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97425844 Emergency Nursing Notes

Published on February 2017 | Categories: Documents | Downloads: 46 | Comments: 0




Care given to patients with urgent and critical
Also for non-urgent cases or whatever the
patient or family considers an emergency
Serious life-threatening cardiac conditions
(Myocardial infarction, Acute heart failure,
Pulmonary edema Cardiac dysrhythmias)

The Emergency Nurse
 Applies the ADPIE on the human
responses of individuals in all age groups
whose care is made difficult by the limited
access to past medical history and the
episodic nature of their health care
 Triage and prioritization.
 Emergency operations preparedness.
 Stabilization and resuscitation.
 Crisis intervention for unique patient
populations, such as sexual assault
 Provision of care in uncontrolled and
unpredictable environments.
 Consistency as much as possible across
the continuum of care
The Nursing Process
 Provides logical framework for problem
solving in this environment
 Nursing assessment must be continuous,
and nursing diagnoses change with the
patient’s condition
 Although a patient may have several
diagnoses at a given time, the focus is on
the most life-threatening ones
 Both independent and interdependent
nursing interventions are required
Emergency Nursing in Disasters
 The emergency nurse must expand his or
her knowledge base to encompass
recognizing & treating patients exposed to
biologic and other terror weapons
 The emergency nurse must anticipate
nursing care in the event of a mass
casualty incident.
Documentation of Consent
 Consent to examine and treat the patient
is part of the ER record.
 The patient must consent to invasive
procedures unless he or she is
unconscious or in critical condition and
unable to make decisions.
 If the patient is unconscious and brought
to the ER without family or friends, this
fact should be documented
 After treatment, a notation is made on the
record about the patient’s condition on
discharge or transfer and about
instructions given to the patient and
family for follow-up care.
Exposure to Health Risks

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All emergency health care providers
should adhere strictly to standard
precautions for minimizing exposure.
Early identification and adherence to
transmission-based precautions for
patients who are potentially infectious is
ER nurses are usually fitted with a
personal high-efficiency particulate air
(HEPA)-filter mask apparatus to use when
treating patients with airborne diseases.

Providing Holistic Care
 Sudden illness or trauma is a stress to
physiologic and psychosocial homeostasis
that requires physiologic & psychological
 When confronted with trauma, severe
disfigurement, severe illness, or sudden
death, the family experiences several
stages of crisis beginning with anxiety,
and progress through denial, remorse &
guilt, anger, grief & reconciliation.
 The initial goal for the patient and family
is anxiety reduction, a prerequisite to
recovering the ability to cope.
 Assessment of the patient and family’s
psychological function includes evaluating
emotional expression, degree of anxiety,
and cognitive functioning.
Nursing Diagnoses
 Possible nursing diagnoses include: Anxiety
related to uncertain potential outcomes of the
illness or trauma and ineffective individual
coping related to acute situational crises
 Possible diagnoses for the family include:
Anticipatory grieving and alterations in family
processes related to acute situational crises
Patient-Focused Interventions
 Those caring for the patient should act
confidently and competently to relieve
 Reacting and responding to the patient in
a warm manner promotes a sense of
 Explanations should be given on a level
that the patient can understand, because
an informed patient is better able to cope
positively with stress.
 Human contact & reassuring words reduce
the panic of the severely injured person
and aid in dispelling the fear of the
 The unconscious patient should be treated
as if conscious (i.e. touching, calling by
name, explaining procedures)
 As the patient regains consciousness, the
nurse should orient the patient by stating
his or her name, the date, and the
Family-Focused Interventions
 The family is kept informed about where
the patient is, how he or she is doing, and
the care that is being given.

Allowing the family to stay with the
patient, when possible, also helps allay
their anxieties.
Additional interventions are based on the
assessment of the stage of crisis that the
family is experiencing.
Helping Them Cope With Sudden Death
Take the family to a private place.
Talk to the family together, so they can
mourn together.
Reassure the family that everything
possible was done; inform them of the
treatment rendered.
Show the family that you care by touching,
offering coffee, and offering the services
of the chaplain.

Helping Them Cope With Sudden Death
 Encourage family members to support
each other & to express emotions freely.
 Avoid giving sedation to family members;
this may mask or delay the grieving
process, which is necessary to achieve
emotional equilibrium and to prevent
prolonged depression.
 Encourage the family to view the body if
they wish; this action helps integrate the
 Spend time with the family, listening to
them and identifying any needs that they
may have.
 Allow family members to talk about the
deceased and what he or she meant to
them; this permits ventilation of feelings
of loss.
 Avoid volunteering unnecessary
Discharge Planning
 Instructions for continuing care are given
to the patient and the family or significant
 All instructions should be given not only
verbally but also in writing, so that the
patient can refer to them later.
 Instructions should include information
about prescribed medications, treatments,
diet, activity, and contact info as well as
follow-up appointments.
Principles of Emergency Room Care
Triage: comes from the French word trier, which
means "to sort;” A method to quickly evaluate
and categorize the patients requiring the most
emergent medical attention.
ER Triage
 Emergent (immediate): patients have
the highest priority; must be seen
 Urgent (delayed or minor): patients have
serious health problems, but not
immediately life-threatening ones; seen
w/in 1 hour
 Non-urgent (minor or support): patients
have episodic illnesses addressed within
24 hours.
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Determination of Priority in ER Triage:
Classified based on principle to benefit the largest
number of people
Determination of Priority in Field Triage
 Critical clients are given lowest priority
 Victims who require minimal care and can be
of help to others are treated first.
1. Red – Emergent (immediate)
2. Yellow – Immediate (delayed)
3. Green – Urgent (minor)
4. Blue – Fast track or psychological support
5. Black – Patient is dead or progressing
rapidly towards death

Triage Tags should be used on all calls
involving 3 or more patients.
The general placement location should be on
one of the patient’s arms.
When a triage tag has been utilized,
remember to document the tag number in the
history portion of your run report.

