Minor Wounds
Place a sterile pad directly over a minor wound that is bleeding. A prepared commercial adhesive bandage strip (e.g., Band Aid) is an adequate dressing for a small cut or scratch. Such strips are packaged in various sizes and should be in every home medicine cabinet. Do not touch the part of the sterile dressing that covers the wound. Put the dressing exactly where it is to stay; it cannot be moved afterward without contaminating it. Be sure that the bandage or adhesive is firm, yet not so tight as to cut off circulation. Telfa (nonstick) pads are much less irritating on removal than conventional gauze bandages. Band Aids impregnated with an antibiotic are available and they often enhance healing.
If a sterile dressing is not readily available, use a clean handkerchief or cloth. Press the dressing firmly on the bleeding area; then apply a firm bandage to hold the dressing in place. The dressing should stop minor bleeding. If bleeding is more severe, apply an inflated blood pressure cuff or air splint, or insert a firmly rolled sterile pad under the dressing. (A rolled pad allows for more pressure than a flat pad.) Fasten the bandage securely in place. Fasten a dressing on an arm or leg with an ACE-type roller bandage. Be sure not to shut off circulation entirely. A roller bandage placed over the dressing may also help to control bleeding.
IN PRACTICE :NURSING CARE GUIDELINES 43-6
GIVING FIRST AID IN SUSPECTED HEART ATTACK (MI)
• Have someone call 911. Rationale: Prompt treatment is vital.
• Keep the person completely quiet. Do not allow the person to move, no matter how much better he or she claims to feel. Rationale: Most people say they feel better. This is part of denial.
• Loosen any tight clothing. Rationale: Loosening clothing helps to make breathing easier.
• Cover the person with a blanket or coat. Put a ground cover under the person, if possible. Rationale: Keeping the person covered helps to prevent chilling and shock. These complications add exertion to the already stressed heart.
• Place something under the person’s head and upper back. If necessary assist the person to sit up to breathe. Rationale: The person usually finds it easier to breathe if the head is elevated.
• If the person shows signs of shock, keep him or her flat, unless this inhibits breathing. Rationale: Lying flat helps to control shock. However, the person will become more panicky if he or she cannot breathe.
• Be prepared to initiate CPR. Rationale: Cardiopulmonary arrest is a relatively common complication of heart attack. If the person can be maintained until arrival at the healthcare facility, the chance for a positive outcome increases.
Skinned or scraped areas, bleeding very little or not at all, can be sprayed with a “liquid bandage,” such as Nu-Skin, to protect the wound.
Hemorrhage
When a blood vessel is cut or torn, blood escapes and bleeding occurs. The amount of bleeding depends on the number and size of injured blood vessels. A person can lose a great deal of blood if bleeding is excessive before clotting occurs.
Key Concept If a person loses a large amount of blood, the hemoglobin reading will not show an immediate drop. The decreased laboratory value will occur in 24 to 48 hours.
Bleeding that is abundant or uncontrollable is called hemorrhage. A severe injury to one large blood vessel can cause a serious hemorrhage; however, an injury to many small vessels or capillaries can cause an equally life-threatening hemorrhage.
In an emergency involving bleeding, the first and most important step is to stop the bleeding. The second step is to treat the shock that accompanies hemorrhage (see discussion earlier in this topic). Because blood is the chief means of transmission of human immunodeficiency virus and other diseases, be sure to follow Standard Precautions.
When you are faced with a situation involving bleeding, quickly assess for the type of bleeding:
• In capillary bleeding, blood oozes slowly out of the wound.
• In arterial bleeding, blood comes in spurts with each heartbeat and is bright red or pink. Arterial bleeding is usually the most severe type of hemorrhage. (Note: If an artery is nicked, it is likely to bleed profusely. If it is cut across (transected), it may bleed very little, because the ends of the vessel draw together. Arterial bleeding is a serious medical emergency.)
• In venous bleeding, blood flows steadily and is dark in color. Usually, venous bleeding is minor and stops by itself, unless the person has a bleeding disorder.
