Care of Clients in Cellular Aberrations, Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106) Acute Biologic Crisis III
Multiple Injuries Definition: Requires rapid and definitive intervention during the 1st hour after the trauma to ↑ chances of survival This first hour has been called the “golden hour” During this time, multiple assessment and intervention may be performed simultaneously by the heat care team
Primary Assessment
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Topics Discussed Here Are: 1. Continuation of Trauma: a. Multiple Injuries b. Shock and Internal Injuries 2. Environmental Emergencies a. Heat Exhaustion b. Heat Stroke c. Hypothermia 3. Behavioral Emergencies a. Violent Patients b. Depression c. Suicidal Ideation 4. Sexual Assault Rape 5. Biological Weapons a. Anthrax b. Small Pox c. Botulism 6. Toxicologic Emergencies a. Ingestion Poisoning b. Food Poisoning c. Injected Poisoning d. Skin Contaminated Poisoning / Chemical Burns e. Dru Intoxication Intoxication / Abuse Abuse
AIRWAY Assume a cervical spine injury and open the airway using the jaw-thrust technique without head tilt Apply suction to clear t he trachea and bronchial tree. Remove debris from the mouth (i.e. broken teeth, mucus) Insert an oropharyngeal airway o To prevent occlusion by the to ngue o Used in UNCONSCIOUS PATIENTS ONLY Prepare for endotracheal tube if adequate airway cannot be maintained If upper airway trauma / edema exist, a cricothyroidotomy may be indicated
BREATHING Note the characteristic and symmetry of chest wall motion and patter n of breathing o Assess for open wounds, deformity and flail segments Auscultate the lungs and assess for tracheal deviati on. If a tension pneumothorax is present, the trachea will shift away from the injury Ask the conscious patient if experiencing difficulty in breathing / chest pain with breathing assist the patient ventilators by bag-valve mask Administer O2 by 100% non-rebreather mask / assist Suspend serious intrathoracic injuries if respiratory distress continues after adequate air way has been established Assess the overall effectiveness of ventilations CIRCULATION Assess cardiac function and treat cardiac arrest o Hypoxia, metabolic acidosis, and chest trauma may precipitate cardiac arrest o For cardiac arrest, start closed chest compression and ventila tion Control Hemorrhage o Apply pressure over bleeding points if hemorrhage is overt Expect significant blood loss in patients with fracture to the shaft of the femur, multiple fracture or pelvic fracture Use tourniquet(s) for massive arterial bleeding from extremit ies that cannot be halted with pressure o This practices is controversial, however Prepare for immediate surgical intervention if patient is bleeding internally Prevent and treat hypovolemic shock o Insert at least 2 (sometimes 4) IV lines o Initiate central venous catheter to monitor the patient’s response to fluid infusion To prevent fluid overload and a route for fluid infusion o Fluid restriction
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Ringer’s Lactate / Saline Solution is given for volume replacement until blood is available Administer Blood Massive transfusion have a cooling effect that can cause cardiac irritability and arrest, blood should be warmed! NOTE: Presence / absence of pulses in fractured extremity
NEUROLOGIC Assess level of responsiveness, pupil size and reactivit y, motor power and reflexes Determine a Glasgow Coma Scale as a baseline If signs of ↑ ICP exist o ICP monitoring may be instituted
Subsequent Assessment and Intervention 1. 2. 3.
