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Good Samaritan Law

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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 tha an unconscious person would give consent if he or she were able; once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training

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primary assessment

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airway, breathing, circulation (pulse and severe bleeding)

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life-threatening situations

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arrested or abnormal breathing or pulse

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assessment of the emergency situation

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primary assessment, life-threatening situations, observe for indications of skull injury and brain or spinal cord damage; fractures, dislocations, and superficial ecchymosis or wounds require attention after the more serious conditions are treated

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reasons why individuals choose not to perform CPR

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lack of motivtaion, fear of doing harm, lack of knowledge, fear of contracting communicable diseases

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once CPR is started, it may not be discontinued except for the following reasons:

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the victim recovers, the rescuer is exhauseted 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

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two purposes of CPR

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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

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clinical death

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the heartbeat and respirations have ceased for four minues

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biological death

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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 clinial death if initiated before four minutes of cardiopulmonary arrest; after 10 minutes without CPR brain death is certain

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brain death

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this is an irreversible form of unconsciousness char by a complete loss of brain function while the heart continues to beat; the usual clinical criteria for this 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 performed 12-24 hours apart (if breathing on own do not meet this criteria)

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shock

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abnormal condition of inadequate blood flow to the body's peripheral tissues, with life-threatening cellular dysfuntion, hypotensions and oliguria; it results from failure of the cv system to provide sufficient blood circulation to the body's tissues and decreased metabolic waste removal; to maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient blood circulation to the body's tissues and decreased metabolic waste removal; to maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient volume of blood

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classifications of shock

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severe blood loss, intense pain, extensive trauma; burns; poisons, emotional stress or intense emotions; extremes of heat and cold; electrical shock; allergic reactions; sudden or severe illness

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assessment of shock

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LOC (circulation to brain - not enough blood or air flow); skin changes (clammy, pale, cool, cyanosis); BP decreased; pulse increased; respirations increased; urinary output decreased; neuromuscular changes (slow responsiveness, weakness, tremors); GI effects slows down

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nursing interventions of shock

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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) unless spinal injury/flat; 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; 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

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effects of blood loss

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causes a decrease in oxygen supply to the body; blood pressure drops; heart pumps faster to compensate for the decreased volume and BP; body will attempt to clot the blood to halt bleeding; usually requiring 6-7 minutes; uncontrolled, bleeding can result in shock and death

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capillary bleeding

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

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venous bleeding

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occurs when the vein is severed or punctured; results in a slow, even flow of dark red blood; embolism may occur if air enters the severed vein

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arterial bleeding

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least common; usually protected by bones, fat and other structures; heavy spurting of bright red blood in the rhythm of the heart beat

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nursing interventions to bleeding/hemorrhage

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direct pressure; the most effective general treatment is to apply direct pressure over the bleeding site; raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body's ability to clot at this site; 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

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application of a tourniquet

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may be used only when the other methods have failed and the victim's life is in danger; it can cause extensive damage to the body part

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epistaxis

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nosebleeds, common but seldom a serious emergency;

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causes of nosebleeds

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trauma, epistaxis digitorum, infections (sinus), hypertension (vessels have lot of pressure), strenuous activity (strain against BP); low humidity

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nursing interventions for nosebleeds

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keep the victim's head tilted slightly forward; apply steady pressure to both nostrils for 10-15 minutes; remind the victim to breathe through the mouth and to expectorate any accumulated blood; apply ie compresses over the nose at the same time on and off; look in the victim's mouth at the back of the throat to assess for bleeding from a posterior site

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internal bleeding

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this is potentionally life-threatening situation; common causes are fractures, knife or bullet wounds, crushing injuries, organ injuries and medical conditions such as ruptured aneurysms

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assessment for internal bleeding

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signs and symptoms of shock; vertigo; hemoptysis or hematemesis; melena; hematuria

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nursing interventions for internal bleeding

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this is a priority medical emergency; place on a flat surface with legs elevated; establish an airway; old compress or ice is placed on the area of injury; maintain body temp with blankets; assess vital signs; oxygen may be ordered by the physician

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closed wounds

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underlying tissue of the body is involved; the top layer of skin is not broken; ecchymoses and contusions occur;

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signs and symptoms of closed wounds

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edema, discoloration, deformity, shock, pain and tenderness, and signs of internal bleeding

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nursing interventions for closed wounds

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small wound: ice packs and elastic bandage; large wound: treat for shock; cold compression and pressure bandage

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open wounds

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openings or breaks in the mm or skin; always danger of bleeding or infection

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types of open wounds

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abrasions, puncture wounds, incisions, lacerations, avulsions, chest injuries

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flail chest

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multiple ribs broken-can't expand chest

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sucking chest wound

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collapsed lung-sucks breath back and forth put three way bandage helps prevent air from coming in but let air out

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avulsions

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forcible tearing or surgical separation of one body part from another

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general principles of bandaging

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bleeding should be controlled before bandage is applied; use sterile material if possible; if not use, the cleanest material possible; wounds should be bandaged firmly but not too tightly; bandage in alignment is desired; tips of fingers and toes should remain exposed if possible

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application of common types of bandages

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bandage compress, triangular bandage, roller bandage

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bandage compress

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most common type of dressing; consists of several thicknesses of gauze, covered with tape or gauze

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triangular bandage

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made of a piece of cloth that is folded diagonally and cut along the fold; used as a sling to support injured bones

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roller bandage

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used to support an injured part apply pressure to a dressing or secure a splint to immobilize a part

