Nursing Care

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Nursing Care Interdisciplinary Roles with
Adult Clients in the Emergency/Disaster
Environment

• Kelle Howard, RN, MSN Modified by
• Darlene M. Wilson, MSN, RN

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Objectives

• Discuss
• Heat Stroke
• Cold Related Emergencies
• Drowning
• Bites/Stings
• Poisoning
• Agents of Terrorism
• Review with regard to each of the said topics
• pathophysiology
• causes
• manifestations potential complications
• treatment interventions
• interdisciplinary management
• Evaluation of Learning
• Case studies

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Heat StrokePathophysiology

• Definition
• Failure of the hypothalamic regulatory process
• Inc. sweating ? vasodilatation ? Inc. RR ? sweat
  glands stop working ? core temp inc.? circulatory
  collapse
• What makes this temperature so dangerous?
• What happens to electrolytes?
• Which ones do you worry about?
• What are some signs/symptoms of these altered
  lytes?
• What are critical labs values for these lytes?

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Heat Strokes/s of electrolyte depletion

• Na lt120 critical
• Change in mental status
• Combative, decreased LOC
• Hallucinations
• Loss of motor control
• Cerebral edema hemorrhage
• K lt2.8 critical
• Hypo-reflexia, muscle weakness
• Respiratory depression
• Diarrhea
• EKG changes

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Heat StrokeCauses

• Development is directly related to
• Amount of time the body temperature is elevated
• What are some common causes?

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Heat StrokeCauses

• Strenuous activity in hot/humid environment
• High fevers
• Clothing that interferes with perspiration
• Working in closed areas/prolonged exposure to
  heat
• Drinking alcohol in hot environment

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Heat StrokeManifestations Complications

• What will your patient look like?

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Heat StrokeManifestations Complications

• Core temp gt 104F
• AMS
• No perspiration
• Skin hot, ashen, dry
• Dec. BP
• Inc. HR
• S/S of what?

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Heat StrokePrognosis

• Related to
• Age
• Length of exposure
• Baseline health status
• Number of co-morbidities
• Which co-morbidities would predispose your
  patient to heat related emergencies?

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Heat StrokeTreatment Interventions

• ABCs must stabilize
• What assessments/interventions will you perform
  initially?
• What do you think the goal of treatment is?
• How would you achieve this goal?

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Heat StrokeTreatment Interventions

• Goal
• Decrease the core temperature
• To what temperature? 102
• Prevent shivering
• Why? thorazine
• How? what med is used? Antipsychotic, CNS
  depression
• Attainment
• Remove clothes, wet sheets, large fan
  (evaporative), ICE water bath (conductive), cool
  IV fluids
• Would you use antipyretics?

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Heat StrokeTreatment Interventions

• Monitor for s/s of rhabdomyolysis
• What is this?
• How would you monitor for this?
• Monitor for s/s disseminated intravascular
  coagulation (DIC)
• What is this?
• How would you monitor for this?

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• Rhabdomyolysis
• Skeletal muscle breakdown
• Monitor ARF cpk, creatinine, urine
• DIC
• Pathological activation of coagulation mechanisms
• Monitor
• bleeding and bruising
• Coags platelets
• ARF what will you see?

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Heat StrokeInterdisciplinary Roles

• Who would be involved in this clients care?
• RN
• MD - which ones?
• RT
• SW why?
• Anyone else?

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HypothermiaPathophysiology

• Definition
• Core temperature less than 95F (35C)
• Core temp lt86F - severe hypothermia
• Core temp lt78F - death
• Heat produced by the body cannot compensate for
  cold temps of environment
• 55-60 of all body heat is lost as radiant
  energy
• Head, thorax, lungs
• Dec body temp ? peripheral vasoconstriction ?
  shivering movement ? coma results lt78F

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HypothermiaCauses

• Exposure to cold temperatures
• Inadequate clothing, inexperience
• Physical exhaustion
• Wet clothes in cold temperatures
• Immersion in cold water/near drowning
• Age/current health status predispose
• What health issues would predispose a patient to
  hypothermia?