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Goal: Rapid determination of the extend of the injury and treatment priority Monitor ECG To detect life threatening dysrhythmias Insert indwelling urethral catheter To monitor UO to aid in diagnosis of shock and monitor effects of therapy DO NOT FORCE the catheter, the patient may have a ruptured urethra Perform an ongoing clinical evaluation to observe for improvement or deterioration Such as changes in VS, improvement in level or responsiveness, skin warmth, and speed of capillary filling Prepare for immediate surgical intervention if the patient does not respond to fluid / blood Inability to restore and circulatory volume Splint fracture to prevent further trauma to soft tissue and blood vessels to relieve pain Examine the patient for abdominal pain, rigidity, tenderness, rebound tenderness, diminished bowel sounds, hypotension and shock Prepare for peritoneal lavage or CT Scan to assess intraperitoneal bleeding Draw blood for laboratory studies Type and Cross Match hemoglobin, hematocrit baseline, CBC, electrolytes, BUN, glucose, PT Insert an NGT to prevent vomiting and aspiration Prepare for laporotomy if the patient shows contributing signs of hemorrhage and deterioration Patient is in NPO Continue to monitor UO q30 minutes Reflects CO and state of perfusion of vital organs Assess for hematuria and oliguria Evaluate the patient for other injuries and institute appropriate treatment, including Tetanus Immunizations Perform a more thorough physical examination after resuscitation and management of the aforementioned priorities
Shock and Internal Injuries Definition: Shock is the common denominator in a wide variety of disease process, that presents as an immediate threat to life Simply defined, shock is i nadequate tissue perfusion This inadequate tissue perfusion is the result of failure of one / more of the following\ o The heart = Pump failure o Blood volume o Arterial resistance vessels o The capillaries of the venous beds Any condition that significantly affects any of the above may precipitate a shock state
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Classifications of Shock 1.
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Hypovolemic Shock Occurs when a significant amount of fluid is lost from the intravascular spaces This fluid may be blood, plasma or electrolytes solutions May result from hemorrhage, burns, GI loses or fl uid shifts Cardiogenic Shock Occurs when the heart fails as a pump Primary causes of this failure are; MI, seizures, cardiac dysrhythmias and myocardial depression Secondary causes include; Mechanical resistance of cardiac function / venous obstruction Cardiac tamponade Vena cava obstruction Tension pneumothorax Distributive Shock Septic Shock • Occurs as the result of bacterial and or toxins circulating in the blood • The primary cause is the vasoconstrictive mediators released by gram negative bacteria affecting almost every physiology system • Any septic focus has the potential to produce septic shock Anaphylactic Shock A severe, whole body allergic reaction • After being exposed to a substance like bee sting venom, the person’s immune • system becomes sensitized to that allergen On a later exposure, an allergic reaction may occur, this reaction is sudden, severe • and involves the whole body • Anaphylactic Shock can occur in response to any al lergen Neurogenic Shock • Sometimes called vasogenic shock, results from the disruption of the Autonomic Nervous System’s (ANS) control over vasoconstriction • The veins and arteries immediately dilate, drastically expanding the volume of the circulatory system with a corresponding reduction of blood pressure Other classifications of shock Spinal Shock Insulin Shock
Primary Assessment and Interventions
Rapid recognition and prompt intervention are essential to ↑ the chances of survival because a downward spiral physiologic responses will occur is shock is not treated The initial priorities in the assessment are the same for all types of shock Is the airway open? Is the patient breathing? Is the patient’s circulation problematic?
Subsequent Assessment
Initiate immediate intervention as indicated Resuscitate as necessary Administer O2 Start cardiac monitoring Control hemorrhage Assess Level of Consciousness Important indicator of shock because it re flects cerebral perfusion Change may include Confusion Irritability Anxiety
