NCLEX-RN: Emergency Nursing

Emergency Nursing: ASSESSING LIFE-THREATENING CONDITIONS

Focus topic: Emergency Nursing

Emergency Nursing: Initial Status Assessment

Focus topic: Emergency Nursing

A. Airway.

  • Open airway—if airway is obstructed, victim cannot get oxygen.
    a. Move fast—time is critical because brain damage could occur after 4 minutes.
    b. Check if tongue is obstructing airway—this is the most common obstruction.
  • Check if spine stabilization or immobilization is needed.
  • Check for respiratory distress, stridor, apnea, drooling, expectorating blood, universal sign for choking.

B. Breathing

  • Assess breathing by watching rise and fall of chest. Check rate, depth, pattern.
  • Listen for air being expelled and for air movement through both lungs.
  • Use head-tilt/chin-lift method if victim is not breathing and airway is not obstructed.
    a. Feel or hear for air movement, which is a reliable indicator of an open airway.
    b. If no response, repeat procedure. (If automated external defibrillator [AED] is available, apply to victim.)

C. Circulation.

  • Check carotid or femoral pulse.
  • Assess bleeding—if not controlled within a short period of time, victim will go into shock.
  • Assess color, temperature, and moisture of skin.
  • Assess capillary refill.
  • Identify type of bleeding.
    a. Arterial bleeding (spurting blood).
    b. Venous bleeding (flowing blood).
    c. Capillary bleeding (oozing blood).
  • Choose appropriate method to control bleeding.
    a. Direct local pressure—place direct pressure over wound and press firmly (95% of bleeding can be controlled by direct pressure with elevation).
    b. Maintain compression by wrapping wound firmly with pressure bandage.
    c. Elevate wound above level of heart.
    d. Use pressure point to slow blood flow to wound—brachial point for arm, femoral point for leg.
    e. Use tourniquet if bleeding cannot be controlled by other methods—this is a last resort because it can present a serious risk to the affected limb if no circulation is present.

Emergency Nursing: Secondary Status Assessment

Focus topic: Emergency Nursing

A. Remove clothes or helmet for total examination of victim.

  • Move client to private room or area.
  • Cover client to keep warm.

B. Obtain vital signs—temperature, pulse, respiratory (T,P,R) and blood pressure (BP)—including pain level.
C. Check initial intervention into an emergency situation (e.g., open wound, bleeding).

D. Follow up major assessment interventions.

  • Heart or echocardiogram (ECG) assessment.
  • Oxygen saturation.
  • Urinary catheter if necessary.
  • Gastrointestinal (GI) tube insertion if necessary.
  • Blood and laboratory studies.
  • Pain/anxiety level.
  • General appearance and demeanor, including mental status.

E. Pay attention to family accompanying client.
F. Obtain full history from client or family.

  • Current problem or complaint.
  • Allergies.
  • Medications/herbs client is taking.
  • Past health history, including surgeries.
  • Physical assessment of client.

Emergency Nursing: Common Emergencies

Focus topic: Emergency Nursing

Emergency Nursing: Wounds

Focus topic: Emergency Nursing

Definition: Break in the continuity of the tissue of the body, either internal or external.
A. Classification.

  • Open—break in the skin or mucous membrane.
  • Closed—injury to underlying tissues without a break in the skin or mucous membrane.

B. Types of open wounds.

  • Incised.
  • Contused.
  • Lacerated.
  • Punctured.

C. The RYB wound classification classifies open wounds that are healing—not usually an emergency.

  • Red wounds (R) are in the inflammatory, proliferative, or maturation phase of healing.
  • Yellow wounds (Y) are infected or contain fibrinous slough and aren’t ready to heal.
  • Black wounds (B) contain necrotic tissue and aren’t ready to heal.
  • Treatment options are based on wound color.

D. First aid for open wounds.

  • Stop bleeding immediately.
  • Protect wound from contamination and infection.
  • Provide shock care.
  • Obtain medical attention.

E. Techniques to stop severe bleeding.

  • Direct pressure.
  • Elevation.
  • Pressure on supplying artery.
  • Tourniquet.

F. Characteristics of closed wounds.

  • No break in skin.
  • Blood loss may be from outer openings of body cavities.
  • Usually caused by an external force.
  • Victim demonstrates signs of internal bleeding.

G. First aid for closed wounds.

  • Check for fractures and other internal injuries.
  • Treat for shock.
  • Do not give fluids by mouth if internal injuries are suspected.
  • Apply ice to small areas of closed wounds.

H. Measures to prevent contamination or infection of wounds.

  • Do not remove cloth pad initially placed on wound.
  • Do not cleanse deep wounds that require medical attention.
  • Use sterile dressing or cleanest dressing available.
  • Do not remove deeply embedded objects.