“E”– Cart
 Located in designated areas where medical
emergencies and resuscitation is needed
 Purpose: to maximize the efficiency in
locating medications/supplies needed for
emergency situations.
 Drawer 5: Contains respiratory supplies
such as oxygen tubing, a flow meter, a face
shield, and a bag-valve-mask device for
delivering artificial respirations
 Drawer 4: Contains suction supplies &
 Drawer 3: Contains intravenous fluids
 Drawer 2: Contains equipment for
establishing IV access, tubes for laboratory
tests, and syringes to flush medication lines.
 Drawer 1: Contains medications needed
during a code such as epinephrine, atropine,
lidocaine, CaCl2 and NaHCO3
 The back of the cart usually houses the
cardiac board.
Assessment and Intervention in the ER
The Primary Survey: Focuses on stabilizing
life-threatening conditions; employs the ABCD
The ABCD Method
 Airway - Establish the airway
 Breathing - Provide adequate ventilation
 Circulation - Evaluate & restore cardiac
output by controlling hemorrhage,
preventing & treating shock, and
maintaining or restoring effective
 Disability - Determine neurologic disability
by assessing neuro function using the
Glasgow Coma Scale

To voice
To pain



Inappropriate words
Incomprehensible sounds



Obeys command
Localizes pain


Head-Tilt-Chin-Lift Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on
the victim’s forehead, and apply firm
backward pressure with the palm to tilt
the head back.
3. Place the fingers of the other hand under
the bony part of the lower jaw near the
chin and lift up.
4. Bring the chin and teeth forward to
support the jaw.

Assess and Intervene: The Secondary
Survey includes:
 A complete health history & head-to-toe
 Diagnostic & laboratory testing
 Application of monitoring devices
 Splinting of suspected fractures
 Cleaning & dressing of wounds
 Performance of other necessary interventions
based on the patient’s condition.
Airway Obstruction

An acute upper airway obstruction is a
blockage of the upper airway, which can be in
the trachea, laryngeal (voice box), or bronchi
Causes: Viral and bacterial infections, fire or
inhalation burns, chemical burns and
reactions, allergic reactions, foreign bodies,
and trauma.
o In adults, aspiration of a bolus of meat
is the most common cause.
o In children, small toys, buttons, coins,
and other objects are commonly
aspired in addition to food.

Clinical Manifestations
1. Choking
2. Apprehensive appearance
3. Inspiratory & expiratory stridor
4. Labored breathing
5. Flaring of nostrils
6. Use of accessory muscles (suprasternal &
intercostal retractions)
7. ñ anxiety, restlessness, confusion
8. Cyanosis & loss of consciousness develops as
hypoxia worsens.
Assessment and Diagnostics
 Involves simply asking whether the patient is
choking & requires help
 If unconscious, inspection of the oropharynx
may reveal the object.
 X-rays, laryngoscopy, or bronchoscopy may
also be performed.
 For elderly patients, sedatives & hypnotic
medications, diseases affecting motor
coordination, & mental dysfunction are risk
factors for asphyxiation of food.
 Victims cannot speak, breath or cough.
 If victim can breathe spontaneously, partial
obstruction should be suspected; the victim is
encouraged to cough it out.
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If the patient has a weak cough, stridor, DOB
& cyanosis, do the Heimlich.
After the obstruction is removed, rescue
breathing is initiated; if the patient has no
pulse, start cardiac compressions.

Jaw-Thrust Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on
each side of the victim’s jaw, followed by
grasping and lifting the angles, thus
displacing the mandible forward.
Oropharyngeal Airway Insertion
A semicircular tube or tube-like plastic device
inserted over the back of the tongue into the
lower pharynx
Used in a patient who is breathing spontaneously
but unconscious.
ET Intubation: Indications
1. To establish an airway for patients who
cannot be adequately intubated with an
oropharyngeal airway.
2. To bypass an upper airway obstruction
3. To prevent aspiration
4. To permit connection of the patient to a
resuscitation bag or mech. ventilator
5. To facilitate removal of tracheobronchial

 Used in the following emergencies in w/c ET
intubation is contraindicated:
1. Extensive maxillofacial trauma
2. Cervical spine injuries
3. Laryngospasm
4. Laryngeal edema
5. Hemorrhage into neck tissue
6. Laryngeal obstruction
Nursing Diagnoses For Airway Obstruction
1. Ineffective airway clearance due to
obstruction of the tongue, object, or fluids
(blood, saliva)
2. Ineffective breathing pattern due to
obstruction or injury

Bleeding that may be external, internal or
External: Laceration, avulsion, GSW, stab

Internal: Bleeding in body cavities and
internal organs

 Results in reduction of circulating blood
vol., w/c is the principal cause of shock
 Signs and symptoms of shock:
1. Cool, moist skin
2. Hypotension
3. Tachycardia
4. Delayed capillary refill
5. Oliguria

 Fluid Replacement
 Two large-bore intravenous cannulae are
inserted to provide a means for fluid and
blood replacement, and blood samples are
obtained for analysis, typing, & crossmatching.
 Replacement fluids may include isotonic
solutions (LRS, NSS), colloid, and blood
component therapy.
• Packed RBCs are infused when there is
massive hemorrhage
• In emergencies, O(-) blood is used for
women of child-bearing age.
• O(+) blood is used for men and
postmenopausal women.
• Additional platelets and clotting factors are
give when large amounts of blood is needed.
Control of External Hemorrhage
 Physical assessment is done to identify area
of the hemorrhage.
 Direct, firm pressure is applied over the
bleeding area or the involved artery.
 A firm pressure dressing is applied, and the
injured part is elevated to stop venous &
capillary bleeding if possible.
 If the injured area is an extremity, it is
immobilized to control blood loss.
Control of Bleeding: Tourniquets
 Applied only as a last resort just proximal to
the wound and tied tightly enough to control
arterial blood flow; tag the client with a “T”
stating the location and the time applied
 Loosened periodically to prevent irreparable
vascular on neuro damage
 If still with arterial bleeding, remove
tourniquet and apply pressure dressing
 If traumatically amputated, the tourniquet
remains in place until the OR.
Control of Internal Bleeding
 Watch out for tachycardia, hypotension, thirst,
apprehension, cool and moist skin, or delayed
capillary refill.
 Packed RBC are administered at a rapid rate,
and the patient is prepped for OR.
 Arterial blood is obtained to evaluate
pulmonary perfusion & to establish baseline
hemodynamic parameters
 Patient is maintained in a supine position and
closely monitored.
Hypovolemic Shock
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A condition where there is loss of effective
circulating blood volume due to rapid fluid
loss that can result to multi-organ failure
1. Massive external or internal bleeding
2. Traumatic, vascular, GI and pregnancy
3. Burns

