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
 
Full thickness (third degree):
White, charred areas
  1. Do not remove charred clothing
  2. Cover burned area with clean towel, sheet
  3. Elevate burned extremities
  4. Apply cold pack to hand, face, or feet
  5. Sit up patient with face or chest wound to assist respirations
  6. Maintain airway
  7. Observe for shock
  8. Do not:
    1. Put ice water on burns or immerse wounds in ice water - may increase shock
    2. Apply ointments
  9. Calm and reassure victim
  10. Get medical help promptly
  11. If patient conscious, not vomiting, and medical assistance is more than 6 hr away: may give sips of weak solution of salt, soda, and water
  1. Do not break blebs or attempt debridement
  2. Assist with application of dressings as ordered
  3. Maintain frequent checks of vital signs, urine output
  4. Provide psychological support - explain procedures, orient, etc.
  5. Assist with application of splints as ordered
  6. Administer tetanus immune globulin or toxoid as ordered
  7. Assist with transfer to hospital unit
 
Fourth degree:
Black
Same as full thickness.
  
 
Chemical burns
  1. Flush with copious amounts of water
  2. Get rid of clothing over burned area
  1. Flush with copious amounts of water
  2. Administer sedation or narcotics as ordered
 
Bums of the eye:
Acid
  1. Flush eye with water for at least 15 min
  2. Pour water from inside to, outside of eye to avoid contaminating unaffected
  3. Cover - seek medical attention at once
  1. Irrigate with water; never use neutralizing solution
  2. Instill 0.5% tetracaine as ordered
  3. Apply patch
 
Alkali (laundry detergent or cleaning solvent)
  1. Do not allow a patient to rub eye
  2. Flush eye with water for at least 30 min
  3. Cover - seek medical attention at once
As above for acid
Abdominal Emergencies
  
Aortic aneurysm—rupture or dissection
Primarily men > age 60
Sudden onset of excruciating pain: abdominal, lumbosacral, groin, or rectal
Orthopnea, dyspnea
Fainting, hypotension; if dissecting, marked hypertension may be present mass in umbilical area Femoral pulse present; dorsalis pedis - weak or absent
  1. Notify physician
  2. Lay patient flat, or raise head if in respiratory distress
  3. Cover - keep warm but not hot
  4. Institute shock measures as above
  5. Calm; reassure that help is on the way.
  1. Assess respiratory and hemodynamic status
  2. Institute shock measures if indicated
  3. Evaluate and compare peripheral pulses
  4. Assist with x-rays
  5. Assist with emergency preoperative treatment