Emergency Nursing: Choking

Focus topic: Emergency Nursing

Definition: Temporary or permanent asphyxia due to obstruction of the airway.

A. Signs and symptoms.

  • Violent choking.
  • Alarming attempts at inhalation.
  • Cyanosis of face, neck, and hands.
  • Cessation of breathing.
  • Inability to speak; universal sign for choking.
  • Unconsciousness.

B. First aid measures.

  • Remove object if possible.
  • Allow victim to assume position of comfort.
  • Encourage coughing.
  • Use maneuver.
  • If person collapses, check pulse and breathing. Start cardiopulmonary resuscitation (CPR) if indicated.
  • Obtain medical assistance.

Emergency Nursing: Poisoning

Focus topic: Emergency Nursing

Definition: Introduction into the body or onto the mucous membranes, skin surface of any solid, liquid, or gas that tends to impair health or to cause death. This may be through inhalation, ingestion, injection, or contact.

A. First aid treatment.

  • Call doctor or poison control center (800-222-1222). Give the following information.
    a. Age of victim.
    b. Name and amount of poison taken.
    c. Route of exposure.
    d. Time exposure occurred.
    e. Whether victim vomited.
    f. Any signs of poisoning.
    g. Any treatment rendered prior to arrival of emergency medical services.
    h. Medical history
    i. Any social, psychological, or environmental risk factors involved.
  • If victim is conscious, give antidote, if known.
  • Induce vomiting if material ingested is not strong acid or petroleum product as these will cause more tissue damage when vomited. With these substances, use activated charcoal.
    a. 50–100 g activated charcoal or prepackaged charcoal/sorbitol product mixed with water.
    b. The earlier charcoal is given, the more effective it is.
  • If inhaled gases, remove victim to fresh air.
  • If contact poison, wash exposed areas.

B. Follow-up treatment as prescribed.

Emergency Nursing: Frostbite and Cold Exposure

Focus topic: Emergency Nursing

Definition: Tissues are frozen, which results in the formation of ice crystals in tissue and cells causing direct, irreversible damage.

A. Signs and symptoms.

  • White, waxy, or grayish-yellow skin.
  • Local pain, sensation of burning, tingling, or numbness.
  • Blisters.
  • Area cold and numb.
  • Mental confusion.
  • Stinging, hot feeling after the tissue thaws.

B. First aid treatment.

  • Cover area.
  • Rewarm area quickly in water bath (102 to 108°F or 38.9 to 42.2°C).
  • Do not rub.
  • Elevate affected area.

Emergency Nursing: Heat Exhaustion

Focus topic: Emergency Nursing

Definition: Response to heat characterized by fatigue and weakness; occurs when intake of water cannot compensate for loss of fluids through sweating. Common in the very young and very old.

A. Signs and symptoms (generally have rapid onset).

  • Pale, clammy skin.
  • Profuse perspiration.
  • Headache.
  • Anorexia.
  • Nausea.
  • Vomiting
  • Dizziness.
  • Fainting.
  • Core body temperature normal or elevated (37–44°C/98.6–111.2°F).

B. First aid treatment.

  • Offer victim sips of fluid and electrolyte replacement—one-half glass every 15 minutes for 1 hour.
  • Remove restrictive clothing and have victim lie down and elevate feet.
  • Place in cool environment.
  • Apply cool, wet cloths.
  • Monitor for circulation, airway, and breathing (CAB).
  • Administer intravenous (IV) fluids and electrolytes as ordered.

Emergency Nursing: Heatstroke

Focus topic: Emergency Nursing

Definition: Response to heat characterized by extremely high body temperature due to disturbance in sweating mechanism—a medical emergency. Common in the very young and very old. Can be precipitated by medications that effect heat production, decrease thirst, or limit diaphoresis.

A. Signs and symptoms occur rapidly.

  • High body temperature—104°F/40°C or higher.
  • Hot, red, dry skin.
  • Rapid, strong pulse.
  • Rapid breathing.
  • Neurological symptoms—hallucinations, confusion.

B. First aid treatment—stabilize CAB (circulation, airway, and breathing).
C. Cool body quickly using whatever methods are available (remove clothing, ice water bath, fan, wet sheets, cool fluids, ice packs axilla and groin, etc.).
D. Rehydrate with room temperature IV fluids.
E. Monitor electrolytes and clotting factors.
F. Check urine for myoglobin as this indicates rhabdomyolysis.
G. Control shivering as this causes body temperature to rise.