Nursing Diagnoses for Hypovolemic Shock
1. Altered tissue perfusion related to failing
2. Impaired gas exchange related to a V-P
3. Decreased cardiac output related to
decreased circulating blood volume
Clinical Manifestations
1. Weakness, lightheadedness, and confusion
2. Tachycardia
3. Tachypnea
4. Decrease in pulse pressure
5. Cool clammy skin
6. Delayed capillary refill
Hypovolemic Shock: Management
1. Rapid blood and fluid replacement; blood
component therapy optimizes cardiac preload,
correct hypotension, & maintain tissue
2. Large-bore intravenous needles or catheters
are inserted into peripheral vv.
3. A central venous pressure catheter may also
be inserted in or near the RA.
4. LRS approximates plasma electrolyte
composition and osmolarity
5. A Foley catheter is inserted to record urinary
output every hour; urine volume indicates
adequacy of kidney perfusion
6. Ongoing nursing surveillance of the total
patient is maintained to assess the patient’s
response to treatment; a flow sheet is used to
document parameters
7. Lactic acidosis is a common side effect &
causes poor cardiac performance

A type of physical trauma wherein the skin is
torn, cut or punctured (open wound), or where
blunt force trauma causes a contusion (closed
Specifically refers to a sharp injury which
damages the dermis of the skin.
Types of Wounds
1. Open (Incised wound, Laceration,
Abrasion, Puncture wound, Gunshot
2. Closed (Contusion, Hematoma, Crushing

Incised Wound
 A clean cut by a sharp edged object such as
glass or metal.
 As the blood vessels at the wound edges are
cut straight across, there may be profuse

Ripping forces or rough brushing against a
surface which can cause rough tears in the
skin or lacerations.
Laceration wounds are usually bigger and can
cause more tissue damage due to the size of
the wound.

 Superficial wounds that occur at the surface
of the skin.
 Friction burns and slides can cause abrasion
 Characteristic in the way that only the top
most layer of the skin is scrapped off.
 Bleeding is not profuse though wounds
Puncture Wound
 Small entry site
 Though not large in surface area, wounds are
deep and can cause great internal damage.

tissue, contraction and eventual spontaneous
migration of epithelial cells.
Wound Healing: By Third Intention
 Occurs when a wound is allowed to heal open
for a few days and then closed as if primarily.
 Such wounds are left open initially because of
gross contamination.

Gunshot Wound (GSW)
 Caused by firing bullets or any other small
 Have a clean entry site but a large and
ragged exit site.
Contusion a.k.a. bruise: Caused by blunt force
trauma that damages tissue under the skin
Hematoma: Also called a blood tumor
 Caused by damage to a blood vessel that in
turn causes blood to collect under the skin
 Caused by a great or extreme amount of force
applied over a long period of time
Patterned Wound: Wound representing the
outline of the object (e.g. steering wheel) causing
the wound
Management: Wound Cleansing
1. Hair around wound may be shaved.
2. NSS is used to irrigate the wound.
3. Betadine & hydrogen peroxide are only used
for initial cleaning & aren’t allowed to get
deep into the wound without thorough rinsing.
4. Use local or regional block anesthetics if
Wound Management
1. Use of antibiotics depends on how the injury
occurred, the age of the wound, & the risk for
2. Site is immobilized & elevated to limit
accumulation of fluid
3. Tetanus prophylaxis is administered based on
the condition of the wound and the
immunization status
Wound Healing: By First Intention
 Occurs when tissue is cleanly incised and reapproximated and healing occurs without
 The incisional defect re-epithelizes rapidly and
matrix deposition seals the defect.
Wound Healing: By Second Intention
 Healing occurs in open wounds.
 When the wound edges are not approximated
and it heals with formation of granulation
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The unintentional or intentional wound or
injury inflicted on the body from a
mechanism against w/c the body cannot
protect itself
Leading cause of death in children and in
adults younger than 44 y/o
Alcohol & drug abuse are implicated in both
blunt & penetrating trauma
Collection of Forensic Evidence: Included
in documentation are the ff:
1. Descriptions of all wounds
2. Mechanism of injury
3. Time of events
4. Collection of evidence
5. Statements made by the patient
If suicide or homicide is suspected in a
deceased patient, the medical examiner will
examine the body on site or have it moved to
the medico-legal office for autopsy.
All tubes & lines are left in place.
Patient’s hands are covered with paper bags
to protect evidence.

Injury Prevention Components
1. Education: Provide information and
materials to help prevent violence, and to
maintain safety at home and in vehicles.
2. Legislation: Provide universal safety
measures without infringing on rights
(Seatbelt Law).
3. Automatic Protection: Provide safety
without requiring personal intervention
(Airbags, seatbelts).
High incidence of injury to hollow
organs, particularly the small
The liver is the most frequently injured
solid organ.
High velocity missiles create extensive
tissue damage.
Intra-abdominal Injuries: Blunt (MVA, falls,
Associated with extra-abdominal injuries to chest,
head, extremity
Incidence of delayed & trauma-related
complications is higher
Leads to massive blood loss into the peritoneal
Trauma: Assessment
1. Inspection of abdomen for signs of injury
(bruises, abrasions)
2. Auscultation of bowel sounds
3. Watch out for signs of peritoneal
irritation like distention, involuntary
guarding, tenderness, pain, muscular

rigidity, or rebound tenderness together
with absent BS.
Trauma: Diagnostic Findings
1. Urinalysis to detect hematuria
2. Serial hematocrit to detect presence or
absence of bleeding
3. WBC count to detect elevation
associated with trauma
4. Serum amylase to detect pancreatic or
GIT injury