In any case of hemorrhage, place the person on a flat surface and slightly elevate his or her feet (unless the person has a head injury or nosebleed).
Applying Direct Pressure
In external hemorrhage, cut the person’s clothes away from the site to reveal the site and amount of bleeding. Apply direct, firm pressure at the site, which will control bleeding in most injuries. Elevate the injured part, unless the possibility of fracture or other trauma to the area exists.
Applying Indirect Pressure
If direct pressure does not control hemorrhage, you may need to apply indirect pressure. This means that you do not apply pressure directly to the wound, but to an artery at a pressure point between the wound and the heart (see Fig. 43-5). You will need a firm surface to press against, to cut off the blood flow from the heart to the wound. Therefore, choose a pressure point in which the supplying artery lies close to a bone. If bleeding is severe enough to require the use of a pressure point, maintain the pressure until medical assistance arrives. If you release pressure, the clot that formed may dislodge and bleeding will resume. Danger of embolism also exists.
Nursing Alert Never wipe a blood clot from a wound. The clot acts as a plug for ruptured blood vessels. If the clot breaks loose, death may result from external hemorrhage or from embolism.
Using a Tourniquet
A tourniquet is a tie used on an extremity over a pressure point to stop hemorrhage. Use a tourniquet only as a last resort. The tourniquet must be tight enough to cut off the blood flow in the artery completely. If it is too loose, it will only prevent the blood from flowing back through the veins, and thus will increase bleeding. In Practice: Nursing Procedure 43-3 outlines the steps for applying a tourniquet.
Nursing Alert Using a tourniquet may mean that the person will lose the limb as a result.
MAST Trousers
Military antishock trousers (MAST) may be used in cases of massive internal hemorrhage or hypovolemia. MAST trousers are pneumatic and serve to provide pressure evenly to the body, support circulation, and lessen shock (Fig. 43-12). MAST trousers are not to be used in pulmonary edema, cardiogenic shock, increased ICP, or evisceration (protrusion of viscera through the skin, most often through an unhealed surgical incision).
You may see paramedics applying MAST trousers, or a person may come into an ED with them in place. Only emergency personnel apply MAST trousers. Nurses do not apply or remove them. In some areas, MAST trousers are rarely used because rapid transport of the critically ill person is preferable to taking extra time to apply the trousers.
Indications for the use of MAST trousers include very low or rapidly falling blood pressure; loss of consciousness;decreased or absent leg pulses; pale, mottled, and cold feet; and severe respiratory distress (dyspnea, tachypnea, gasping breaths, cough, or pink and frothy sputum).
FIGURE 43-12 · The military antishock trouser (MAST) is a garment designed to correct internal bleeding and hypovolemia (low blood volume) by the application of counterpressure around the legs and abdomen. This pressure creates an artificial peripheral resistance and helps sustain coronary perfusion. It should be applied as soon as possible after injury, preferably before the client is transferred to the emergency department.
Internal Bleeding
A person experiencing internal bleeding can develop life-threatening shock before the bleeding is discovered. Consider internal bleeding in all cases of trauma, especially in older clients. Possible causes of internal bleeding include blunt trauma, fractures, GI bleeding, and vaginal bleeding. A fracture is the most common cause of internal bleeding. A fractured pelvis is the most severe fracture related to blood loss. Signs of upper GI bleeding may include vomiting bright red blood or passing bloody or black stools. Coffee ground-like emesis or rectal bleeding usually indicates bleeding in the lower GI tract. A person with gastrointestinal bleeding can deteriorate very quickly.
Report the following observations to the EMTs or physician immediately if you see them in any person, regardless if the person is in a healthcare facility or not:
• Large or unexplained bruises and contusions
• Bleeding from the mouth, rectum, ears, or other body opening
• Dizziness when rising from a lying to a standing position, without a known cause
• Cold, clammy skin
• Profuse sweating
• Restlessness, anxiety, unexplained combative behavior
• Confusion, without other known causes
• Weak, rapid pulse
• Shallow, rapid breathing
• Extreme thirst
• Unexplained weakness
• Falling blood pressure
• Altered LOC
Treatment is aimed at stopping bleeding and replacing blood and fluids lost.
