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.
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
Condition
Assessment: Signs and Symptoms
Prehospitalization Nursing Care
In-hospital Nursing Care
Blunt injuries - spleen
Left upper quadrant pain, tenderness and moderate rigidity; left shoulder pain (Kehr’s sign)
Hypotension; weak, thready pulse; increased respirations (shock)
  1. Lay patient flat
  2. Institute shock measures
  1. Assess respiratory and hemodynamic status
    1. Maintain airway and ventilation as indicated
    2. Institute infusions of colloid or crystalloids as ordered
    3. Insert both CVP and arterial monitoring lines
    4. Insert Foley catheter
  2. Prepare for splenectomy
Eye and Ear Emergencies
Chemical burns
See Burns
See Burns
See Burns
Blunt injuries secondary toflying missiles, e.g., balls.striking face against car dashboard
Decreased visual acuity, diplopia, blood in anterior chamber
Pain, conjunctiva reddened, edema of eyelids
  1. Prevent victim from rubbing eye
  2. Cover with patch to protect eye
  3. Seek medical help immediately
  1. Test visual acuity of each eye
    using Snellen or Jaeger chart
  2. Assist with fluorescein administration - to facilitate identifying breaks in cornea
Sharp ocular trauma - secondary to small or larger foreign bodies
Reports feeling as if something were hitting eye
Pain, tearing, reddened conjunctiva
Blurring of vision
Foreign object may be visible
  1. Keep victim from rubbing eye
  2. Cover very lightly - do not apply pressure
  1. Check visual acuity in both eyes
  2. Check pupils
  3. Instill 1% tetracaine HCI as ordered to relieve pain
  4. Administer antibiotic drops or ointment as ordered
  5. Apply eye patch
  6. Provide instructions for subsequent care and follow-up
Foreign bodies in ears —beans, peas, candy, foxtails, insects
Decreased hearing; pulling, poking at ear and ear canal; buzzing, discomfort
  1. Do not attempt to remove object
  2. Seek medical assistance
  1. Inspect ear canal
  2. Assist with sedating children - restraint may be necessary
  3. Assist with procedures to remove object:
    1. Forceps or curved probe for foxtails, irregularly shaped objects
    2. 10F or 12F catheter with tip cut squarely off and attached to suction to remove round object
  4. Irrigate external auditory canal to flush out insects, materials that do not absorb water; do not irrigate if danger of perforation