PE for Internal Bleeding
 Inspect body for bluish discoloration,
asymmetry, abrasion, & contusion
 FAST (Focused Assessment for
Sonographic Examination of the Trauma
Patient) exam through CT scan to assess
hemodynamically unstable patients and
detect intraperitoneal bleeding
 Pain in the left shoulder is common in a
patient with bleeding from a ruptured
 Pain in the right shoulder can result from a
laceration of the liver.
 Administration of opioids is avoided during
the observation period.
Trauma: Genitourinary Injury
 A rectal or vaginal exam is done to determine
any injury to the pelvis, bladder, and
intestinal wall.
 To decompress the bladder & monitor urine
output, a Foley catheter is inserted AFTER
 A high-riding prostate gland indicates a
potential urethral injury.
Trauma: Management of Intra-abdominal
1. A patent airway is maintained.
2. Bleeding is controlled by applying direct
pressure to any external bleeding wounds &
by occlusion of any chest wounds.
3. Circulating blood vol. is maintained with
intravenous fluid replacement including blood
component therapy.
4. In blunt trauma, cervical spine immobilization
is maintained until cervical x-rays have been
obtained & injury is ruled out.
5. All wounds are located, counted &
6. If abdominal viscera protrude, the area is
covered with sterile, moist saline dressing to
prevent drying.
7. Oral fluids are withheld and stomach contents
are aspirated with an NGT in anticipation of
Tetanus and broad-spectrum antibiotics are
given as prescribed.
8. If still with evidence of shock, blood loss, free
air under the diaphragm, evisceration,
hematuria or suspected abdominal injury,
transport to OR.

Crushing Injuries: Assessment
 Watch out for paralysis of a body part,
erythema & blistering of skin, damaged part
appearing swollen, tense & hard.
 Renal dysfunction is secondary to prolonged
 Myoglobinuria is secondary to muscle damage
causing ARF.
 In conjunction with ABC’s, the patient is
observed for acute renal insufficiency
 Major soft tissue injuries are splinted early to
control bleeding and pain.
 A ò serum lactic acid concentration to <2.5
mmol/L indicates successful resuscitation.
 If an extremity is involved, it is elevated to
relieve swelling & pressure.
 A fasciotomy is done to restore neurovascular
 Medications for pain & anxiety are given as
prescribed, and the patient is transported to
the OR for debridement & fracture repair
Trauma: Multiple Injuries
 Requires a team approach with one person
responsible for coordinating the treatment
 Immediately after injury, the body is
hypermetabolic, hypercoagulable, and
severely stressed.
 Mortality is related to the severity & the
number of systems involved.
Multiple Injuries: Nursing Responsibilities
1. Assessing & monitoring the patient
2. Ensuring venous access
3. Administering prescribed meds
4. Collecting laboratory specimens
5. Documenting activities and the patient’s
6. Gross evidence may be slight or absent; the
injury regarded as the least significant may be
the most lethal.
7. Determine the extent of injuries & establish
priorities of treatment (ABC’s)
8. Establish airway & ventilation.
9. Control hemorrhage.
10. Prevent & treat hypovolemic shock & monitor
intake & output.
11. Assess for head & neck injuries.
12. Evaluate for other injuries – reassess head &
neck, chest; assess abdomen, back &
13. Splint fractures.
14. Carry out a more thorough and ongoing
examination & assessment.

Trauma: Crushing Injuries

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Occur when a person is caught between
objects, run over by a moving vehicle, or
compressed by machinery
Watch out for hypovolemic shock from
extravasation of blood & plasma into injured
tissues after compression has been released.

When a client is being examined for a
fracture, the body part is handled gently & as
little as possible.
Clothing is cut off to visualize the body &
assessment is done for pain over or near a

bone, swelling, & circulatory disturbance,
ecchymosis, tenderness & crepitation.
Management of Fractures
 ABCD Method & evaluation for abdominal
injuries is performed BEFORE an extremity is
treated unless a pulseless extremity is seen.
 If the extremity is pulseless, repositioning of
the extremity to proper alignment is required.
Pulseless Extremities
 If the pulseless extremity involves a fractured
hip or femur, a Hare traction may be applied
to assist w/ alignment.
 If repositioning is ineffective in restoring the
pulse, a rapid total body assessment is
completed, followed by a transfer to the
operating room for arteriography and possible
arterial repair.
Management of Fractures
 After the 1° survey, the 2° survey is done
using a head-to-toe approach.
 Observe for lacerations, swelling &
deformities including angulation, shortening,
rotation, & symmetry.
 Palpate all peripheral pulses.
 Assess extremity for coolness, blanching,
decreased sensation & motor function.
Splinting of Extremities
 Before moving the patient, a splint is applied
to immobilize the joint above & below the
 Relieves pain, restores circulation, prevents
further tissue injury

1. One hand is placed distal to the fracture &
some traction is applied while the other
hand is placed beneath the fracture for
2. The splint should extend beyond the joints
adjacent to the fracture.
3. Upper extremities must be splinted in a
functional position.
4. If a fracture is open, moist, sterile dressing
is applied.
5. Check the vascular status by assessing
color, temperature, pulse, and blanching
of the nail bed.
6. If there is neurovascular compromise, the
splint is removed and reapplied.
7. Investigate complaints of pain or pressure.

People at Risk:
 those not acclimatized to heat
 elderly and very young people
 those unable to care for themselves
 those w/ chronic & debilitating dse
 those taking tranquilizers, diuretics,
anticholinergics, and beta blockers.
 exertional heat stroke occurs in healthy
individuals during sports or work activities.
Heat Stroke
 An acute medical emergency caused by
failure of the heat-regulating mechanisms.
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Usually occurs during extended heat waves,
especially when accompanied by high

 Hyperthermia results because of inadequate
heat loss, which can also cause death.
 Most heat-related deaths occur in the elderly,
because their circulatory systems are unable
to compensate for the stress imposed by heat
 Elderly people have ò ability to perspire as
well as a ò thirst mechanism to compensate
for heat.
 Causes thermal injury at the cellular level,
resulting to widespread damage to the heart,
liver, kidney, and blood coagulation
 Watch out for profound CNS dysfunction
(confusion, delirium, bizarre behavior, coma),
ñ body temperature (>40.6°C), hot, dry skin,
anhidrosis, tachypnea, hypotension, and
 The primary goal is to reduce the high
temperature as quickly as possible, because
mortality is directly related to the duration of
 Simultaneous treatment focuses on stabilizing
oxygenation using the ABC’s of basic life
 After clothing is removed, core temperature is
reduced to 39°C ASAP by one or more of the ff
1. Cool sheets & towels or continuous
sponging with cool H2O
2. Ice applied to neck, groin, chest, &
axillae while spraying with tepid
water; cooling blankets
3. Iced saline lavage of stomach or
colon if temperature does not
4. Immersion in cold water bath

During cooling, the patient is massaged to
promote circulation and maintain cutaneous
An electric fan is positioned so that it blows
on the patient to augment heat dissipation by
convection and evaporation.
Client’s core temperature is constantly
monitored w/ a thermometer placed in the
rectum, bladder, or esophagus
Avoid hypothermia; prevent spontaneous
recurrence of hyperthermia

Nursing Interventions
 Monitor vital signs, ECG, CVP and level of
 Administer 100% oxygen to meet tissue needs
exaggerated by the hypermetabolic condition.
 NSS or LRS is initiated to replace fluid losses
and maintain circulation
 Urine output is monitored to detect acute
tubular necrosis from rhabdomyolysis.