Anaphylaxis
Normally, when the body senses the presence of an antigen, an antigen-antibody reaction occurs.This constant neutralizing reaction protects the person from toxins and infections. In anaphylaxis, the antigen-antibody reaction works to the person’s detriment. The release of chemicals in the body, such as histamine, causes reactions affecting several body systems (systemic). Anaphylaxis (anaphylactic shock) is a type I allergic, life-threatening reaction to a substance. A severe type I reaction occurs within minutes of exposure. Anaphylaxis is life threatening.
Nursing Alert Anaphylaxis is a true medical emergency Time is crucial.
Anaphylaxis is highly individualized; people can be hypersensitive to almost any substance. Common triggers for anaphylaxis include:
• Bee stings
• Certain foods (e.g., peanuts and chocolate)
• Food additives or preservatives (e.g., sulfite, MSG)
• Medications (e.g., antibiotics, aspirin)
• Chemicals
• Inhaled substances
In Practice: Data Gathering 43-1 lists signs and symptoms of anaphylactic shock. The person’s LOC is especially significant. The person will be restless and panicky and may faint or have a seizure. Loss of consciousness often occurs early in severe anaphylaxis. The time range for an allergic reaction is from a few seconds to several hours. Reactions are often generalized and violent. Each occurrence is more serious than the last. People who have severe allergies should carry medication such as subcutaneous (SQ) epinephrine (e.g., an “Epi-pen”) with them at all times. Family and friends, as well as the person, should learn how to administer the medication. This person should wear a MedicAlert tag at all times. Common medications for anaphylaxis are listed at In Practice: Important Medications 43-1.
IN PRACTICE :DATA GATHERING IN NURSING 43-1
SIGNS AND SYMPTOMS OF ANAPHYLAXIS Skin
♦ Raised hive-like patches (urticaria)
♦ Burning of the skin
♦ Severe itching (pruritus)
♦ Pallor
♦ Perspiration
♦ Cold, clammy skin or flushed skin
♦ Blueness (cyanosis) around the lips and nails
Neurologic System
♦ Dizziness
♦ Weakness
♦ Restlessness
♦ Panic
♦ Tingling and numbness
♦ Seizures or stroke
♦ Coma
Circulatory System
♦ Dilation of blood vessels
♦ Blood volume loss
♦ Decreased cardiac stroke volume
♦ Decreased cardiac output
♦ Lowering of blood pressure
♦ Weak, rapid pulse
♦ Irregular pulse
♦ Circulatory collapse
♦ Cardiac standstill
Respiratory System
♦ Coughing, sneezing, wheezing
♦ Itching nose
♦ Swelling of face, tongue, and airway
♦ Chest tightness
♦ Dyspnea
♦ Choking sensation
♦ Respiratory arrest
Gastrointestinal System
♦ Nausea and vomiting
♦ Abdominal cramping
♦ Diarrhea
Other
♦ Watery, itching eyes
♦ Throbbing in the ears
♦ Incontinence
IN PRACTICE :IMPORTANT MEDICATIONS 43-1
TO TREAT ANAPHYLAXIS
For severe anaphylaxis, the following drugs may be used:
♦ Epinephrine (Adrenaline)
♦ Corticosteroids
♦ Histamine-1 receptor antagonists (antihistamines)
For milder forms of anaphylaxis, medications such as diphenhydramine hydrochloride (Benadryl) or hydroxyzine (Vistaril, Atarax) may be used.
Remember the acronym SIRES when faced with an allergic or anaphylactic situation:
S = Stabilize I = Identify the toxin R = Reverse the effect of the toxin E = Eliminate the toxin
S = Support (respiration, circulation, and so forth)
First-aid care begins with creating an open airway. Activate the EMS system immediately. Ask the person if appropriate medication is available. If so, the person may need assistance in administering this.
Nursing Alert Usually the faster an allergic reaction occurs, the more severe and life threatening it is.