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Agitation Inability to concentrate Watch for increasing lethargy progressing to obtundation and coma, indicates progression of SHOCK Monitor arterial Blood Pressure Fall in the systolic pressure o There is no absolute value in a blood pressure that indicates a stroke state o It is the deviation from normal that is important o A systolic pressure below 80 mm Hg or a mean arterial pressure below 60 mm Hg is indicative of SHOCK Assess pulse quality and rate change o The rate usually is increased o Weak, thread pulse due to ↓ cardiac output and ↑ peripheral vascular resistance Assess Urine Output o A ↓ in renal blood flow or pressure will result in ↓ UO o Ideally, in an adult, the UO should be 30 – 60 mL/hr o An output of less than 25 mL/hr may indicate SHOCK Assess capillary perfusion o Pale, ashen, mottled, cold and sweating skin indicates potent vasoconstriction o Capillary refill of greater than 2 seconds indicates vasoconstriction Also assess for: o Subjective feelings of impending doom o Metabolic Acidosis due to anaerobic metabplism within cells o Excessive thirst
General Interventions o
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Administer 100% O2 By non-rebreather face mask to maintain the partial pressure of arterial oxygen at 90 – 100% Assist with intubation if the patient is unable to maintain airway Fluid restriction! 2 large bore IV lines should be established Ringer’s Lactate is the initial fluid choice Normal Saline is the 2nd choice, because of hyperchloremic acidosis may develop if • massive amounts of normal saline is i nfused Rate of infusion depends on severity of bl ood loss and clinical evidence of hypovolemia Pack Red Blood Cells (PRBCs) are infused when there is massive blood loss Additional platelet and coagul ating factors are given when large amounts of blood are needed because replacement blood is deficient in clotting factors. WARM the blood Insert an indwelling urinary catheter Record UO q15- 30 minutes Urinary volume reveals adequacy of kidneys and visceral perfusion Maintain patient in supine position with the legs elevated This position is CONTRAINDICATED in patients with HEAD INJURIES ECG Monitoring Dysrhythmias may contribute to shock Maintain ongoing nursing survey of total patient reaction to treatment VS Hct and Hmg Color Coagulation CVP Electrolytes ABGs UO Nursing ALERT! ECG Trendelenburg position is no Immobilize fracture to minimize blood loss longer recommended because of Maintain normothermia the potential for risking Too much heat produces vasodilation, it compromise because of pressure can ↑ fluid loss through perspiration on abdominal organs
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A patient who is in septic shock should be kept COOL because ↑ temperature increases the cellular metabolism effects of shock
Pharmacologic Interventions
Vasopressin may be necessary but not until volume is Antibiotics – Broad spectrum for septic shock
Environmental Emergencies (Heat Exhaustion, Heat Stroke and Hypothermia) HEAT EXHAUSTION Is the inadequacy or the collapse of peripheral circulation due to volume and electrolyte depletion Risk Factors Advanced age Strenuous exercise in heath Anticholinergics that interfere with perspiration Inappropriate clothing Inadequate fluid intake Poor environmental conditions Assessment Skin is usually pale, ashen and moist Body temperature: Normal or as high a s 104°F (40 °C) Assess VS for hypotension, orthostatic changes, tachycardia and tachypnea Check for hemoconcentration Hyponatremia (If Na depletion is the main problem) Hypernatremia (If water depletion is the main problem) Treatment of Nursing Care LOL: Goal: Reduce temperature Drink fluids Move the patient to a cool environment Cold compress Remove all clothing Lie down Provide sponge baths and fans Elevate feet Place patient on a Trendelenburg Position Use a fan to ↓ temperature Monitor patient’s VS IVF of choice: PNSS / Ringer’s Lactate Patient Education Advise the patient to avoid immediate exposure to ↑ temperature Emphasize the importance of maintaining: o Adequate fluid intake o Wearing loose clothing o Reducing activities in hot weather HEAT STROKE It is defined as the combination of HYPERPYREXIA 105°F (40.6 °C) and NEUROLOGIC SYMPTOMS Cause: Shutdown / failure of the heat-regulating mechanism of the body
Primary Assessment -
Assess Airway, Breathing and Circulation Check for Level of Consciousness
Risk Factors 1. 2. 3.
Nursing ALERT!
When the diagnosis of heat stroke is made or suspected, it is imperative to reduce patient temperature!
Advanced age Strenuous exercise in heat Medications such as Anticholinergics that interfere with perspiration
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Subsequent Assessment 1. 2. 3.