Blood specimens are obtained to detect DIC
and to estimate thermal hypoxic injury to the
liver, heart, and muscle tissue
Dialysis is done for renal failure.
Give benzodiazepines or chlorpromazine for
seizures; K for hypokalemia; Na bicarbonate
for metabolic acidosis

Nurse Teachings
 Advise client to avoid immediate exposure to
high temperature (10am-2pm).
 Emphasize importance of adequate fluid
intake, wearing loose clothing, and reducing
activity in hot weather.
 Monitor weight and fluid losses during
workouts; replace fluids
 Use a gradual approach to physical
conditioning; allow acclimatization
 Trauma from exposure to freezing
temperatures that results to actual freezing of
the tissue fluids in the cell and intracellular
 Results in cellular and vascular damage
 Body parts most frequently affected are the
feet, hands, nose and ears
 Ranges from 1st (erythema) to 4th degree (fulldepth tissue destruction)
 Frozen extremity may be cold, hard, and
insensitive to touch
 Appears white or mottled blue-white
 Extent of injury from exposure to cold is not
initially known; assess for concomitant injury
 History includes environmental temperature
duration of exposure, humidity, and presence
of wet conditions
 The goal is to restore normal body
temperature; controlled yet rapid rewarming
is instituted
 Constrictive clothing and jewelry that could
impair circulation are removed.
 Patient should NOT be allowed to ambulate if
the lower extremities are involved.
 Place extremity in a 37° to 40°C circulating
bath for 30- to 40-min.
 Repeat treatment until circulation is
effectively restored.

Early rewarming ò amount of tissue loss.
Analgesic is given during rewarming since
process may be very painful.
Avoid handling of body part to prevent further
ELEVATE to prevent further swelling.
Sterile gauze or cotton is placed between
affected fingers or toes to prevent
A foot cradle is used to prevent contact with

Compiled Notes of Bernie C. Butac

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Blebs are left intact and not ruptured,
especially if they are hemorrhagic.
Risk for infection is great; strict aseptic
technique is used during dressing changes,
and tetanus prophylaxis & anti-inflammatory
medications are given
Whirlpool bath for affected extremity to aid
circulation, debride necrotic tissue and
prevent infection
Escharotomy to prevent further tissue
damage, allow normal circulation and permit
joint motion; fasciotomy
After rewarming, hourly active motion of
affected digits is done to promote maximal
restoration of function and to prevent
Refreezing is avoided
Avoid tobacco, alcohol, and caffeine because
of vasoconstrictive effects which further
reduce the already deficient blood supply to
injured tissues.

 A condition in which core temperature is 35°C
or less as a result of exposure to cold
 Occurs when patient loses ability to maintain
body temperature
 Urban hypothermia is associated with a high
mortality rate affected are the elderly, infants,
patients with concurrent illnesses, and the
 Alcohol ingestion ñ susceptibility due to
systemic vasodilation.
 Trauma victims are at risk resulting from
treatment with cold fluids, unwarmed oxygen,
and exposure during examination.
 Hypothermia takes precedence in treatment
over frostbite.
 Watch out for progressive deterioration, with
apathy, poor judgment, ataxia, dysarthria,
drowsiness, pulmonary edema, acid-base
abnormalities, coagulopathy & coma
 Shivering may be suppressed below 32.2°C
due to ineffective mechanism
 Peripheral pulses are weak and become
undetectable; cardiac irregularities,
hypoxemia and acidosis may occur.
Management: Monitoring
 VS, CVP, urine output, arterial blood gas
levels, blood chemistry and chest xray are
frequently evaluated.
 Body temp is monitored with a rectal,
esophageal, or bladder thermometer.
 Continuous ECG monitoring is done because
cold-induced myocardial irritability can lead to
v. fibrillation.

Management: Core Rewarming
 Include cardiopulmonary bypass, warm fluid
administration, warm humidified oxygen by
ventilator, and warm peritoneal lavage
 Done for severe hypothermia

Monitoring for ventricular fibrillation as the
patient passes through 31° to 32°C is

Management: Passive External Rewarming
 Includes the use of warm blankets or over-thebed heaters
 Increases blood flow to the acidotic, anaerobic
 Cold blood returning to the core can cause
cardiac dysrhythmias & electrolyte
Supportive Care
 External cardiac compression
 Defibrillation of v. fibrillation (ineffective if
core temp is <31°C)
 Mechanical ventilation and heated, humidified
 Warmed IVF to correct hypotension and
maintain urine output and core rewarming
 Sodium bicarbonate to correct metabolic
acidosis if necessary
 Antiarrhythmic medications
 Insertion of Foley catheter to monitor fluid
 Survival for at least 24 hours after submersion
 Most common consequence is hypoxemia
 One of the leading causes of death in children
younger than 14 y/o; children younger than 4
y/o account for 40% of all drownings
Risk Factors
1. Alcohol ingestion
2. Inability to swim
3. Diving injuries
4. Hypothermia
5. Exhaustion
 Successful resuscitation with full neurologic
recovery has occurred in drowning victims
after prolonged submersion in cold water.
 After surviving submersion, ARDS resulting in
hypoxia, hypercarbia, & respiratory or
metabolic acidosis can occur.

