life
thrombosed
veins
circumferential burns of the
normalizes
Marked edema
extremities can produce a
PRIORITY NURSING CARE: Preservation of
tourniquet-like effect and lead to
Distal circulation
evidences
vascular compromise
may be decreased
TREATMENT: Crisis Intervention
(compartment syndrome).
Painless
4. Depth
BURN TRAUMA
- Is the damage
4th degree
Skin,caused
muscle,to
Dry, charred, bone may
Requires excision, grafting
skin and deeper
body
structures
by
deep full
tendon,heat
bonde
be visible
and sometimes amputation
thickness

5. Size: Rule of nine

Assessment

Child
<3
years
old

Adult

Head and
neck

18%

9%

1 arm

9%

9%

Posterior
trunk

18%

18%

Anterior
trunk

18%

18%

1 leg

14%

18%

Perineum

1%

1%

6. Temperature
determines the extent of injury
7. Exposure to the Source
Thermal Burns caused by
exposure to flames, hot liquids,
steam or hot objects
Chemical Burns caused by tissue
contact with strong acids, alkalis
or organic compounds
Electrical Burns result in internal
tissue damaging, alternating
current is more dangerous than
direct current for it is associated
with cardiopulmonary arrest,
ventricular fibrillation, titanic
muscle contractions, and long
bone and vertebral fractures.
Radiation Burns are caused by
exposure to ultraviolet light, xrays or a radioactive source.
Types of Burns and their Treatment:
Scald
burn caused by hot liquid
immediately flush the burn area
with water (under a tap or hose
for up to 20 min)

 if no water is readily available,

remove clothing immediately as
clothing soaked with hot liquid
retains heat
Flame
Smother the flames with a coat or
blanket, get the victim on the floor
or ground (stop, drop, and Roll)
Prevent victim from running
If water is available, immediately
cool the burn area with water
If water is not available, remove
clothing; avoid pulling clothing
across the burnt face
Cover the burn area with a loose,
clean, dry cloth to prevent
contamination
Do not break blisters or apply
lotions, ointments, creams or
powder
Airway
if face or front of the trunk is
burnt, there could be burns to the
airway

there is a risk of swelling or air

passage, leading to difficulty in
breathing
Smoke inhalation
Urgent treatment is required with
care of the airway, breathing and
circulation
When 02 in the air is used up by
fire, or replaced by other gases,
the oxygen level in the air will be
dangerously low
Spasm in the air passages as a
result of irritation by smoke or
gases
Severe burns to the air passages
causing swelling and obstruction
Victim will show signs and
symptoms of lack of O2. He may
also be confused or unconscious
Electrical
check for Danger
turn of the electricity supply if
possible
avoid any direct contact with the
skin of the victim or any

conducting material touching the

victim until he is disconnected
once the area is safe, check the
ABCs
if necessary, perform rescue
breathing or CPR
Chemical
Flood affected area with water for
20-30 min
Remove contaminated clothing
If possible, identify the chemical
for possible subsequent
neutralization
Avoid contact with the chemical
Sunburn
Exposure to ultraviolet rays in
natural sunlight is the main cause
of sunburn
General skin damage and
eventually skin cancer develops
The signs and symptoms of
sunburn are pain, redness and
fever