TABLE 7-46 Nursing Care of the Adult in Medical and Surgical Emergencies - continued
Condition
Assessment: Signs and Symptoms
Prehospitalization Nursing Care
In-hospital Nursing Care
Abdominal injuries
    
  1. Observe for rigidity
  2. Check for hematuria
  3. Auscultate for bowel sounds
  4. Assist with paracentesis to confirm bleeding in abdominal cavity
  5. Prepare for exploratory laparotomy
  6. Insert nasogastric tube - to detect presence of upper GI bleeding
  7. Monitor vital signs
If organs protruding:
  1. Flex patient’s knees
  2. Cover intestines with sterile towel soaked in saline
  3. Do not attempt to replace organs
Fractures
    
  1. Administer tetanus toxoid as ordered
  2. Observe for pain, peripheral pulses, pallor, loss of sensation and/or movement
  3. Assist with wound cleansing, casting, x-rays, reduction
  4. Prepare for surgery if indicated
  5. Monitor vital signs
Bums - tissue trauma secondary to scalding fluid or flame, chemicals, or electricity
Superficial (first degree): Erythema and tenderness Usually sunburn
Relieve pain by applying cold, wet towel or cold water (not iced)
  1. Cleanse thoroughly with mild detergent and water
  2. Apply gauze or sterile towel
  3. Administer sedatives and narcotics as ordered
  4. Arrange for follow-up care, or prepare for admission if burn ambulatory care impractical
 
Partial thickness (second degree):
Swelling, blisters; moisture due to escaping plasma
  1. Douse with cold water until pain relieved
  2. Blot skin dry and cover with clean towel
  3. Do not: break blisters, remove pieces of skin, or apply antiseptic ointments
  4. If arm or leg burned, keep elevated
  5. Seek medical attention if second-degree burns:
    1. Cover 10% of body surface
    2. Involve hands, feet, or face
  1. Check tetanus immunization status
  2. Administer sedatives or narcotics as ordered
  3. Assess respiratory and hemodynamic status; oxygen or ventilatory assist as indicated, intravenous infusions as ordered to combat shock
  4. Remove all clothing from burn area
  5. Using aseptic technique, cleanse burns as indicated.