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assessment of poisoning

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s/s may be delayed for hours; respiratory distress; n&v or diarrhea; seizures, abnormal constriction or dilation of pupils abnormal eye movement; decreased level of consciousness; restlessness, delirium, agitation; color changes; signs of burns, skin irritation, pain on swallowing; unusual urine color; shock or cardiac arrest

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ingested poisons

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by mouth is the most common type of poisoning, esp in children; common substances include household cleaning products, garden and garage supplies, drugs, medications, food and plants

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nursing interventions for poisons

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immediately call poison control center; do NOT induce vomiting; 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; threat for shock and administer CPR if needed

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absorbed poisons

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poisons, caustic chemicals, and poisonous plants that come in contact with the skin; causes burning, skin irritation, allergic responses, or severe system reactions

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s/s of absorbed poisons

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n&v, diarrhea, flushed skin, dilated pupils, cv abnormalities, and CNS reactions

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nursing interventions for absorbed poisons

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quickly remove the source of the irritation; wash with soap and water; skin preparations include baking soda, Burows solution and oatmeal and calamine lotion and hydrocortisone cream are effective to relieve pruritus

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injected poisons

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minor reactions to inset bites; remove stinger, if present, by scraping, wash the bite with soap and water; apply cold paks; baking soda paste;

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severe reactions to insect bites

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urticaria, wheezing, edema of the lips and tongue; generalized pruritus and respiratory arrest

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nursing interventions for insect bites

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

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alcohol mild intoxication s/s:

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n&v, 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

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serious intoxication s/s

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drowsiness to coma, rapid weak pulse, depressed, labored breathing or respiratory arrest, loss of control of urinary and bowel funtions, disorientation, restlessness, and hallucinations

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drugs s/s

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loss of reality orientation, hallucinations, and varying degrees of consiousness, slurred speech; extremes in mood swings; inappropraite behavior; anxiety; flushed skin; diaphoresis; lack of coordination; impaired judgment; increased or decreased pulse; pupils onstricted or dilated; needle marks on the arms, legs and neck

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nursing interventions for drug and alcohol emergencies

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obtain info about the substance ingested; life-threatening situations are handled first; establish airway; if unconscious, turn on 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

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heat exhaustion

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the most common type of heat injury, this results from prolonged perspiration and the loss of large quantitites of salt and water; observe for s/s of headache, vertigo, nausea, weakness and diaphoresis; mental disorientation and brief LOC may occur

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nursing interventions to heat exhaustion

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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 hours; if the clinical setting, IV fluids are given

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heatstroke

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more serious heat injury; death can result; the most common cause is vigorous physical ativity in a hot, humid env; the body becomes overheated but the cooling mehanism of perspiration does not operate

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assessment of heat stroke

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rapidly rising body temp; hot, dry, erythemic skin; no visible perspiration; pulse rapid initialy and then slow and bp falls; breathing deep an rapid; victim complains of headache, dry mouth, N&V

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nursing interventions of heat stroke

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cool the victim as quickly as possible; use cold packs around the victim's neck, under the arms, and around the ankles to cool the blood in the main arteries; establish and maintain an airway; monitor for chilling as the body temp falls; cool slowly, take temp every 15 mins if 100-101, start backing off so no shivering ocurs

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fractures

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a break in the continuity of a bone; types of common fractures (open or compounds fracture, closed, comminuted, greenstick, spiral, impacted, compressed, depression

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assessment for fractures

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radiography can determine if a bone is fractured; there is pain and tenderness in the area and pain during movement; defority of the limb may be obvious with edema and discoloration of the area; fragments of bone may be protruding through the skin; crepitus

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crepitus

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grating sound is heard when the affected part is moved

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nursing interventions for fractures

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do not move unless he or she is in danger; ABCs of first and take priority; control bleeding if present; immobilize the fracture but do not attempt to realign the bone; monitor circulation in the limb; apply ice or cold packs to the area

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dislocations

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occurs in joints; usually results from a blow or fall

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assessment for dislocations

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

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nursing interventions for dislocations

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never attempt to reduce a dislocation; splint the injury; apply ice or cold packs

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spinal cord injuries

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assess for paralysis, test for sensation; assess for abrasions and ecchymosis on the back

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nursing interventions of spinal cord injuries

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take spinal cord precautions; maintain airway; keep head in a neutral position

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shallow partial-thickness burns

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involves the outer layer of the skin; caused by simple subburns or burns from contract with hot objects

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nursing interventions for shallow partial-thickness burns

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the burns should be cooled immediately by soaking in old water or applying cold compress; a sterile dressing should be placed over the burn to prevent infection

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deep partial-thickness burns

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involve the entire first layer of skin as well as some of the underlying tissue; severe sunburn, scalding liquids, direct flame and chemical substances

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assessment of deep partial-thickness burns

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deep erythema of the skin, or mottled skin with blister formation; weeping of fluid through the skin surface and intense pain

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full thickness-burns

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these burns involved 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, beceause nerve endings my be severed; wounds weep a great deal of fluid and blood; causes: direct flame, explosions and gasoline or oil fires

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nursing internventions for deep partial thickness and full thickness burns

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establish airway, assess respiratory and cardiac function; remove al of victim's clothing, shoes and jewelry; administer CPR if necessary; treat for shock; cool the burn with cool compresses for partial thickness burns; avoid touhing the burng with anything but sterile dressings

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nursing diagnosis

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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

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