 Fresh water aspiration results in loss of
surfactant, hence the inability to expand the
 Salt water aspiration leads to pulmonary
edema from the osmotic effects of the salt
within the lungs.
 Treatment Goals
 Maintaining cerebral perfusion and adequate
oxygenation to prevent further damage to
vital organs
 Immediate CPR is the factor with the greatest
influence on survival
 Prevention of hypoxia by ensuring an
adequate airway and respiration, thus
improving ventilation and oxygenation
Compiled Notes of Bernie C. Butac

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 ABG analyses are performed to evaluate O2,
CO2, HCO3 and pH
 If the patient is not breathing spontaneously,
ET intubation with positive-pressure
ventilation improves oxygenation, prevents
aspiration, and corrects intrapulmonary
shunting and V-P abnormalities
 If the patient is breathing spontaneously,
supplemental O2 may be given by mask
 Because of submersion, the patient is usually
hypothermic; use a rectal probe to assess
 Prescribed warming procedures such as
corporeal rewarming, warmed PD, inhalation
of warmed aerosolized O2, and torso warming
depends on the severity & duration of
 Intravascular volume expansion & inotropic
agents are used to manage hypotension &
impaired tissue perfusion; ECG monitoring is
done to monitor dysrhythmias.
 A Foley catheter is used to measure output;
NGT intubation is used to decompress the
stomach & prevent aspiration of gastric
 Close monitoring continues with serial VS,
serial ABG’s, ECG monitoring, ICP
assessments, serum electrolyte levels, I & O,
& serial CXR.
 Complications include hypoxic or ischemic
cerebral injury, ARDS, pulmonary damage 2°
to aspiration, & cardiac arrest.
Decompression Sickness (DCS)
 Occurs in patients who have engaged in
diving, high-altitude flying, or flying in a
commercial aircraft 24 hrs after diving
 Results from nitrogen bubbles trapped in joint
or muscle spaces, resulting in musculoskeletal
pain, numbness, & hyperesthesia
 Bubbles can become emboli in the
bloodstream & cause stroke, paralysis, or
 A rapid history & recompression is done ASAP
& may necessitate a low altitude flight to the
nearest hyperbaric chamber.
 Evidence of rapid ascent, loss of air in the
tank, buddy breathing, recent alcohol intake
or lack of sleep, or a flight within 24 hours
after diving are risk factors.
 Signs and symptoms:
1. Joint/extremity pain
2. numbness, hypesthesia
3. loss of ROM
4. neuro Sx mimicking CVA
5. CP arrest in severe cases
 A patient airway and adequate ventilation are
established & 100% O2 is given throughout
treatment & transport
 A CXR is obtained to identify aspiration, and
at least 1 IV line is started with LRS or NSS.
 If a head injury is suspected, the head of the
bed is lowered.
 Wet clothing is removed and the patient is
kept warm.

Transfer to the closest hyperbaric chamber is
Antibiotics may be prescribed if aspiration is

 An acute systemic hypersensitivity reaction
that occurs w/in seconds or min. after
exposure to foreign substances such as
medications & other agents
 Repeated administration of oral & parenteral
therapeutic agents may cause this when
initially only a mild allergic response occurred
 Antigen-antibody interaction
 Antigen – allergen
 Antibody – IgE previously sensitized basophils
and mast cells
 Release of mediators like histamine and
prostaglandin cause the systemic reactions
 Penicillins – most common
 Contrast media
 Bee stings
 Food
Anaphylaxis Signs and Symptoms
1. Respiratory Signs:
 nasal congestion
 itching, sneezing, coughing
 bronchospasm & laryngeal edema
 chest tightness, dyspnea
 wheezing & cyanosis
2. Skin:
 flushing with sense of warmth & diffuse
 generalized itching over entire body
(systemic reaction)
 urticaria (hives);
 massive facial angioedema (with
accompanying upper respiratory edema)
3. Cardiovascular:
 Tachycardia or bradycardia
 Peripheral vascular collapse
indicated by pallor, imperceptible
pulse, ò BP, circulatory failure,
coma & death
4. GIT:
 nausea & vomiting
 colicky abdominal pains, diarrhea
Anaphylaxis Management
 Establish an airway & ventilation while
another gives epinephrine.
 Early ET intubation avoids loss of the airway,
& oropharyngeal suction removes secretions.
 If glottal edema occurs, a crico-thyroidotomy
is used to provide an airway.
Anaphylaxis: Epinephrine Administration
 Subcutaneous injection for mild, generalized
Compiled Notes of Bernie C. Butac

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IM injection for more severe & progressive
reactions with the possibility of vascular
IV route for rare instances where there is LOC
& severe cardiovascular collapse; may cause

Anaphylaxis: Additional Treatments
 Antihistamines are given to block further
histamine release
 Aminophylline by slow IV trans-fusion for
severe bronchospasm & wheezing refractory
to treatment
 Albuterol inhalers or humidified treatment to
ò bronchoconstriction
 Crystalloids, colloids, or vasopressors for
prolonged hypotension
 Isoproterenol or dopamine for reduced cardiac
output; O2 to enhance tissue perfusion
 IV benzodiazepines for seizure control;
corticosteroids for prolonged reaction with
persistent hypotension or bronchospasm
Anaphylaxis Prevention
 Be aware of the danger signs of anaphylaxis.
 Ask the patient about previous allergies (e.g.
allergies to eggs)
 Before giving antigenic agents, ask caregiver
whether agent was received at an earlier
 Avoid giving medications to patients with
allergic disorders unless necessary.
 Perform a skin test before administration of
certain agents; have epinephrine readily
 If dealing with outpatients, keep them in the
clinic for at least 30 min after injection of any
 Caution patients who are highly sensitive to
carry medical kits.
 Encourage wearing of medical IDs.
Poisoning: Ingested Poisons
 May be corrosive (alkaline and acid agents
that cause tissue destruction)
 Alkaline products: Lye, drain and toilet bowl
cleaners, bleach, non-phosphate detergents,
button batteries
 Acid products: toilet bowl and metal cleaners,
battery acid
Poisoning Management
 Control the airway, ventilation and
 ECG, VS, and neurologic status are monitored
for changes.
 Shock resulting from the cardio-depressant
action of the ingested substance, or from ò
circulating blood volume due to ñ capillary
permeability, is treated.
 A Foley catheter is inserted to monitor renal
function and blood examinations are done to
test for poison concentration.
 The amount, time since ingestion, signs and
symptoms, age and weight and health history
are determined.
 Patient who ingested a corrosive poison is
given water or milk to drink for dilution (not
attempted if patient has acute airway

obstruction, or if with evidence of gastric or
esophageal burn or perforation.
The following procedures may be done:
Ipecac syrup to induce vomiting in the alert
Gastric lavage for the obtunded patient;
aspirate is tested
Activated charcoal administration if poison
can be absorbed by it
Cathartic, when appropriate
Ingested Poison Warnings
Vomiting is NEVER induced after ingestion of
caustic substances or petroleum distillates.
The area poison control center should be
called if an unknown toxic agent has been
taken or if it is necessary to identify an
antidote for a known toxic agent.