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HypothermiaManifestations Complications

• What will your patient look like?

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HypothermiaManifestations Complications

• Vary dependent upon core temp
• Mild (93.2F - 96.8F)
• Lethargy, confusion, behavior changes, minor HR
  changes, vasoconstriction
• Moderate (86F 93.2F)
• Rigidity, dec HR, dec RR, dec BP, hypovolemia,
  metabolic resp acidosis, profound
  vasoconstriction, rhabdomyolysis
• Shivering usually disappears at 92F
• What about each system?
• Profound/(Severe) (lt86F)
• Person appears dead attempt to re-warm to 90F
• Reflexes vitals very slow
• Profound bradycardia, asystole 64.4F, or Vfib
  71.6F usual cause of death?

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Hypothermia ModerateManifestations
Complications

• Hematologic
• HCT inc. as volume dec. ?
• cold blood thickens, thrombus occurs
• Neuro
• Stroke ?
• lack of blood flow due to vasoconstriction/thrombu
  s
• Cardiac
• Irritable myocardium ?
• atrial ventricular fibrillation, MI
• Respiratory
• PE
• Acidosis ?
• lactic acid builds up ? anaerobic metabolism ?
  metabolic acidosis
• Renal
• Dec blood flow, dehydration, rhabdomyolysis ?
• Acute Kidney Injury

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HypothermiaPrognosis

• Dependant upon
• Core body temperature
• Co-morbidities

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HypothermiaTreatment Interventions

• ABCs must stabilize
• What interventions will you perform initially?
• What do you think the goal of treatment is?
• How would you achieve this goal?

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HypothermiaTreatment Interventions

• Goal
• Rewarming to temp of 95F
• Correction of dehydration acidosis
• Treat cardiac dysrhythmias
• Attainment
• Passive active external rewarming
• What are some examples?
• Passive move to warm place dry place
• remove wet clothes, apply
  warm blankets
• Active -- body to body contact, fluid or air
  filled blankets,
• Active core rewarming
• warm IV fluids, heated humidified O2,
• peritoneal , gastric or colonic lavage
• What should be warmed first core or
  extremities?
• Why?

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HypothermiaTreatment Interventions

• Monitor
• Core temp
• for marked vasodilatation hypotension
• After drop
• What is this?
• Teach
• Warm clothes hats, layers, high calorie foods,
  planning

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HypothermiaInterdisciplinary Management

• Who would be involved in this clients care?
• RN
• MD
• PT/OT
• SW
• CM
• RT

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Submersion InjuryCauses Incidence

• 8000 submersion injuries
• per year
• 40 children under 5yrs
• Categorized as
• Drowning
• Near drowning
• Immersion syndrome
• Risk factors
• Inability to swim entanglement with objects in
  water
• ETOH or drug use
• Trauma
• Seizures
• Stroke

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Submersion Injury Pathophysiology

• Definition
• Drowning
• Death from suffocation after submersion in water
  or other fluid medium
• Near Drowning
• Survival from potential drowning
• Immersion syndrome
• Immersion in cold water ? stimulation of vagus
  nerve potentially fatal dysrhythmias
  (bradycardia)

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Submersion Injury Pathophysiology

• Death is caused by hypoxia
• Victims that aspirate
• secondary to aspiration swallowing of fluid
• fluid aspirated into pulmonary tree ? PULMONARY
  EDEMA - HYPOXIA
• Victims that do not aspirate
• bronchospasm airway obstruction ? dry
  drowning - HYPOXIA

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Submersion Injury Manifestations Complications

• What will your patient look like?
• Pulmonary
• Cardiac
• Neuro

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Submersion Injury Manifestations Complications

• Dependant upon length of time amount of
  aspirate
• Pulmonary
• Ineffective breathing, dyspnea, distress, arrest,
  crackles rhonchi, pink frothy sputum with
  cough, cyanosis
• What interventions would you perform?
• Cardiac
• Inc./dec. HR, dysrhythmia, dec. BP, cardiac
  arrest
• Neuro
• Panic, exhaustion, coma

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Submersion Injury Treatment Interventions

• ABCs must stabilize
• What interventions will you perform initially?
• What should you assume with all victims?
• What do you think the goal of treatment is?
• How would you achieve this goal?

