Emergency Nursing Part 2

POISONING

- Includes accidental or intentional (overdose) poisoning requiring emergency care has remained a major cause of accidental deaths; having a higher morbidity among children than in adults.

Poisoning in adults commonly occurs from –

 Not checking medication labels (overdose or wrong medication)

 Lack of knowledge – taking alcohol and sedatives together

 Taking an excess amount in an attempt to obtain a desired effect, as in suicide attempt

 Prognosis depends on the amount of poison absorbed, its toxicity, and the interval poisoning and treatment.

• PREVENTION

• Education of the public especially directed towards increasing their awareness of safety hazards in the homes, particularly in homes with children.

• Non-potable liquids should be kept tightly capped in their original containers in places that are not accessible to children and should never be placed in a soft-drink bottle, drinking glass, or cup.

• Read all labels on all medication vials before taking the medication.

• Read labels on all over-the-counter drugs to identify possible hazards.

• Take all medications in the prescribed doses.

– Do not increase dosage outside of stated limits in an effort to increase the desired effect.

ASSESSMENT FINDINGS

– may vary according to the poison

• decreased LOC

• headache

• hypertension

• cardiac arrhythmias

• dyspnea

• seizure

• blisters or erythema

• burning sensation in the throat and mouth

MANAGEMENT – SIRES

• Stabilize the Individual – ABCs, respiratory support, oxygen

• Identify the Toxic Substance – make a rapid examination, obtain appropriate lab studies, obtain an accurate history.

• Reverse the Effect – select appropriate means of reversing or eliminating toxic substances – shower or washing off externally; giving antidotes for injected substances; lavage or emesis for ingested substances.

• Eliminate the Substance from the Body – for non-corrosive ingested substances use

• Support the person/ significant others physically and psychologically.

• Syrup of Ipecac (emetic) – 15 to 30 ml followed by an adequate amount of water – a second dose can be given 20 minutes after the first dose did not induce emesis.

• Gastric lavage/ gut lavage – for those patients with diminished or absent gag reflex.

• Absorptives – to absorb any remaining particles of toxic substances.

• Cathartics – seldom used except with activated charcoal.

• Giving antidotes/antagonists

• For caustic/corrosive substances – such as acids – toilet bowl cleaners, sulfuric acids

Inhaled Poisoning

Carbon Monoxide – one of the most common toxic gases; it cannot be filtered with the use of cloth face mask; Toxicity occurs because of the higher affinity of the hemoglobin for carbon monoxide than for oxygen.

Assessment Findings

1. elevated blood pressure

2. dilated pupils

3. muscular rigidity

4. bounding pulse

Treatment

 Remove person from the site to fresh air

 Give oxygen if possible

 Assess cardiovascular status and start CPR if indicated

 Bring to the hospital

Contact Poison – poisonous substances absorbed through the skin or mucous

membranes

Treatment

1. Rinse off skin or mucous membrane with copiuos amount of water.

2. Remove garments containing the substance and rinse skin again.

3. Place the person in a shower if the body is involved.

Ingested Poison – most common form poisoning by ingestion is by ingestion of

a poisonous substance and ingestion of an excessive amount of drug.

Intervention Guidelines – SIRES

Injected Poisons – toxic substances can be injected through the skin by insect bites or by needle injections.

Treatment – give specific antidotes

For Stinging Insects such as Bees – the symptoms will be related to anaphylactic reactions.

Interventions – Epinepherine; Remove stinger by scraping to prevent squeezing more venom into the skin; Apply paste or baking soda to counteract the formic acid that is present in the venom; Cold application

Food Poisoning – a sudden, explosive illness which may occur after ingestion of food or drink.

Plant Poisoning – especially mushroom poisoning

Symptoms

o nausea and vomiting

o bloody diarrhea

o dehydration

o muscle tremors and weakness

o sweating, lacrimation and salivation

o respiratory and circulatory depression

Treatment

Induce vomiting with syrup of ipecac

Give fluids

Give activated charcoal

Bacterial Food Poisoning

Prevention

 Keep meats, fish, poultry, mayonnaise and cream filled foods refrigerated

 Use slow cooling of meat and poultry

 Discard any can that bulges

 Food handlers should not be allowed to work if they have minor infection on their hand or do not adhere to the requirements for hand washing after using the toilet

 Rigid controls of slaughterhouses

Symptoms

• vomiting

• Diarrhea

Interventions

• no intervention when symptoms are mild

• bed rest

• restore fluid balance

• support the respiratory system

Disasters – are sudden catastrophic events that disrupt patterns of life and in which there is possible loss of life and property in addition to multiple injuries.

