REIMBURSEMENT ISSUES

1

Chapter 24 Emergency First Aid Nursing
2
Obtaining Medical Emergency Aid

• The nurses 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.

3
Moral and Legal Responsibilities of the Nurse

• 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.

4
Assessment of the Emergency Situation

• 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.

5
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

6
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.

7
Events Requiring CPR

• CPR is indicated in any syndrome where
  respiration or respiration and 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

8
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.

9
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.

10
Adult One-Rescuer CPR

• Airway
• Determine responsiveness.
• Gently shake and shout, Are you OK?
• Call for help.
• Open the airway.
• To determine breathlessness
• Look for the rise and fall of the chest.
• Listen for sounds of breathing.
• Feel for the warmth of the victims mouth against
  the cheek.

11
Adult One-Rescuer CPR

• Breathing
• Mouth-to-mouth ventilation is the quickest method
  of supplying oxygen to the victims lungs.
• Rescuer takes a deep breath, seals the lips
  around the outside of the victims mouth, and
  gives two full breaths lasting 1.5 to 2 seconds.
• If the initial attempt to ventilate the victim is
  unsuccessful, the rescuer should reposition the
  head and attempt to ventilate again.
• If the second attempt is also unsuccessful
  proceed to foreign body airway obstruction
  management.

12
Adult One-Rescuer CPR

• 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.

13
Adult One-Rescuer CPR

• Circulation (continued)
• External cardiac compressions are performed on
  the lower half of the sternum with the heel of
  both hands elbows are locked, arms straight the
  rescuer leans forward, creating pressure to
  depress the sternum.
• Perform 15 compressions and 2 slow breaths for 4
  cycles check the pulse if no pulse, continue.

14
Adult Two-Rescuer CPR

• When One-Rescuer CPR Is Already in Progress
• The most logical time for entrance of the second
  rescuer is after a completed cycle of 15
  compressions and 2 slow breaths.
• The second rescuer identifies himself by saying,
  I know CPR moves to the head opens the
  airway and checks a carotid pulse.
• The other rescuer takes position at the chest and
  finds the proper hand placement for chest
  compressions.

15
Adult Two-Rescuer CPR

• When No CPR Is in Progress
• One rescuer activates EMS while the other
  initiates one-rescuer CPR.
• If the EMS can be activated by another person,
  the two rescuers should proceed as follows.

16
Adult Two-Rescuer CPR

• First Rescuer
• Determine unresponsiveness.
• Position the victim.
• Open the airway.
• Assess for breathing.
• If breathing is absent, say No breathing and
  give 2 ventilations.
• Assess for pulse if pulse is absent, say No
  pulse.

17
Adult Two-Rescuer CPR

• Second Rescuer, at the Same Time, Does the
  Following
• Finds the location for external cardiac
  compressions
• Assumes proper hand position
• Begins external cardiac compressions after the
  No pulse statement is made by the first rescuer

18
Adult Two-Rescuer CPR

• Switching Procedures
• Switching the positions of the ventilator and the
  compressor prevents fatigue of both rescuers and
  allows time for the ventilator to evaluate the
  effectiveness of CPR.
• The switch is initiated by the rescuer performing
  chest compressions at the end of the 152
  sequence.
• After giving a breath, the ventilator moves to
  the chest and gets into position to give
  compressions.
• The compressor moves to the head and checks the
  pulse. If no pulse, state resume CPR.

19
Pediatric CPR Child/Infant

• 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 and 8 years

20
Pediatric CPR Child/Infant

• Airway
• Unresponsiveness Should Be Determined
• Gently shake the child tap the heels of an
  infant.
• Call for Help
• If the rescuer cannot immediately activate EMS,
  perform BLS for 1 minute before going to activate
  EMS.
• Position victim on a firm, flat surface for
  effectiveness of CPR.
• Open the airway do not hyperextend in infants.

21
Pediatric CPR Child/Infant

• Breathing
• Look for movement of the chest, listen for breath
  sounds, and feel for exhaled airflow.
• If there is no breathing, inhale and seal the
  mouth and nose of the infant.
• Two breaths are given, with a pause between each
  breath the volume of air in the infants lungs
  is smaller than that in an adults adjust to
  allow for appropriate rise and fall of the chest.

22
Pediatric CPR Child/Infant

• Circulation
• Assessment of Pulse
• Carotid artery of the child
• Brachial artery of the infant
• If there is a pulse, rescue breathing should be
  continued at a rate of 1 breath every 3 seconds.
• If there is no pulse, external cardiac
  compressions must be performed.

23
Pediatric CPR Child/Infant

• Circulation
• Infant CPR (Two Health Care Providers)
• Visualize an imaginary line between the nipples.
• Use a two-thumb, encircling-hands compression
  technique, performing compressions with the
  thumbs.
• The breastbone is compressed to a depth of 0.5 to
  1 inch at a rate of at least 100 times per
  minute.
• At the end of each compression, pressure is
  released and the sternum is allowed to return to
  normal position.
• The sequence is 5 compressions to 1 breath.

24
Pediatric CPR Child/Infant

• Circulation
• Child CPR
• The lower margin of the childs rib cage is
  palpated with the middle and index fingers while
  the head tilt is maintained.
• Place the heel of the hand on the sternum
  avoiding the xiphoid process.
• The chest is compressed 1 to 1.5 inches, 100
  times per minute.
• The sequence is 5 compressions to 1 breath.