Hot, dry, flushed skin progressing to pallor in late circulatory collapse Elevation of body temperature above 105 °F (40 °C) CNS disturbances include: Tremors, seizure, fixed and dilated pupils
Treatment of Nursing Care
Goal: Rapidly reduce temperature Hypothermia blanket Cool water baths Cool enemas Reduce the core (internal) temperature to 102 °F (38.9 °C) Spray tepid water on the s kin while electric fans are used Apply ice packs to the neck, groin, axiallae and scalp IMMERSION IN COLD WATER IS CONTRAINDICATED If the temperature fails to decrease, initiate core cooling: Iced saline lavage of stomach Cool fluid peritoneal dialysis Cool fluid bladder irrigation Discontinue active cooling when the temperature reaches 102 °F (38.9 °C) Administer oxygen to meet the ↑ metabolic demands IVF of choice: Ringer’s Lactate! Medications: Diuretics such as Mannitol (Osmitrol) – to promote dieresis o Monitor the patient for development of seizure Diazepam (Valium) – To control intense shivering ANTIPYRETICS ARE NOT USEFUL IN TREATING HEAT STROKES Differences~ Heat Exhaustion Heat Stroke 1. Moist and dry skin 1. Dry skin 2. Pupillary dilation 2. Constricted pupil 3. Normal / Subnormal Temperature 3. Very high body temperature
HYPOTHERMIA Is a condition in which the core (internal) temperature of t he body is <95 °F (35 °C) as a result of exposure to cold
Risk Factors
Exposure to cold Submersion in cold water Age (Elderly and very young)
Assessment
Locate signs and symptoms Pallor Paresthesia Pain to absence of sensation of invol ved body part Systemic Signs and Symptoms Core temperature < 94 °F (34.4 °C) Weak and irregular pulse ↓ Level of consciousness
Treatment and Nursing Care
Shock: Rewarm without precipitating cardiac dysrhythmias Monitor Core Temperature
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Continually assess cardiac status ABGs Electrolytes Glucose BUN Start appropriate IV line: PNSS DO NOT GIVE RINGER’S LACTATE o Cold liver may not be able to metabolize the Lactate Rewarming Techniques: To prevent cardio collapse Passive External Rewarming (Temperature above 82.4 °F or 28 °C) o Remove all wet / cold clothes and replace with warm clothing o Provide insulation by wrapping the patient in several blankets o Provide warm fluid to drink o Disadvantage: Slow process Active External Rewarming (Temperature above 82.4 °F) o Provide external heat for the patient – warm hot water Do not apply hot water bottles directly to the skin o Warm water immersion o Disadvantage: Causes peripheral vasodilation returning cool blood to the core causing an initial lowering of the core temperature Active Core Rewarming (Temperature below 82.4 °F) o Inhalation of warm, humidified oxygen by mask / ventilator o Warmed IVF and gastric lavage / warmed standardized dialysis solution
Frostbite Definition: A trauma due to exposure to freezing temperature that cause actual freezing of tissue fluids in the cell and intracellular spaces, resulting in vascular damage
Nursing ALERT!
Primary Assessment and Intervention 1. 2.
Extreme caution should be maintained when transporting hypothermia patients since the heart is near fibrillation threshold
Assess Airway, Breathing and Circulation Protect frostbitten tissue while performing other intervention
Subsequent Assessment
Types of Frost Bite Frost Snip o Initial response to cold (Gradual onset) o Signs and Symptoms: Skin appears white; body parts: numb and pain free Superficial Frost Bite o White and waxy skin o Palpation: Stiff skin with pliable sift and normal bounce of underlying tissue o Sensation is absent Deep Frost Bite o White, yellow-white or mottled blue-white skin o Palpation: Both the surface and underlying ti ssue is frozen o The affected part has no sensation
Nursing ALERT! Treatment and Nursing Care 1. 2.
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Frost Snip Place the warm hand over the affected area Superficial Frost Bite Handle the part gently and remove all materials that may impede circulation Deep Frost Bite
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Definite rewarming should be continuous until it is complete Refreezing of partially thawed area reverses ice crystal formation In tissue that may cause further tissue damage
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Rewarming with tepid water 98.6 °F and 104 °F (37 – 40 °C). The rewarming procedure may take 20 – 30 minutes Protect the thawed part from infection Place sterile gauze / cotton between affected finger / toes Elevate the part to help control swelling Use a foot cradle to prevent contact with bleeding Provide appropriate electrolyte Pharmacologic Intervention Opioids pain control Antibiotic if there is an open wound Tetanus Prophylaxis