Gastric Lavage Guidelines
1. Remove dentures and inspect for loose
2. Measure the distance between the bridge
of the nose and the xiphoid process and
mark tube with indelible pencil or tape.
3. Lubricate tube with KY-Jelly.
4. If comatose, patient is intubated with
cuffed nasotracheal or endotracheal tube
before placement of NGT.
5. Place patient in a left lateral position with
head lowered 15°.
6. Pass the tube orally while keeping the
head in neutral position. Pass tube to
marking (50 cm).
7. Aspirate gastric contents with the syringe
attached to the tube before instilling
water/antidote & save specimen.

8. Remove syringe and attach funnel to the
end of the tube or use a 50mL syringe to
instill solution into tube.
9. Elevate funnel above patient’s head and
150-200mL of solution into it.
10. Lower funnel and siphon the gastric
contents, or connect to suction.
11. Save the samples of the first two
12. Repeat the lavage until the returns are
clear and no particulate matter is seen.
13. The stomach may be left empty, and an
absorbent or saline cathartic is instilled
and allowed to remain inside.
14. Pinch out the tube during removal or
suction while withdrawing and keep head
lower than the body.
15. Warn patient that stools will turn black
from the charcoal.
 The specific chemical is given as early as
possible to reverse effects.
 Procedures include administration of charcoal,
diuresis, dialysis, and hemoperfusion.
 If poisoning is due to a suicide attempt,
psychiatric evaluation is requested; if
accidental, home poison-proofing directions
are given
Inhaled Poisons: CO Poisoning
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A result of industrial or household incidents,
or attempted suicide
Implicated in more deaths than any other
toxins, except alcohol.
CO exerts its toxic effects by binding to
circulating hemoglobin, reducing its oxygencarrying capacity. Hemoglobin absorbs CO
200x more readily than O2.
Carboxyhemoglobin doesn’t have O2
CNS symptoms predominate with CO toxicity.
Watch out for headache, muscle weakness,
palpitation, dizziness, and confusion, which
rapidly leads to coma.
Skin color ranges from cherry-red to pale and
is not a reliable sign.
Pulse oximetry will record false (+)’s.

CO Poisoning Management
 Goal: to reverse cerebral and myocardial
hypoxia and hasten elimination of CO by:
1. Carrying the patient to fresh air
immediately and opening doors and
2. Loosening all tight clothing
3. Initiate CPR if required; give O2.
4. Prevent chilling; wrap in blankets.
5. Keep patient as quiet as possible.
6. Do NOT give alcohol in any form.
7. Upon arrival at the ER, analyze
carboxyhemoglobin levels and give 100%
O2 until level is <5%.
8. Watch out for psychoses, spastic paralysis,
ataxia, visual disturbances, and
deterioration in mental status and
behavior which may be symptoms of brain
9. If accidental poisoning occurs, the DOH
should be informed so that the dwelling
could be inspected.
Food Poisoning
 A sudden illness that occurs after ingestion of
contaminated food or drink
 Some of the most common diseases are
infections caused by bacteria, such as
Campylobacter, Salmonella, Shigella, E. coli
O157:H7, Listeria, and botulism
 A bacterium that causes acute diarrhea
 Transmitted through ingestion of
contaminated food, water, or unpasteurized
milk, or through contact with infected infants,
pets or wild animals.
 Transmitted by drinking unpasteurized milk or
by eating undercooked poultry and poultry
products such as eggs
 Any food prepared on surfaces contaminated
by raw chicken or turkey can also become
 May also stem from food contaminated by a
food worker
 Transmitted through feces. It causes
dysentery, an infection of the intestines
causing severe diarrhea. The disease

generally occurs in tropical or temperate
climates, especially under conditions of
crowding, where personal hygiene is poor
E. Coli O157:H7
 Associated with eating undercooked,
contaminated ground beef. Drinking
unpasteurized milk and swimming in or
drinking sewage-contaminated water can also
cause infection
 found in many types of uncooked foods, such
as meats and vegetables, as well as in
processed foods that become contaminated
after processing, such as soft cheeses (such
as feta and crumbled blue cheese) and cold
 Unpasteurized milk or foods made from
unpasteurized milk may also be sources of
listeria infection
 Linked to home-canned foods with a low acid
 Foods include asparagus, green beans, beets,
and corn.
 Other sources include chopped garlic in oil,
chili peppers, tomatoes, improperly handled
baked potatoes cooked in aluminum foil, and
home-canned or fermented fish (such as
Food Poisoning: MC Foods
 Honey should NOT be given to children
younger than 12 months of age, as it can
contain spores of C. botulinum and is known
to cause infant botulism
 Staphylococcus aureus in spaghetti
 Bacillus cereus in fried rice
 Toxins in mushrooms, shellfish, including the
puffer fish

1. How soon after eating did the symptoms
2. What was eaten in the previous meal? Did
the food have an unusual odor or taste?
3. Did anyone else become ill from eating the
same food?
4. Did vomiting occur? What was the
appearance of the vomit?
5. Did diarrhea occur?
6. Any other neurologic symptoms?
7. Does the patient have a fever?
8. What is the client’s appearance?
 Determine the source and type of food
 Food, gastric contents, vomitus, serum and
feces are collected for examination.
 Patient’s VS, sensorium and muscular activity
are closely monitored.
 Support the respiratory system and assess
fluid and electrolyte balance; watch out for
Compiled Notes of Bernie C. Butac

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lethargy, ñPR, fever, oliguria, anuria,
hypotension, and delirium.
Administer IV antiemetic medications for mild
nausea, give sips of weak tea, carbonated
drinks, or tap water.
Clear liquids for 12 to 24 hrs after nausea and
vomiting subside, and then progressed to a
low-residue bland diet.