25
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.

26
Foreign Body Airway Obstruction Management

• 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?

27
Foreign Body Airway Obstruction Management

• Conscious Victim
• Heimlich Maneuver
• 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.

28
Foreign Body Airway Obstruction Management

• Conscious Victim (continued)
• Heimlich Maneuver (continued)
• Stand behind the victim.
• Wrap your arms around the victims waist.
• Make a fist with one hand and place the thumb of
  the fist against the middle of the victims
  abdomen slightly above the navel and well below
  the xiphoid process.
• Wrap the other hand over the fist into the
  victims abdomen with a quick upward thrust.
• Repeat thrusts until the foreign body is expelled
  or the victim becomes unconscious.

29
Foreign Body Airway Obstruction Management

• 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 victims thighs and place
  the heel of one hand against the victims
  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.

30
Foreign Body Airway Obstruction Management

• Unconscious Victim (continued)
• Infant (continued)
• The infant is straddled over the rescuers arm
  with head lower than the trunk, with the face
  down.
• With this arm resting on the rescuers thigh, the
  other arm delivers five back blows between the
  shoulder with the heel of the hand.
• The rescuer places his or her free hand on the
  infants back so that the victim is sandwiched
  between the two hands.

31
Foreign Body Airway Obstruction Management

• Unconscious Victim (continued)
• Infant (continued)
• The rescuer turns the infant and places the
  infant on the rescuers thigh with the head lower
  that than the trunk.
• Five chest thrusts are performed with the hands
  in the same position as when performing external
  cardiac compressions.

32
Shock

• Shock is an abnormal condition of inadequate
  blood flow to the bodys 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 bodys 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.

33
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

34
Shock

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

35
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.

36
Figure 24-9, A
Body positions for shock. A, Modified
Trendelenburg.
37
Figure 24-9, B
Body positions for shock. B, If head, neck, or
spinal injuries are suspected.
38
Figure 24-9, C
Body positions for shock. C, Breathing problems.
39
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.

40
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.

41
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.

42
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

43
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 bodys ability to
  clot at this site.

44
Figure 24-10
(From Sorrentino, S.A. 1996. Mosbys textbook
for nursing assistants. 4th ed.. St. Louis
Mosby.)
Applying pressure to wound site.
45
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 victims life is in
  danger.
• It can cause extensive damage to the body part.

46
Figure 24-11
(From Kidd, P.S., Stuart, P.A. 1996. Mosbys
emergency nursing reference. St. Louis Mosby.)
Applying pressure to wound site.
47
Skill 24-1 Step 7
Applying a tourniquet.
48
Bleeding/Hemorrhage

• Epistaxis
• Nosebleed
• Common but seldom a serious emergency
• Causes
• Trauma
• Epistaxis digitorum (trauma from nasal picking)
• Infections
• Hypertension
• Strenuous activity
• Low humidity

49
Bleeding/Hemorrhage

• Epistaxis
• Nursing Interventions
• Keep the victims 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 victims mouth at the back of the
  throat to assess for bleeding from a posterior
  site

50
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

51
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.

52
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

53
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

54
Figure 24-12
(From Lewis, S.M., Heitkemper, M.M., Dirksen,
S.R. 2004. Medical-surgical nursing assessment
and management of clinical problems. 6th ed..
St. Louis Mosby.)
Flail chest.
55
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.

56
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.

57
Figure 24-13
(From Henry, M.C., Stapleton, E.R. 1997. EMT
prehospital care. 2nd ed.. Philadelphia
Saunders.)
Use of roller bandage.
58
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.

59
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.

60
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.

61
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.

62
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

63
Poisons

• Absorbed Poisons
• Nursing Interventions
• Quickly remove the source of the irritation wash
  with soap and water.
• Skin preparations include baking soda, Burows
  solution, and oatmeal.
• Calamine lotion and hydrocortisone cream are
  effective to relieve pruritus.

64
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.

65
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

66
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

67
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.

68
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.

69
Thermal and Cold Emergencies

• 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.

70
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

71
Thermal and Cold Emergencies

• Heat Injury (continued)
• Heatstroke (continued)
• Nursing interventions
• Cool the victim as quickly as possible use cold
  packs around the victims 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.

72
Thermal and Cold Emergencies

• 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

73
Thermal and Cold Emergencies

• 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.

74
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.

75
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.

76
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

77
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.

78
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.

79
Figure 24-14
(From Henry, M.C., Stapleton, E.R. 1997. EMT
prehospital care. 2nd ed.. Philadelphia
Saunders.)
Immobilization of fractured arm.
80
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.

81
Skill 24-2 Step 4
Applying an arm splint using a triangular (sling
and swathe) bandage.
82
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
• 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

83
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

84
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.

85
Skill 24-3 Step 1
Moving the victim with a suspected spinal cord
injury.
86
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.

87
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.

88
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

89
Burn Injuries

• Deep Partial-Thickness Burns and Full-Thickness
  Burns
• Nursing interventions
• Establish airway.
• Assess respiratory and cardiac function.
• Remove all of victims 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.

90
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