Patient Education
Reinforce NO SMOKING POLICY because of t he vasoconstricting effects of nicotine which further reduce the already deficient blood supply to injured tissue Elevate the part to help Use a foot cradle
Behavioral Emergency Violent Patient Assessment o Overacting o Aggression o Anger out of proportion to the circumstance Determine Risk Factors for Violence Intoxication with drugs / alcohol Acute paranoid psychosis, paranoia / borderline personality
Treatment and Nursing Care Goal: Take the violence under control Protect patient and staff from harm Establish control Keep the door of the room open and be in the clear view of the staff Give the patient space Do not make any sudden movement Avoid touching an agitated patient / standing too close Ask if he / she has a weapon and request it to place in a neutral area If the patient will not surrender the weapon, leave the room and allow security personnel to take over the situation Try not to leave the patient alone This may be interpreted as rejection of the patient and they may try to harm themselves Adopt a calm approach Provide emotional support. Listen to the patient Acknowledge the patient’s state of agitation (e.g. “I want to work with you, to relieve your stress” Crisis Intervention is best done with an attitude of interest to the patient and with an attempt to “tune-in” to the patient while remaining firm. Provide emotional support Gain the patient’s opportunity to ventilate anger verbally; avoid challenging the delusional state Try to LISTEN what the patient is saying Make the patient aware that help is available to gain control If verbal management techniques fail to attenuate the patient’s tension, administer Tranquilizers Secure assistance
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Use restraints but with minimal force Have a specific plan and well trained personnel available when applying restraints. If patient is intoxicated, restraint in a left lateral position and monitor closely for aspiration Use emphatic and supportive verbal interactions while applying restraints Check circulation of restrained extremities
Depression -
Disorder of mood / affect characterized by feelings of depression, sadness and hopelessness
Assessment
Signs and Symptoms Sadness Apathy Feelings of worthlessness Self blame Suicidal thoughts Desire to escape Worsening of a mood in morning Anorexia Weight loss and sleeplessness
Treatment and Nursing Care -
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Listen to the patient in a calm and unharmed manner Let the patient ventilate with this feelings / give opportunity to talk about problems Anticipate the patient to be suicidal Attempt to find out if the patient has thought about / attempted suicide. “Have you ever thought about taking your own life?” Notify relatives about a seriously depressed patient. Do not leave the patient alone, because SUICIDE is committed IN SOLITUDE Point out to the patient that depression is treatable Refer for psychiatric consultation
Suicidal Ideation -
Is a common medical term for thoughts about suicide which may be as detailed as a formulated plan without the suicidal act itself
Assessment
Assess for psychiatric risk factors Associated psychiatric diseases (e.g. substance abuse, affective disorders) Personality traits such as aggression, impulsivit y, depression and hopelessness Persons who have early loss, ↓ social loss Genetic and familial factors: family history of suicide, certain alcoholism and alcoholic abuse Determine whether patient has committed suicidal intent, such as talking of someone else’s suicide Determine if patient has suicidal attempts. This type of patient has greater potential risk Ask if there is a specific plan for suicide and means to carry out the suicide
Treatment and Nursing Care
Use Crisis Intervention (a form of brief psychotherapy to determine suicide potentials and discover areas of depression and conflicts Prevent further self-injury
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Sexual Assault Rape -
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The management of the sexual assault is important, but immediate physical history should be ensured first A complete primary and focused assessment should take place, being alert for: Signs of internal hemorrhage Shock Respiratory distress If the victim has suffered trauma in the form of physical assault (e.g. head or abdominal trauma) the trauma should be managed in the order of established priorities Initiating a supportive relationship…
