1.

ED nurses may provide care for patients with cold-related

injuries. Discuss presentation and appropriate nursing care for
these patients.
Hypothermia presentation: Mild – shivering, slurred speech, mental
slowness, diuresis; Moderate – muscle weakness, acute confusion,
apathy, incoherence, decreased clotting; Severe – bradycardia, severe
hypotension, decreased RR cardiac dysrhythmias, decreased reflexes,
acid-base imbalance, decreased pain responsiveness
Hypothermia Care: Mild – remove from cold environment, remove wet
clothing, rewarm patient but monitor for a burn injury; Moderate –
position patient supine, protect from further heat loss, rewarm patient
(trunk first, then extremities) using warm IV fluids, heated oxygen and
heated lavage methods; Severe – extracorporeal rewarming
(hemodialysis and cardiopulmonary bypass as examples)

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2. ED nurses may also provide care for patients with heat-related

co
illness. Discuss presentation and appropriate nursing care for these

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patients.
Heat Exhaustion Presentation: flu-like symptoms headache, N/V,

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weakness, perspiration despite dehydration; Heat Exhaustion Care:
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move to cool area, stop physical activity, remove constrictive clothing,
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give sports drink NOT water, monitor VS, rehydrate with 0.9% NaCl,
and monitor electrolytes
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Heat Stroke Presentation: may have lack of perspiration, temp > 104,
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change in mental status, low BP, high HR, high RR, electrolyte
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imbalances. Heat Stroke Care: make pt NPO, monitor ABC’s, administer

O2, multiple IVs with 0.9% saline, insert indwelling catheter to monior
strict I&Os, cool patient to lower temp
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3. Explain the disaster triage tag system (triage during mass

casualty conditions). Include specific injuries appropriate for each
category.
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Red tag – immediate threat to life (airway obstruction, shock)

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Yellow tag – major injuries that need treatment within 30min to 2 hours
(open fracturs, large wounds)
Green tag – walking wounded (simple fractures)
Black tag – expected and allowed to die (massive head trauma,
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extensive full thickness body burns)

4. Explain the ED three-tiered triage system (triage under normal

conditions). Include specific injuries appropriate for each category.

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 Emergent – life threatening situation such as resp distress, stroke,
chest pain with diaphoresis, active hemorrhage or unstable VS
Urgent – quick tx needed but not life threatening such as severe abd
pain, multiple fractures/displaced fractures, or new onset resp infection
Nonurgent – situations that have little fear of worsening in a short
period of time such as a skin rash, colds, strains/sprains, and simple
fractures

5. What are the priorities for discharging patients if inpatient

beds are needed in a disaster?
Medically stable patients discharge early such as: those admitted for
observation and are not bedridden, those scheduled for discharge and
can be cared for at home, those who have had no critical change in
past 3 days, and those who could be cared for in another facility

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Reference:

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Ignatavicius, D. D., Workman, L. M., & Rebar, C. (2018). Medical- surgical
nursing: Concepts for interprofessional collaborative care, single volume (9th

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ed.). St. Louis, MO: Saunders/Elsevier, Inc.
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