Causes Of Disasters

• Natural Disasters

 Air – tornado, hurricane

 Land – earthquake, volcano eruption

 Water – floods, tidal waves

• Man – made Disasters

 Transportation – air, water, land

 Fire – housing, forest, explosions

 Disease – epidemics

 Civil Disorders – riots, wars (nuclear attacks)

Three Types Of Disasters

• Multiple Patient – involve up to 10 people and occur with events such as multiple vehicle crashes, fires, bomb explosion

• Multiple Casualty Disasters – as many as 100 people may be injured in events such as airplane disasters, riots, tornadoes

• Mass Casualty Disasters – large-scale disasters resulting in large numbers (over 100) of injured persons and disruption of community services and resources such as large-scale earthquakes, war bombings

Effects Of Disasters

• People are killed or injured and separated from their family

• People become homeless

• In large-scale disasters, confusion and chaos occur during the early stages. Panic rarely occurs, but when it does, it is because the involved person believe that escape routes are limited and may be closing off

• Transportation difficulties are created as streets and roads become clogged by persons trying to get away from the impact area or trying to get in

• Food, water supplies become contaminated and nonexistent, inadequate medical supplies

Role Of Nurses In Disasters

• Provide triage and first aid in emergency aid stations and hospitals

• Two Different Approaches to Triage of Victims During a Disaster:

• Military Triage System – based on the philosophy of doing the “best for the most with the least by the fewest”. Victims with injuries of such magnitude are given low priority for transportation. In this system the number of critically injured must greatly outnumber the health and transportation personnel available. Victims are reclassified as the emergency situation changes. Priority is given to those victims with the greatest chance of survival.

– Civilian Triage System – more commonly used, giving most priority to life-threatening injuries and least priority to minimal injuries.

• Providing health care at the shelters.

• Providing emotional support to persons at emergency.

PREVENTION OF DISASTERS

• Community planning to identify and prevent the occurrence.

• Education of the public to minimize the number of casualties.

DISASTER SYNDROME –the behavior of victims after the impact of disaster and canbe characterized as progressing through the phase of shock, awareness, euphoria and anger. The victims are experiencing loss; therefore the phases are similar to those experienced by others during any kind of loss (grieving).

ADAPTATION OF LOSS

after large-scale community disasters may differ from

• adaptation to losses under normal life situations because of lack of individual support

• systems as a result of –

• death of the usual support persons

• inability of the usual support persons to provide support because of their own personal losses

• loss of community support systems

• ACUTE BIOLOGIC CRISIS – a severe, decisive or critical period in an individual’s life that could be a life-threatening situation. The care of these patients require the skill of a competent nurse using her critical and careful judgment in prioritizing and planning for the patient care.

• CRITICAL CARE UNIT – a unique environment in which the most sophisticated medical, nursing and technical interventions can be integrated to combat life-threatening illness.

• In any critical setting the goal of nursing remains the same: to provide continuous, optimal nursing care to patients in life-threatening situations, remaining alert to the physiologic, psychologic, and social needs of the patient as an integrated being.

• The NURSING PROCESS is the same in critical care situations as it is in any other patient setting. Management of critically ill patients requires establishing a data base, identifying real and potential problems, delineating priorities, defining outcome criteria, determining goals for intervention, executing the planned intervention and modifying future goals and plans based on outcomes.

• The Assessment Process for the critically ill patient differs from the assessment of other patients only in reference to the types of technical devices available to assist in data collection such as – cardiac monitors, hemodynamics, monitoring lines, and laboratory analyses. These are adjuncts to the direct observational data, which the nurse gathers through a careful history taking and physical examination.

• Nursing Intervention – the ultimate goal of nursing intervention is to promote, sustain and restore optimal levels of physiologic, psychologic and social functioning. However, in a critical care setting, the immediate goal of ensuring a patient’s survival initially determines the priorities intervention: physiologic problems must be addressed first. Once life-threatening stressors have been alleviated, priorities are reorganized and other problems can be addressed.

– The highest priority in caring for a critically ill individual is the maintenance of a patent airway and adequate ventilation.

• CIRRHOSIS – a chronic process or disorder marked by a diffuse destruction of hepatic cells and subsequent fibrous band formation and nodule regeneration. As necrotic tissue yields to fibrosis, liver structure and normal vasculature is altered resulting to an impairment of blood and lymph flow, as well as bile flow, and ultimately causing hepatic insufficiency.