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Submersion Injury Treatment Interventions

• Goal
• Correct
• hypoxia
• acid/base balance
• fluid imbalances
• correct dysrhythmias
• Attainment
• Anticipate intubation
• 100 O2 via non-rebreather
• IV access

• Near drowning victims
• Nursing assessment
• Pulmonary Edema
• SPO2

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Submersion Injury Interdisciplinary Management

• Who would be involved in this clients care?
• RN
• MD
• RT
• SW
• Chaplain

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Real Life Drowning Victim

• http//www.youtube.com/watch?vroFGBt8xEisfeature
  related

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Bites StingsPathophysiolgy

• Direct tissue damage is a product of
• Animal size
• Characteristics of animals teeth
• Strength of jaw
• Toxins released
• Death is due to
• Blood loss
• Allergic reactions
• Lethal toxins

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Poisoning

• 1-800-221-1212
• Treatments
• Activated charcoal, gastric lavage, eye/skin
  irrigation, hemodialysis, hemoperfusion, urine
  alkalinization, chelating agents and antidotes
  acetylcysteine (Mucomyst)
• Contraindicated (charcoal gastric lavage)
• AMS, ileus, diminished bowel sounds, ingestion of
  substance poorly absorbed by charcoal (alkali,
  lithium, cyanide)

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Agents of TerrorismTypes

• Bioterrorism
• Anthrax, plague, tularemia, smallpox, botulism,
  hemorrhagic fever
• Chemical terrorism
• Sarin, phosgene, mustard gases
• Radiological/Nuclear terrorism

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Tularemia
Plague
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Botulism The good, the bad the ugly
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Agents of TerrorismTreatment

• Bioterrorism
• Anthrax, Plague, Tularemia
• Treatment antibiotics (streptomycin or
  gentamicin)
• Smallpox
• Treatment vaccine
• Botulism
• Treatment antitoxin
• Hemorrhagic fever
• Treatment no established treatment
• Provided there is sufficient supply treatment
  occurs in a timely manner!!!!!!!

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Agents of TerrorismTreatments

• Chemical Terrorism
• Sarin gas
• Nerve gas (highly toxic)
• Can cause death within minutes of exposure
  paralyzing respiratory muscles
• Treatment antidote atropine 2-PAM chloride
• Phosgene gas
• Colorless gas
• Can cause respiratory distress, pulmonary edema
  death
• Treatment treat S/S, remove from exposure
• Mustard gas
• Yellow/brown in color , garlic like odor
• Can irritate eyes, burn skin and creates
  blisters, damage lungs if inhaled
• Treatment decontamination, treat symptoms

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Agents of TerrorismTreatments

• Radiologic/Nuclear Terrorism
• Radiologic dispersal devices (RDDs)
• Aka dirty bombs
• Made of explosives radioactive material
• When detonated smoke radioactive dust enter
  air
• Treatment limit contamination (cover mouth
  nose) decontamination (shower, proper disposal
  of clothing)
• Ionizing radiation (nuclear)
• Acute radiation syndrome (ARS)
• External radiation exposure

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Radiologic/Nuclear Terrorism(FYI)

• American Nuclear Society
• Extremity (arm, leg, etc) Xray 1 mrem
• Dental Xray 1 mrem
• Chest Xray 6 mrem
• Nuclear Medicine (thyroid scan) 14 mrem
• Neck/Skull Xray 20 mrem
• Pelvis/Huip Xray 65 mrem
• CAT Scan 110 mrem
• Upper GI Xray 245 mrem
• Barium Enema 405 mrem
• A single dose of around 300,000-500,000 mrem is
  usually considered produce death in 50 of the
  cases.

