Electric Shock/Lightning Injury

KEY QUESTIONS:
Name • Age • Onset • Cause • Vital Signs • Pain Scale • Entrance and Exit Wounds • Oxygen
Saturation

ACUITY LEVEL/ASSESSMENT NURSING CONSIDERATIONS

Level 1: Critical Resuscitation

Apnea or severe respiratory distress Refer for immediate treatment

Pulseless Staff at bedside
Unresponsive Mobilization of resuscitation team
Pale, diaphoretic, and lightheaded or weak Many resources needed
Hypotension

Level 2: High Risk Emergent

Confusion, lethargy, disorientation Do not delay treatment

Severe pain Notify physician
Copyright © 2019. Springer Publishing Company. All rights reserved.

Altered mental status Multiple diagnostic studies or procedures

Weakness, chest pain, irregular pulse, Frequent consultation
palpitations Continuous monitoring
Evidence of burn marks (entrance and/or exit Monitor for internal injury, even if no external
wounds) signs of burn are present
Seizure Perform frequent extremity vascular checks
Age <18 months Obtain 12-lead EKG as soon as possible
History of unconsciousness Observe for entrance/exit burn wounds
Pallor, diaphoresis Start IV line if patient burned or monitoring
Oxygen saturation <92% on room air shows abnormalities
| Electric Shock/Lightning Injury

Level 3: Moderate Risk Urgent

History of cardiac disease Refer for treatment as soon as possible

Exposure to 220-W voltage or greater Monitor for changes in condition
Burn to face Monitor for internal injury, even with no exter-
Bloody/cloudy urine nal signs of burn

(continued )
69

Briggs, Julie K., RN, BSN, MHA, and Valerie Aarne, MALS, BSN, RN Grossman. Emergency Nursing 5-Tier Triage Protocols,
Second Edition, Springer Publishing Company, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/qut/detail.action?docID=5884640.
Created from qut on 2020-02-23 15:52:08.

Briggs37883_PTR_CH21-40_49-88_08-11-19.indd 69 09-Aug-19 5:51:27 PM

 Level 3: Moderate Risk (continued) Urgent

Muscle pain Perform frequent extremity vascular checks

Headache May need multiple diagnostic studies or
Fatigue procedures
Obtain 12-lead EKG as soon as possible
Apply dry dressing to burn wounds
If abnormal vital signs, consider Level 2

Level 4: Low Risk Semi-Urgent

Asymptomatic but parent or patient concerned Reassess while waiting, per facility protocol
Offer comfort measures
May need simple diagnostic study or
procedure

RELATED PROTOCOLS:
Chest Pain • Extremity Injury

NOTES
Copyright © 2019. Springer Publishing Company. All rights reserved.

| Electric Shock/Lightning Injury

70

Briggs, Julie K., RN, BSN, MHA, and Valerie Aarne, MALS, BSN, RN Grossman. Emergency Nursing 5-Tier Triage Protocols,
Second Edition, Springer Publishing Company, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/qut/detail.action?docID=5884640.
Created from qut on 2020-02-23 15:52:08.

Briggs37883_PTR_CH21-40_49-88_08-11-19.indd 70 09-Aug-19 5:51:27 PM