FOUR TYPES OF CIRRHOSIS

• Laennec’s Cirrhosis – caused by chronic alcoholism, nutritional deficiencies or both, which accounts for about one-half of all cirrhosis cases. In this type the liver becomes enlarged and greasy as lipid metabolism changes to fatty infiltrates. In the advanced stages, the liver atrophies and hardens.

• Biliary Cirrhosis­ – leads to jaundice, pruritus, and steatorrhea early in the disease. Fibrosis, ductal cell destruction and inflammation makes the liver enlarged, firm and green.

• Postnecrotic Cirrhosis – caused by hepatic necrosis usually following hepatitis, infection, metabolic liver disease or exposure to hepatotoxins or industrial chemicals. The liver appears small and distorted.

• Cardiac Cirrhosis – can stem from liver congestion caused by severe, chronic right-sided congestive heart failure; mitral or tricuspid valvular disease; wherein the liver becomes congested with blood and edema; hepatic cells become anoxic and die and fibrotic scarring develops.

Assessment Findings

Early and vague GI symptoms include –

• Anorexia

• Indigestion

• Nausea and vomiting

• Constipation or diarrhea

• Dull abdominal ache, possibly with swelling

Respiratory symptoms

• Pleural effusion

CNS symptoms

• progressive symptoms of hepatic encephalopathy, including lethargy, mental changes, slurred speech, asterixis (flapper tremor), peripheral neuritis, paranoia, hallucinations, extreme obtundation and coma.

 

Hematologic symptoms

• bleeding tendencies

• anemia

Endocrine symptoms

• testicular atrophy

• menstrual irregularities

• gynecomastia

• loss of chest and axillary hair

Skin

• severe pruritis

• extreme dryness

• poor tissue turgor

• abnormal pigmentation

• spider angiomas

• palmar erythema

• possibly jaundice

Hepatic symptoms

• Jaundice

• Hepatomegaly

• Ascites

• Edema of the legs

Other symptoms include

• Musty breath

• Enlarged superficial abdominal veins

• Muscle atrophy

• Pain in the RUQ that worsens when the patient sits upright or leans forward

• Palpable liver or spleen

• Temperature of 101o to 103o F (38.3o to 39.4o C)

• Bleeding from esophageal varices

Major Complications:

• Portal hypertension

• Fluid retention (ascities, edema)

• Hepatic encephalopathy (hepatic coma)

TREATMENT

Nutritional Measures

 complete abstinence from alcohol

 diet should contain at least 1 Gm of protein/ kg and 2000 to 3000 cal./day – provided there is no evidence of an impending coma

 supplemtal vitamins – A, B complex, C and K

Management of Vericeal Hemorrhage

• In massive hematemesis or melena – quantitative replacement of blood

• Infusion of vasoconstrictors (Vasopressin IV) – to lower the splanchnic blood flow and portal pressure thus reduce or stop hemorrhage

• Balloon Tamponade – with the use of the Sengstaken-Blakemore gastric tube – a mechanical means to stop vericeal bleeding by compressing on the submucosal veins thereby tamponade the bleeding sites

• L gastric vein occlusion

• Endoscopic sclerosis of the varices

• Emergency surgical shunting procedures – to divert blood into the low-pressure vena caval vein and reduce portal pressure

Management of ascites and fluid retention

• Bedrest

• Strict fluid and sodium retention

• Daily weight

• Diuretics

• Albumin infusion

• Surgical implantation of a plastic shunt between the peritoneal cavity and the SVC

• Therapeutic paracentesis – up to 3 L of fluid is removed over a four-hour period

Management of Hepatic Encephalopathy

• Neomycin (PO) to decrease ammonia production

• Protein is totally removed temporarily from the diet until the patient improves and protein can be tolerated

• Oral or enemas of lactulose to decrease absorption of ammonia

NURSING DIAGNOSES

• Alteration In Nutrition – Less Than The Body Requirements related to excessive ingestion of alcohol and decreased metabolic function of the liver

• Activity Intolerance, fatigue, related to nutritional deficits

• Potential For Fluid Volume Excess related to ascites and sodium retention

• Potential for Injury – Hemorrhage, related to decreased prothrombin production

NURSING INTERVENTIONS

• Check always for bleeding – the skin, gums, stools and vomitus regularly for bleeding.

• Observe closely for signs of behavioral or personality changes – reports increasing stupor, lethargy, hallucinations or neuromuscular dysfunction.

• Assess for fluid retention – weigh the patient daily, measure andominal girth daily, record I and 0

• To prevent skin breakdown associated with edema and puritus, avoid using soap to bathe the patient, use lubricating lotion or moisturizing agent.

