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 patients 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
D
e
f
i
n
i
t
i
o
n

It is the failure of the
heat regulating
mechanism of the
body
M
a
n
i
f
e
s
t
a
t
i
o
n

- Elevated body
temp (above
40.6*C/105*F
- Tachycardia &
tachypnea
- Hypotension
- Confusion
- Hot dry skin

M
a
n
a
g
e
m
e
n
t

Remove patients
clothing,
Sponge the client
with cool water
Apply ice on the
neck, axillae and
groin areas
Increase fluid intake
Give oxygen
(100%),
Monitor urine output

Hypothermia
Loss of the ability to maintain normal body
temperature (Below 35*C)
Definition
Apathy, dysarthria, drowsiness, decreased body
temp (below 35*C or 95*F)
If left untreated may lead to coma
Manifestation
Continuous monitoring
Rewarming
Removal of wet clothing
Insulation
Nursing
Action
Near-drowning
Near drowning is the
survival for at least
24 hours after
submersion that
caused a respiratory
arrest.

Signs &
Symptoms:
> Hypoxia
>Hypercapnia
>Bradycardia
>Dysrhythmia

Management:
>Cardiopulmonary
Resuscitation
>Ventilatory support:
ET Tube
>May have
hypothermia: perform
rewarming
Decompression
sickness
> Joint or extremity
pain
> Numbness
> Loss of range of
motion
> Neurologic
symptoms (same as
stroke/spinal cord
injury
Manifestation
>Establish patent
airway and adequate
ventilation
>100% O2
administration
>Place in hyperbaric
chamber
>Remove wet
clothing and keep
patient warm
Management
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
from immediate
danger
Activate
alarm
Confine the fire
(close windows
and 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
bookcases or
furniture that
can fall on you.
Stay away from
windows.
Stay indoors
until the
shaking stops
and you're sure
it's safe to exit.
Drop down;
take cover
under a desk or
table and hold
on.
If you are in a
car, slow down
and drive to a
clear place. Stay
in the car until
the shaking
stops.
If you are
outdoors, find a
clear spot away
from buildings,
trees, and power
lines. Drop to the
ground.
If you are in bed,
hold on and stay
there, protecting
your head with a
pillow.
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
Manifestation
Headache, fever, muscle spasm during deglutition
(due to fear of water/ hydrophobia) paralysis,
delirium and convulsion
Nursing
Action
Wash the area with soap and water for at least
10 minutes.
Nurse should wear PPE when handling saliva
and contaminated clothing
Confine and observe the suspected animal for
10 days
Administer rabies immunization as prescribed:
rabies immune globulin (passive immunization)
and human diploid cell vaccine (active
immunization)
>Cleanse the
wound
> Seek medical
treatment if
symptoms
persist for more
than 24 hours;
needs anti-
venom
Nursing
Consideration
>Red,
raised wheal
>Swelling &
Itching
> Painful
rash
>Necrotic
tissue (seen
in brown
recluse
spiders)
Manifestation
Black widow
spiders are
the most
poisonous;
Brown
recluse
spiders
cause large
wounds
Spider bite

Pain, Urticaria, Stridor
Redness, Swelling
Manifestation
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
area to control swelling
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)
Nursing
Action
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
Manifestation: Intense stinging pain, itchiness and
redness, Nausea, vomiting and diarrhea, Swelling of
lymph nodes, Muscle cramps
Note: Box Jelly fish sting may cause death
in a matter of minutes