Color Coding

A – Airway
 B – Breathing
 C – Circulation
 D – Disability
 E – Exposure
 Complete health history
 Assessment (cephalocaudal)
 Diagnostic & Lab tests
 Splinting of fractures
 Cleansing, closure and dressing of wounds
 Performance of other necessary interventions based
on the patient’s condition
 Include pain management (use rapid-acting agents)
 Provide support to patient and family
Airway Obstruction
 Partial
Obstruction
 Complete Obstruction
 To establish an airway for a patient who cannot be
adequately ventilated with an oropharyngeal airway
 To bypass an upper airway obstruction
 To prevent aspiration
 To permit connection of patient to a resuscitation
bag or mechanical ventilator
 To facilitate the removal of tracheobronchial
secretion
Hemorrhage
 Control of External
Bleeding :
◦ Apply firm, direct
pressure over the area
or involved artery
 Control of Internal
Bleeding:
◦ Prepare for surgery
◦ Give packed RBC
 Tachycardia
 Falling blood pressure
 Increasing pulse rate
 Cold moist skin
 Delayed capillary refill
 Pallor
 Thirst
 Altered sensorium
 Oliguria
Heat Stroke
 It is the failure of the - Elevated body Remove patient’s
Definition

Management
Manifestation
heat regulating temp (above clothing,
mechanism of the 40.6*C/105*F Sponge the client
body - Tachycardia & with cool water
tachypnea Apply ice on the
- Hypotension neck, axillae and
- Confusion groin areas
- Hot dry skin Increase fluid intake
Give oxygen (100%),
Monitor urine output
Hypothermia
 Definition • Loss of the ability to maintain normal body
temperature (Below 35*C)

• Apathy, dysarthria, drowsiness, decreased body temp

Manifestation (below 35*C or 95*F)
• If left untreated may lead to coma

• Continuous monitoring
• Rewarming
Nursing Action • Removal of wet clothing
• Insulation
Near-drowning
 Management:
Near drowning is Signs & Symptoms:
>Cardiopulmonary
the survival for at > Hypoxia
least 24 hours after Resuscitation
>Hypercapnia
submersion that >Ventilatory support:
caused a >Bradycardia ET Tube
respiratory arrest. >Dysrhythmia >May have
hypothermia: perform
rewarming
Decompression
sickness
Manifestation Management
>Establish patent
> Joint or extremity airway and adequate
pain ventilation
> Numbness >100% O2
administration

> Loss of range of >Place in hyperbaric

motion chamber
> Neurologic >Remove wet clothing
symptoms (same as and keep patient
stroke/spinal cord warm
injury
Poisoning
 Identify whether the patient took a corrosive or
noncorrosive agent
 Management:
◦ For corrosive poison: give water or milk to dilute the agent;
perform gastric lavage
◦ Give syrup of ipecac (for noncorrosive agent only)
◦ Activated charcoal or cathartic may also be given
◦ Continue monitoring patient
 Manifestation:
◦ Headache, muscular weakness, palpitation, dizziness and
confusion. May progress to coma.
 Management:
◦ Carry the patient to fresh air immediately; open all doors
and windows
◦ Loosen all tight clothing
◦ Initiate CPR; administer 100% O2
◦ Wrap patient in a blanket to keep warm
Remove anyone Activate alarm Confine the fire
from immediate (close windows and
danger door)

Evacuate the
building
 Use RACE:
◦ IF THE PATIENT IS WITHIN THE
VICINITY!
 Use ARCE:
◦ IF YOU ARE LOCATED IN A PLACE
WHERE YOU ARE TOO FAR TO BE OF
IMMEDIATE HELP TO A PATIENT YOU
STOP DROP ROLL
 Stay away from
Drop down; Stay indoors
bookcases or
take cover until the
furniture that
under a desk or shaking stops
can fall on you.
table and hold and you're sure
Stay away from
on. it's safe to exit.
windows.

If you are If you are in a

If you are in bed, outdoors, find a car, slow down
hold on and stay clear spot away and drive to a
there, protecting from buildings, clear place. Stay
your head with a trees, and power in the car until
pillow. lines. Drop to the the shaking
ground. stops.
Check for injuries and treat the injured with first aid.

Stay calm and use common sense.

Use the telephone only to report severe emergencies. Do not

touch downed power lines or broken appliances

Watch for falling objects when you enter or leave buildings. Do

not enter severely damaged structures.

Be prepared for aftershocks. They can cause added damage. If near

large body of water, evacuate to higher safe ground.
 Most common poisonous snake: PIT
VIPER; Most common site of bite:
UPPER EXTREMITIES

Manifestation: Fang punctures, pain,

edema and redness on the bite area

Nursing action: Have the patient lie down,

remove constrictive clothing, provide warmth,
cleanse the wound and cover it with a light
sterile dressing, immobilize the injured part
below the level of the heart. NO
TOURNIQUET/ICE; Take to the hospital to give
antivenin
 • Headache, fever, muscle spasm during deglutition
Manifestation (due to fear of water/ hydrophobia) paralysis, delirium
and convulsion

• Wash the area with soap and water for at least 10

minutes.
• Nurse should wear PPE when handling saliva and
contaminated clothing
Nursing • Confine and observe the suspected animal for 10
Action days
• Administer rabies immunization as prescribed:
rabies immune globulin (passive immunization)
and human diploid cell vaccine (active
immunization)
 Nursing
Spider bite Manifestation Consideration

Black widow >Red, raised >Cleanse the

spiders are wheal wound
the most >Swelling & > Seek medical
poisonous; Itching treatment if
Brown symptoms
recluse > Painful
rash persist for more
spiders than 24 hours;
cause large >Necrotic needs anti-
wounds tissue (seen venom
in brown
recluse
spiders)
 • Pain, Urticaria, Stridor
Manifestation • Redness, Swelling

•Remove the sting by flicking

it with a flat object (ex.
Credit card)
•Wash the bite area with
soap and water
•Apply ice on the affected
Nursing area to control swelling
Action •For pain may take over the
counter pain killers (ex.
Ibuprofen)
•Keep the wound clean to
prevent infection (may take
2-5 days before the sting
heal)
Note: Box Jelly fish sting may cause death in a
matter of minutes

Manifestation: Intense stinging pain, itchiness and

redness, Nausea, vomiting and diarrhea, Swelling of lymph
nodes, Muscle cramps

Nursing action: Apply alcohol, vinegar or acetic acid on the

site, Do not rub on the area, Do not apply ice or hot water,
Remove the tentacles with a stick or tweezers, Apply shaving
cream or paste of baking soda on the affected area to
decrease the pain, Administer acetaminophen for pain