Assessment
Patient received and treated in the Emergency Department may affect the psychological well-being of the patient in the future Call the rape council intervention center DO NOT LEAVE the PATIENT ALONE and accept emotional reactions of the patient Emotional trauma may be present for weeks, months, and years Rape Trauma Syndrome The reaction of the patient towards the incident Phases of Rape Trauma Syndrome: (Acute Phase, Denial Phase, Reorganization Phase) 1. Acute Phase Other term is Disorganization Phase Patient is in the state of: 1. Shock 2. Disbelief 3. Fear 4. Anxiety 5. Guild 6. Humiliation 7. Suppression of feelings My last for months to years 2. Denial Phase Unwillingness to talk about the incident ↑ Anxiety and fear Patient experiences 1. Flashbacks 2. Sleep disturbances 3. Hyperalertness 3. Reorganization Phase Putting incident into perspective Signs and Symptoms: 1. Sexual fears 2. Phobias Interview the patient Consent should be obtained before examination Most Emergency Departments have prepared rape evidence collection kit Written protocols for treatment of injuries Legal documents, STDs and pregnancy prevention Remember that the evidence collection kit is meant to preserve for forensic evidence Verbatim transcription of patient history Ask the patient if: o Douched o Bathed o Gargled / Brushed teeth o Changed clothes
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o Urinated / Defecated since the i ncident This may alter interpretation of subsequent findings Record Time of admission Examination date Time of sexual assault General appearance of the patient Document evidences of trauma Bruises Lacerations Secretions Torn bloody clothing (Body diagram) Describe the emotional state of the patient
Treatment and Nursing Care
Preparation for Physical Examination Assist the patient to undress over a sheet / large piece of paper Place a label and clothing in a separate bag o To prevent formation of moist, cold and mildew o It can destroy evidences Inform the patient about the procedure Provide rationale for each questions asked Physical Examination – Head-to-Toe Assessment Assess for external trauma, bruises, lacerations Assess for direct semen stain Inspect fingers for broken nails and tissue and foreign materials Assist in conducting oral examination o To compare with the assailant Obtain saline specimens Pelvic and Rectal Examination Inform patient of the uncomfortable feeling o Examine perineum and thighs by ultra violet light (Wood’s Lamp) Which may indicate semen and urine stai ns o Note color and consistency of discharge if any o Use water moistened vaginal speculum during examination DO NOT USE LUBRICANT CONTAINING CHEMICALS that may interfere with late forensic testing o f the specimens Obtain specimen Collect vaginal aspirate o To check for presence of sperm Obtain separate smears o Oral o Vaginal o Anal areas Obtain swabs of body orifices for gonorrhea and chlamydia o To determine pre-existing infection if sympto ms are not present Trim areas of pubic hair suspected containing semen – LABEL APPROPRIATELY Obtain blood semen for Syphilis Collect foreign materials o Leaves o Grass o Dirt Examine rectum o Signs of trauma o Blood o Stains
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Conduct pregnancy test Label all specimen Name of patient Date and Time of collection Body area from which specimen were obtained Names of personnel collecting the specimen Give the specimen to the crime laboratory Obtain an itemized receipt Photographs should be taken by authorized persons ONLY Other interventions: Treat physical trauma Protect patient from STD Give antibiotic prophylaxis for 7 days o Ceftriaxone o Tetracycline o Zithromax Protect patient against pregnancy Determine if pregnancy existed before the att ack Negative pregnancy test should be obtained before giving post coital contraceptives (e.g. Estradiol) Hormonal Treatment o To prevent pregnancy – Morning Pills Allay fear for HIV by considering prophylactic treatment Offer cleansing facilities o Douching o Showering o Mouth wash Follow-Up Interventions Make a follow-up appointment o Except for patients who have Syphilis o 6 weeks later Inform patient that counseling services are available both to the patient and the family Encourage patients to resume previous functions unless contraindicated Patient should be accompanied by a friend / family when leaving the hospital
Biological Weapons and Preparedness Biological Agents -
Bioterrorism consists of the intentional release of bacteria, virus or toxin intended to cause a wide spread illness or death
Signs of Bioterrorism 1. 2. 3. 4. 5. 6.