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BioterrorismInterdisciplinary Management

• Who would be involved in this clients care?
• EVERYONE

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Emergency Nursing

• Triage
• Rapid assessment skill to determine acuity
• Threat to life, vision, or limb are treated
  before other patients

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Emergency Nursing- Primary Survey

• Airway, breathing, circulation, and disability
  (ABCD)
• Identifies life-threatening conditions
• Necessary interventions started immediately
  before proceed to next step of the survey

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Primary Survey

• Airway with cervical spine stabilization and/or
  immobilization
• Signs/symptoms of compromised airway
• Dyspnea
• Inability to vocalize
• Presence of foreign body in airway
• Trauma to face or neck (See Notes below for
  Primary Survey)

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Primary Survey

• Maintain airway Least to most invasive method
• Open airway using the jaw-thrust maneuver

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Primary Survey

• Maintain airway Least to most invasive method
  cont.
• Suction and/or remove foreign body
• Insert nasopharyngeal/oropharyngeal airway
• Endotracheal intubation
• Cricothyroidotomy or tracheostomy

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Primary Survey

• Stabilize/immobilize cervical spine
• Face, head, or neck trauma and/or significant
  upper torso injuries
• Remember Cervical Spine Stabilization is
  always part of the primary survey!!!

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Primary Survey

• Breathing Assess for dyspnea, cyanosis
  paradoxic/asymmetric chest wall movement,
  decreased/absent breath sounds, tachycardia,
  hypotension
• Administer high-flow O2 via a nonrebreather mask
• Bag-valve-mask (BVM) ventilation with 100 O2 and
  intubation for life-threatening conditions
• Monitor patient response

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Primary Survey

• Circulation Check central pulse (peripheral
  pulses may be absent because of injury or
  vasoconstriction)
• Assess skin for color, temperature, moisture
• Assess mental status and capillary refill
• Insert two large-bore IV catheters
• Initiate aggressive fluid resuscitation using
  normal saline or lactated Ringers

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Primary Survey

• Disability Measured by patients level of
  consciousness
• AVPU
• A alert
• V responsive to voice
• P responsive to pain
• U unresponsive
• Glasgow Coma Scale Assess arousal aspect of
  patients consciousness (EVM) Note
• Pupils Size, shape, response to light, equality

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Secondary Survey

• Definition Brief, systematic process to identify
  all injuries after key life threats identified
  and treated
• Exposure/Environmental control
• Remove clothing
• Provide temperature controlavoid hypothermia

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Secondary Survey

• Full set of vital signs
• Blood pressure (bilateral)
• Heart rate
• Respiratory rate
• Temperature (rectal)

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Secondary Survey

• Five interventions
• Initiate ECG/EKG monitoring
• Initiate pulse oximetry
• Insert indwelling catheter
• Insert orogastric/nasogastric tube
• Collect blood for laboratory studies

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Secondary Survey

• Facilitate Family presence
• Supported family members during invasive
  procedures or resuscitation Allow family in the
  room when resuscitation is happening. Have a
  staff member at their side explaining what is
  happening.
• Give comfort measures
• Pain management measures

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Secondary Survey

• History and Head-to-toe assessment
• Obtain history of event, illness, injury from
  patient, family, and emergency personnel
• AMPLE
• Allergies, Meds, Past health, Last meal, Events
• Perform head-to-toe assessment to obtain
  information about all other body systems

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Secondary Survey

• Head-to-toe assessment
• Gently palpate with palms check
• Head and spine look for blood/CSF - stabilize
• Chest
• Listen to abdomen first - OR
• Pelvis (avoid rocking)
• Check perineum
• Limbs reduce fractures

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Secondary Survey

• Inspect the posterior surfaces
• Logroll patient (while maintaining cervical spine
  immobilization) to inspect the posterior surfaces
• Ecchymoses, wounds, deformities, spine alignment,
  pain, rectal exam for tone and blood
• Warm patient warm IV fluids

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Secondary Survey

• Evaluate need for tetanus prophylaxis
• Provide ongoing monitoring and evaluate patients
  response to interventions
• Prepare to
• Transport for diagnostic tests (e.g., x-ray)
• Admit to general unit, telemetry, or intensive
  care unit
• Transfer to another facility

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Questions?