Emergency Nursing: Burns

Focus topic: Emergency Nursing

Definition: Injury of the skin, subcutaneous tissue, muscle, and/or bones caused by heat, chemical agent, or radiation. Burn injury results in vasodilatation, increased capillary permeability, intravascular fluid loss, and tissue edema.

ASSESS THE AIRWAY FIRST AND OFTEN. All individuals with burns should receive supplemental oxygen until deemed unnecessary.

A. Classification of burns.

  • Superficial (first-degree)—red skin, mild swelling and pain, rapid healing.
  • Deep, partial thickness (second-degree)—red or mottled skin, blisters, considerable swelling, wet appearance due to loss of plasma, and severe pain.
  • Full thickness (third-degree)—deep tissue destruction, white or charred appearance, complete loss of all layers of skin. Skin graft needed for healing.

B. First aid treatment for superficial burn.

  • Apply cold water or submerge in cold water.
  • Prevent contamination.
  • Avoid greasy substances.
  • Apply aloe vera gel if available.

C. First aid treatment for deep, partial-thickness burn.

  • Immerse burn, if fairly small area, in cold water for 1–2 hours.
  • Apply clean cloths.
  • Blot area dry.
  • Do not break blisters.
  • Do not apply antiseptic preparations or home remedies.
  • Elevate affected extremities.
  • Seek medical attention.

D. First aid treatment for full-thickness burns.

  • Do not attempt to remove clothing from burned area.
  • Cover burn with sterile dressing.
  • Elevate involved extremities.
  • Do not immerse burn in water or apply ice water.
  • If medical help is not quickly available, and victim is conscious and not vomiting, give victim, at 15-minute intervals, a solution of fluid and electrolytes if available or ½ teaspoon of salt and ½ teaspoon of soda in a quart of water.

Emergency Nursing

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Emergency Nursing: Fractures

Focus topic: Emergency Nursing

Definition: A break or crack in a bone.
A. Types of fractures.

  • Open or compound—bone ends protrude through skin. Increased risk of neurovascular complications, blood loss, and infection
  • Closed or simple—bone cracked or broken but does not protrude through skin.

B. Signs and symptoms.

  • Victim heard or felt bone snap.
  • Abnormal or false motion in body area.
  • Differences in shape and length of corresponding bones.
  • Obvious deformities.
  • Swelling.
  • Discoloration.
  • Pain or tenderness to touch.

C. First aid measures.

  • Prevent motion of injured parts and adjacent joints.
  • Elevate involved extremities.
  • Apply splints.

D. Splinting—device used to immobilize extremity or trunk when a fracture is suspected.

  • Purpose.
    a. Immobilize part.
    b. Decrease pain.
    c. Reduce chance of shock.
    d. Protect against further injury during transportation.
  • Principles.
    a. Ensure splint is long enough to extend past joint on either side of suspected fracture to stabilize bone.
    b. Place pad between splint and skin to prevent pressure points and breakdown.
    c. Immobilize joints above and below location of suspected fracture.
    d. Apply splint to extremity; do circulation checks to fingers/toes.

Emergency Nursing: Sprains

Focus topic: Emergency Nursing

Definition: Injury to a joint ligament or a muscle tendon in region of a joint.

A. Signs and symptoms.

  • Swelling.
  • Tenderness.
  • Pain on motion.
  • Discoloration.

B. First aid measures.

  • Do not allow walking if ankle or knee sprained.
  • Elevate limb above heart level for 24 hours.
  • Apply ice first 24 hours.
  • f swelling and pain persist, seek medical attention.

C. Common athletic injuries (even those that require clinical attention) use the formula RICE.

  • Rest—immobilize injured part.
  • Ice—apply ice to dull pain and reduce blood flow.
  • Compression—apply pressure with towel or elastic bandage.
  • Elevation—for first day or two keep injured area elevated.

Emergency Nursing: Strains

Focus topic: Emergency Nursing

Definition: Injury to a muscle and its facial sheath as a
result of overstretching.

A. Signs and symptoms.

  • Pain on motion.
  • Discoloration.
  • Edema.
  • Decrease in function.

B. First aid measures.

  • Bed rest.
  • Ice, then after the acute phase (24+ hours), heat may be applied.
  • Bed board (with back sprain).
  • Elastic wrap.

Emergency Nursing: Dislocations

Focus topic: Emergency Nursing

Definition: Injury to capsule and ligaments of a joint that results in displacement of a bone end at a joint.

A. Signs and symptoms.

  • Swelling.
  • Obvious deformity.
  • Pain upon motion.
  • Tenderness to touch.
  • Discoloration.

B. First aid measures.

  • Splint and immobilize affected joint in position as found.
  • Do not reduce dislocation or correct deformity near a joint.
  • Apply sling if appropriate.
  • Elevate affected part if possible.
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