• Teach the patient rest and regarding good nutrition which will conserve energy and decrease metabolic demands on the liver.

HEPATIC COMA – This neurologic syndrome develops as a complication of hepatic encephalopathy; resulting primarily from cerebral ammonia intoxication. It may be acute and self-limiting or chronic and progressive. In advanced stages, the prognosis is poor despite vigorous treatment.

ASSESSMENT FINDINGS

Prodromal Stage

• Slight personality changes such as disorientation, forgetfulness

• Slurred speech

• Sight tremor

Impending Stage

• Tremor progresses into asterixis (Liver flap)

• Lethargy

• Aberrant behavior

• Apraxia

Stuporous Stage

• Hyperventilation

• Stuporous but noisy and abusive when aroused

Comatose Stage

• Hyperactive reflexes

• Positive Babinski sign

• Fetor hepaticus (musty, sweet breath odor)

• Coma

INTERVENTIONS – directed to reduce blood ammonia levels

Medications such as

• Neomycin – suppresses bacterial ammonia production

• Sorbitol – to induce catharsis to produce osmotic diarrhea

• Lactulose – to reduce blood ammonia levels

• Potassium supplements – to correct alkalosis from increased ammonia levels

• Salt-poor albumin – to maintain fluid and electrolyte balance

Reducing dietary protein intake

Hemodialysis – can temporarily clear the toxic blood

NURSING DIAGNOSES

• Potential/ Actual Alteration In Cerebral Tissue Perfusion related to ammonia intoxication of the brain tissues.

• Alteration In Nutrition – Excess Protein Intake Than The Body Requirement related to the disease process.

• Potential For Injury related to a decreasing level of consciousness.

• Knowledge Deficit related tp adequate information regarding the treatment options.

NURSING INTERVENTIONS

• Frequently assess and record the patient’s LOC – continually orienting him to the place and time.

• Monitor intake, output and fluid and electrolyte balance – check daily weights, measure abdominal girth.

• Provide a specified low-protein diet, with carbohydrates supplying most of the calories.

• Provide good mouth care.

• Provide rest, comfort, and quiet atmosphere.

• Avoid sedatives, if necessary use restraints.

• If the patient is comatose, provide protection to the cornea by instilling artificial tears.

• Provide emotional support for the patient’s family in the terminal stage of hepatic coma.

• END-STAGE RENAL DISEASE (ESRD) – the last stage of chronic renal failure which represents 90%, leaving only 200,000 nephrons intact. The glomerular filtration rate is decreased to 10% of normal or less. The excretory, regulatory, and hormonal renal functions are severely impaired. The kidney is unable to maintain homeostasis – there is fluid, electrolyte and pH imbalances.

ASSESSMENT FINDINGS

• marked anemia – low RBCs

• marked azotemia – elevated BUN and plasma creatinine

• hypocalcemia

• hyperkalemia

• metabolic acidosis

• calcification of soft tissue – due to increased serum-calcium phosphorous ratio

• calcium mobilization from bone

• fluid overload – the patient has oliguria with water retention

• uremic syndrome develops and all body systems are affected from renal failure

INTERVENTIONS

• Dialysis – hemodialysis or peritoneal dialysis

• Renal Transplantation – living-related donor (has higher patient and graft-survival rates; and cadaveric donor (has higher potential for graft rejection)

NURSING DIAGNOSES

• Potential Altered Nutrition – Less Than The Body Requirements related to nausea, anorexia and altered metabolism ad nutrient intake

• Potential Electrolyte Imbalance related to excess potassium intake and metabolic acidosis; surgery or dysfunctional transplanted kidneys

• Potential For Fluid Volume Excess related to fluid retention secondary to dialysis or nonfunctioning transplanted kidneys

• Potential For Impaired Gas Exchange related to fluid overload

• Potential For Ineffective Coping related to changes one’s lifestyle as a result of the artificial support systems to sustain life

• Self-Care Deficits related to dialysis treatment and surgery

• Knowledge Deficits related to inadequate information on the different treatments

NURSING INTERVENTIONS

• Maintain fluid and electrolyte balance – daily weights, I and O, Monitor laboratory studies, assess for edema

• Monitor for early symptoms of azotemia – assess changes in urine amount and color, urinalysis results

• Nutritional intake – Low protein (to decrease urea and uric acid blood levels), high calories (to spare protein)

• Continuous monitoring and assessment to prevent, multi-system problems such as cardiac, respiratory, GI, etc.