Large number of people with similar disease Cases of unexplained illness More severe illness expected for a specific pathogen Illness resistance to treatment Unusual occurrence of disease A single case f unusual disease
POTENTIAL BIOLOGICAL WEAPONS: Anthrax, Small Pox, Botulism Anthrax
Transmission: Consumption of animal products and air borne spores of Bacillus anthracis 1 – 6 days of incubation
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Assessment
Signs and symptoms: Fever Cough Widened mediastinum on chest X-rays
Treatment and Nursing Care
Ensure universal precaution Persons infected with anthrax, treat it with: 500 mg Ciprofloxacin twice per day for 30 days accomplished with 3 doses of vaccine 60 days 500 mg Ciprofloxacin twice per day without vaccine
Small Pox
Transmission Inhaled / direct contact with variola virus 2 weeks incubation period
Assessment
Signs and Symptoms Rash developing then turns to a blister after 3 days through the face, then to the trunk, high fever, fatigue
Treatment and Nursing Care
Isolate the patient until all the scabs have fallen off Hydrate with IV Give Small Pox vaccine within 2 – 3 days of exposure Person who had contact with the patient should be isolated for 17 days
Botulism
Transmission Ingestion of contaminated food infected with Clostridium botulinum
Assessment
Slurred speech N/V Diarrhea Descending muscle weakness
Treatment and Nursing Care
Give antitoxin during early stage o f disease Universal precaution
Toxicologic Emergencies -
The goals of Toxicologic emergencies are the following: 1. Supportive 2. To prevent / minimize absorption and promote excretion 3. TO provide an antidote
Ingestion Poisoning / Swallow Poisoning -
Sudden explosive illness which may o ccur after ingestion of contaminated substances
Primary Assessment
Assess for Airway, Breathing and Circulation
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Maintain an open airway Some substances may cause soft tissue swelling of the airway
Primary Assessment
Identify the poison / brief history taking Monitor neurologic and fluid and electrolyte status Diagnosis: Blood and urine test, serious cases gastric contents can be submitted for evaluation
Treatment and Nursing Care
Administer O2 for respiratory distress Treat anaphylactic shock immediately Minimizing absence of the ingested content For conscious clients: Administer activated charcoal with a cathartic Induction of emesis with syrup of ipecac Minimized absence of the ingested content For obtunded clients: Left side lying position Gastric lavage Minimizing absence of the ingested content For deteriorating patients: Forced dieresis Hemoperfusion Hemodialysis Repeated doses Provide an antidote that will neutralize the poison Psychiatric evaluation
Food Poisoning -
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Sudden explosive illness which may occur after ingestion of food / drink that is contaminated Identify the amount and type of food If possible, bring the food / gastric contents / vomitus / serum or feces to the health care center • for further evaluation Assess fluid and electrolyte balance
Treatment and Nursing Care
Weight the patient for baseline data Medications: Antiemetics Health Teaching: CLEAR LIQUID DIET or LOW RESIDUE DIET
CORROSIVE POISONING Secondary intake of substances that is BASIC / ACIDIC • Alkaline Products: Drain Cleaners (NaOH) Toilet Bowel Cleaners Non Phosphate Detergent (Ex. Surf) • Acidic Products Muriatic Acid Pool, tiles and metal cleaners (Acetic, sulphuric, oxalic, nitric acid) Rust remover
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Assessment: • • •
Identify the substance if it is basic / acidic Note the amount of substance induced Assess for clinical manifestations: Signs and Symptoms Burning sensation where the substance was taken Dysphagia – Due to injuries to tissues Vomiting
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Drooling – Fear of swallowing due to pain produced Destruction of mucosa -
Treatment and Nursing Care • • • •
Dilute the chemical substances with milk or water Avoid inducing vomiting Submit the patient immediately to the nearest health facility When in the hospital: Elective endoscopy Insert an NGT for gastric lavage
NON CORROSIVE POISONING Secondary intake of substances such as chalk / watusi Assessment Identify the substance induced • Treatment and Nursing Care Induce vomiting if the nurse is certain that it is non-corrosive • Bring the container of the i nduced substances Dilute the chemical substances with 3 – 4 glasses of milk / water • • Carry out NGT plus gastric la vage • Induce vomiting using the syrup of ip ecac, Heimlich Maneuver and gag reflex stimulation
Inhaled Poison: Carbon Monoxide Poisoning
Its toxic effects is by binding to circulating hemoglobin to reduce the O2-carrying capacity of the blood The affinity between carbon monoxide and hemoglobin is 200 – 300 times
Assessment •
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Risk Factors: Environmental exposure (Length) Underlying disease such as anemia Respiratory and cardiovascular problems that may aggravate the pati ent’s condition Assess adventitious sounds such as: Stridor = May indicate poisoning is caused by smoke inhalation, rales / wheezes Assess LOC Pink, cherry-red /cyanotic pale skin Diagnostics: ABGs
GOAL: a) Reverse cerebral and myocardial hypoxia b) Hasted carbon monoxide elimination
Treatment and Nursing Care
Administer 100% O2 with a tight fitting mask Obscure for possible signs of respiratory and CNS da mage Obtain arterial blood samples for carboxyhemoglobin levels Normal: Less than 12% Severe: Greater than 30 – 40%
Injected Poisoning (Insect Stings, Snake Bites) 1.