 Alteration in skin and underlying tissues as a
result of:
 Too much exposure to sun and UV
 Direct contact with heat and burning
 Hot water and liquids
 Chemicals

Factors considered when assessing the
severity of a burn:
 depth of the burn and size
 the part of the body burned
 the age of the client, and the
 client's previous and past medical history

“Rule of Nines” Chart
Assessment of Damage
 Lund & Browder Method: Assigns percentage
of BSA for various
anatomic parts; more precise method of
estimating the extent of burn
 Palm Method: The size of the palm
(approximately 1% of BSA)
can be used to assess the extent of burn
injury in patients with scattered burn.
Factors considered when assessing the
severity of a burn:
 depth of the burn and size
 the part of the body burned
 the age of the client, and the
 client's previous and past medical history
Depth of Burns: Superficial burn
 The epidermal layer is damaged and hurt
 Wound is quite painful.
 Skin is characteristically red and dry.
 Redness generally subsides within 24 to 48
 Scarring does not occur
Depth of Burns: Deep partial thickness
 Burns affect the dermal layer of the skin.
 The injured skin is red or mottled, possibly
weepy with vesicles
or blisters and considerable swelling.
 When healing is complete, the skin is usually
somewhat discolored
Tightening and contracture may develop.
Depth of Burns: Full thickness burn
 the injury extends all the way through the
subcutaneous tissue
 sometimes to muscle and bone
 no regeneration can occur
 skin is leathery and charred.
 The surface is dry and edema is present.

Part of the Body Burned
 Special attention to the hands, head, neck,
chest, ears, face, perineum and feet
 Prevention of contractures in these areas is
crucial to good healing.
 Any time there is soot around the nose or
mouth, burned nasal hairs, stridor,
hoarseness, decreased breath sounds, upper
airway damage should be suspected.
Burns in the Extremes of Age
 In pediatric clients under age 2, the
immunologic response to stress and trauma is
not fully developed, and a burn injury can be
 In the elderly, these responses are diminished
and the person's general health may be
compromised by existing medical problems.
Burn Management
Maintenance of Airway Patency
A. Assess the airway.
B. Auscultate the trachea, and monitor for
adventitious breath sounds or decreased
breath sounds.
C. If client is dyspneic or if there is carbon
monoxide poisoning, a high liter flow of 8
to 10 liters of oxygen is recommended.
D. If compromise is suspected, the victim
may be intubated and ventilated.
 Indications for intubation are
airway obstruction and a PaO2 of
less than 60 mm Hg.
 The continuous monitoring by
means of a pulse oximeter assists
in assuring adequate oxygenation.
E. The client's level of consciousness should
be carefully monitored. Burn victims are
most often alert, oriented and cooperative
even with extensive injuries.
Fluid Resuscitation
 The maximum loss of fluid occurs within 12 to
18 hours after the burn.
 The total quantity of fluid required to correct
this volume deficit is replaced in the first 24
hours following the burn injury.
 The amount of fluid required to correct the
deficit is calculated to be 2 to 4 mL per cent
burn per kilogram of body weight.
 Administration of the fluids takes place over a
24-hour period with half the amount given in
the first 8 hours and the remainder over the
next 16 hours.

Fluid Loss Management
1. Consensus Formula: 2-4 mL x body weight
(kg.) x % body surface area burned. Half to be
given in first 8 hours, remaining half to be
given over next 16 hours.
2. Evans Formula
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Colloids: 0.5 mL x body weight (kg.) x
%BSA burned
Electrolytes: 1.5 mL x body weight (kg) x
% BSA burned
Glucose: 2000 mL for insensible loss
Day 1: Half to be given in the first 8 hours;
remaining half over next 16 hours

3. Parkland Formula
 Lactated Ringer’s Solution: 4 mL x
body weight (kg) x % BSA burned
 Day 1: Half to be given in first 8 hours;
half to be given over next 16 hours
 Day 2: Varies. Colloid is added (e.g.
albumin, dextran)
Burn Management
 Obtain laboratory data
 Monitor urine output and vital signs
 Administer tetanus antitoxin/toxoid
 Hypertonic Saline Solution
 Goal: to increase serum sodium level and
osmolarity to reduce edema and prevent
pulmonary complications
 Concentrated solutions of sodium chloride
(NaCl) and lactate are given sufficiently to
maintain a desired volume of urinary output.
Phases of Burn Care: Emergent
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Fluid Resuscitation

Assess for Acute Respiratory Failure
Assess for Acute Renal Failure
Assess for Distributive Shock
Assess for Compartment Syndrome (Assess
peripheral pulse, capillary refill.)
Assess for Paralytic Ileus (Auscultate bowel
sounds, abdominal distention.)
Assess for Curling’s Ulcer (Assess gastric pH,
occult blood in stools.)

Burn Care: Acute Phase
 Begins 48 to 72 hours post-injury
 Assess for edema, jugular vein distention,
crackles, increased arterial pressure
 Use asepsis & reverse isolation.
 Give high-calorie, high-protein diet
 Assess the graft sites. Report signs of poor
healing, graft take or trauma.
 Prevent flexed position in burned areas.
 Burn Care: Rehabilitation Phase
 Wound healing, psychosocial support, and
restoring maximal functional activity remain
Chemical Burn
 Most chemicals that cause burns are either
strong acids or bases
 The severity of a chemical burn is determined
by the mechanism of action, the penetrating
strength and concentration, & the amount
and duration of exposure of the skin to the

 The skin should be continuously drenched
immediately with running water from a
shower, hose or faucet as the patient’s
clothing is removed.
 The skin of the health care professional
assisting should also be appropriately
Chemical Poison Warnings
 Water should NOT be applied on burns from
lye or white phosphorus because of a
potential for an explosion or for deepening of
the burn.
 All evidence of these chemicals should be
brushed off the patient before any flushing.
 Determine the identity and characteristics of
the chemical agent for future treatment.
 The standard burn treatment for the size &
location of the wound (antimicrobials,
debridement, tetanus toxoid) is instituted.
 The patient may require plastic surgery for
further wound management
 The patient is instructed to have the affected
area re-examined at 24 & 72 hours and in 7
days because of the risk of under-estimating
the extent & depth of these types of injuries.

Compiled Notes of Bernie C. Butac

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