Animal Bites and Scratches
Animal bites and scratches are a common problem, particularly among children. Most often, the child is bitten by a household pet. Rabies, a communicable disease transmitted through animal bites, is caused by the rhabdovirus. The virus travels along the person’s nerves to the CNS. Untreated rabies is almost always fatal. A specific antidote (a substance that neutralizes poisons) for rabies is available, but it is painful and expensive.
Animal bites and scratches can also cause an infection, which may become serious. Cat bites or scratches are usually more likely to become infected than dog bites. Cat and dog infections include cat-scratch disease (fever), which is usually mild, resulting only in swelling of regional lymph nodes. Cat-bite disease can be more serious. Usually, the cat does not show any signs of disease in either case. A dog bite can be very serious and disfiguring, especially if it involves the face. Some dog attacks can result in death, particularly in children.
When a person is bitten, cleanse the wound with warm, soapy water and rinse the area thoroughly. Swab the area with Zephiran or alcohol. If a puncture wound is present, flush the area with sterile normal saline. Do not delay in obtaining medical care.
Follow the physician’s orders for further care. Usually, the nurse or physician will debride (cut away) any loose tissue. A tetanus injection or antibiotics to prevent or treat infection may be administered. An antibiotic commonly used in the case of an animal-related injury is dicloxacillin (Dynapen). If a rabies antiserum is required, the manufacturer will include specific instructions for its use. These instructions must be followed exactly.
Key Concept In the case of an animal bite, the animal is captured and observed whenever possible. If it cannot be located or captured, obtain an accurate description of the animal and the circumstances. Do not destroy the animal; sometimes a length of time in quarantine is needed to determine if it is diseased or not. In the case of a household pet, the animal will be subject to an enforced quarantine. If the animal is not available for observation, the person must undergo antirabies treatment. A fine may be assessed if the animal has bitten someone previously The law requires reporting any animal bite to the Public Health Department and the police immediately Human bites may also cause infection.
Exposure to Hazardous Materials
Hazardous materials (HAZMATs) are used in the production of many common products including fuel, medications, plastics, and home cleaning agents. These materials are normally stored, used, and transported safely. However, when they are improperly handled, they may become hazardous to the environment. These powerful chemical products can cause poisoning, burns, exposure to toxic fumes, contamination of groundwater, and explosions. Other environmental emergencies are chemical or oil spills and gas leaks. The oil spill in the Gulf of Mexico in 2010 is an example of an environmental emergency of the greatest magnitude.
Primary exposure is when a person is exposed directly to a hazardous substance, for example by breathing fumes from evaporating liquids. Secondary exposure occurs when the rescuer or healthcare provider is exposed to the contaminated person. To prevent exposure, follow these safety measures:
• Do not walk into or touch spilled material.
• Avoid inhalation of gases, fumes, and smoke.
• Do not assume that gases or vapors are harmless because they are odorless.
• Do not go near accident victims if you cannot identify the hazardous material.
• Do not walk into or drive into a gas cloud. If you are accidentally caught in one and are unable to drive out, roll up your car windows, close the vents, turn off the fan, unlock the doors, and wait for assistance.
Emergency personnel specially trained in the management of hazardous materials will respond to eliminate and prevent contamination. Clients exposed to hazardous materials require specialized care. Take these additional precautions:
• Wear personal protective equipment (PPE) to help prevent secondary exposure.
• Decontaminate the victim. Remove his or her clothing and rinse off the chemical. Most EDs have showers available for this purpose.
If a contaminated person presents to the ED or clinic, avoid exposing the entire department to the hazard. After a hazardous chemical enters a building, the area may require evacuation and decontamination. Most EDs have plans for decontaminating victims outside the area using special rooms with an outside entrance, portable self-contained showers, or hoses. Remove the victim’s clothes and store them in appropriate bags. Use special decontamination stretchers for clients who are unable to shower independently. Complete the process as quickly as possible, and then treat the victim’s injuries. If life-saving procedures are necessary before decontamination is possible, personnel must wear appropriate protective barriers to avoid contamination.