Insect Stings Primary Assessment and Intervention: o Assess Airway, Breathing and Circulation o Assess for anaphylactic reactions and associated signs and symptoms o Remove the stringer immediately through scraping
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Drug of Choice: EPINEPHRINE Administer bronchodilators to help relieve t he bronchospasm o IVF of Choice: Lactated Ringers Subsequent Assessment: o Obtain history of insect stings, previous exposure and allergies o Inspect skin for local reactions (Erythema, pain and edema on site of inj ury) o Continue to monitor BP and respiratory status General Interventions and Nursing Care o Apply ice packs to relieve pain o Elevate extremity with large edematous local reactions o Clean the wound thoroughly with soap and water / anti-septic solution Pharmacologic Intervention: Oral antihistamine for local reactions o Administer Tetanus prophylaxis if not to date Health Education: o When sting occurs, take EPINEPHRINE IMMEDIATELY o Do not squeeze venom sac because this may cause additional venom to be injected o Report immediately to the nearest health facility Bites Primary Assessment and Intervention o Assess Airway, Breathing and Circulation if patient is not alert o Observe for neurotoxicity accompanied by respiratory paralysis, shock, coma, death during severe envenomation o Be prepared to do CPR Subsequent Assessment o Locate bites to the head and trunk may progress more rapidly o Assess for local reactions: Burning pain, swelli ng and numbness o WOF Systemic reactions including: Nausea, sweating, weakness, paralysis, signs of shock and coma General Interventions o Keep the patient calm and rest in recumbent position with the affected extremities o Administer O2 o IVF of Choice: Lactated Ringers o Monitor for bleeding o Administer blood products for coagulopathy o Pharmacologic Treatment: 1. Antivenin and be alert to allergic reactions 2. Vasopressor for shock treatment o o
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Skin Contaminated Poisoning / Chemical Burns CHEMICAL BURNS
Assessment: Assess the severity of the affected area
Treatment -
Immediately expose the skin with running water \ Please keep in mind the safety of the health care provider attending to the patient Standard Burn Treatment: Debridement and plastic surgery (Chronic Burn) Administration of prophylactic medications Schedule a follow-up check up / refer to a Dermatologist for further evaluation
Drug Intoxication / Abuse Assessment and Intervention -
Assess presence and adequacy of respiration Intubate / provide associated ventilation in severe respiratory depressed patients / lacking of cough reflex Pharmacologic Treatment
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Naloxone HCl (Narcan) Identify the amount and type of drug Conduct history taking: Supportive, realistic and emphatic
Subsequent Assessment -
Perform Physical Examination If the patient is unconscious, consider all the possible causes of lo ss of consciousness and monitor levels of level of consciousness Monitor VS Monitor pupils for extreme miosis (pinpoint pupils) which may indicate narcotic overdose Look for needle marks and external evidences of trau ma Perform a rapid neurologic assessment: LOC, pupil size, and reactivity and reflexes Examine the patient’s breath for characteristic odor of alcohol and acetone Keep in mind that many drug abusers take multiple drugs simultaneously Try to obtain history from the patients
General Interventions Goal: A. Support the respiratory and cardio function B. Give definite treatment for drug o verdose C. Prevent further absorption, enhance drug elimination and reduce its toxicity
Stabilize ABC Airway: Insert Endotracheal Tube Breathing: Respiratory rate, ventilatory-ambu-€bag Circulation: CVP line, ECG, Pulse Rate Remove drug from stomach immediately if the patient is conscious, IF unconscious, perform Gastric Lavage In patients lacking gag reflex o r cough / cough reflex, perform this procedure onl y after intubation with cuffed endotracheal tube to prevent aspiration of gastric contents Provide comfort measures If hypothermia / hyperthermia IVF of Choice, if there is Hypotension: PNSS Treat seizure with Diazepam (Valium) and promote seizure precaution
Laboratory: Urinalysis
Provide psychiatric precaution measures to the patient / refer to psychotherapy. Consult if necessary When the patient’s physiologic status is abnormal, refer to the rehabilitation program
SPECIFIC DRUGS: 1. 2. 3. 4. 5.
CNS Stimulants Hallucinogens Opioids Sedatives Alcohol Abuse
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