I Ill/Multi-Organ

Nursing Care of Clients with Ufe Threatening Conditions/Acute Y Lecture

· · Acute & Chron Ic •
Problems/High Acuity and Emergency S1tuat1ons, ·ty Sheet
Module #21 Student Act1VI

Class number: _ __
N=3 me. Emroa~\t Lave ~I.!--DlliemJlau.LJ..!IUIUl~ - - -- - - - - -
Date: _ _ _ _ __
Section : \.\S~N ''\ Schedule: _ _ _ __ _ _ _ _ _ _ _ __

Materials:
Lesson title: ENVIRONMENTAL EMERGENCIES (HEAT
Electronic gadget, pen, & notebook
STROKE, FROSTBITE, ANO HYPOTHERMIA)

Learning Targets:
Al the end of the module. students will be able to·
1 Identify the environmental emergencies; Reference:
2 Describe the common causes of these environmental
emergencies: Hinkle, J. L., & Cheever, K. H. (2018).
3 Explain the clinical manifestation of heat stroke, frostbite Brunner & Suddarth's textbook of
and hypothennia; and, medical-surgical nursing (14th ed.).
4. Discuss the nursing management process of client with heal Philadelphia, PA: Lippincott Williams
stroke, frostbite and hypothermia. &Wilkins.
sr

A. LESSON PREVIEW/REVIEW

Let us have a quick review of what you have learned from the previous session. Kindly answer the posted task on the
space provided. You may use the back page of this sheet, if necessary. Here is the task:

List down at least three (3) conditions of a patient who may be at risk for developing MODS.

B. MAIN LESSON

HEAT STROKE is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body.
✓- The most common cause of heat stroke is prolonged exposure to an environmental temperature of greater than
39.2C (102 SF). It usually occurs during extended heat waves, especially when they are accompanied by high
humidity.
✓- People at risk for heat stroke are those:
not acclimatized to heat
those who are elderly or very young
those unable to care for themselves
those with chronic and debilitating diseases
those taking certain medications (e.g., major tranquilizers. antichollnergics, diuretics, beta-blockers)
✓ Exertional heat stroke occurs in healthy individuals during sports or work activities (e.g., exercising in extreme
heat and humidity).
,/ Hyperthermia results because of inadequate heat loss. This type of heat stroke can also cause death.
✓ Another form of heat stroke is heat exhaustion in which the patient's temperature may be normal to 40C (104F).
The patient demonstrates weakness, hypotension, increased heart rate, and increased thirst.

t\ssessment and Diagnostic Findings

Heat stroke causes thermal injurv at the cellular level, resulting in coagulopathies and widespread damage to the heart,
liver, and kidneys. Recent patient history reveals exposure to elevated ambieni temperature or excessive exercise during
extreme heat.

- • i>~,~"IS"I"'~ · ~....~ • • l

This document is the property of f-'H!, lf,11A clJULA I h.Jr:

-------
 - --- - - - -- - - -- -

1\31

. . Threatening Conditions/Acutely Ill/Multi-O

Nursing Care of Clients with Life rgan
5't fons Acute & Chronic - Lecture
Problems/High Acuity and Emergency '~:~
ule 'u21 Student Activity Sheet

Na m e: _ _ _ _ _ __ _ _ __ class num ber: _ __

_ _ _ _ _ _ __ _ ___ _

Sertion: _ __ _ _ Schedule: _ _ __
____ _ __ ___ __ _ _ Date:

hrn•olc:c h1 1- Clllr /
When assessing the patient, the nurse notes
the following tymptoms: .
- - profound central nervous system (CNS) ..
dysfunction (manifested by confumon , dehnum, •zarre behavior coma )
elevated body temperature (4o.s ·c [105"F] or bi '
higher)
hot, dry skin
usually anhidrosis (absence of sweating)
lachypnea , hypotension, and tachycardia

Mana geme nt: The primary goal is to reduc

e the high body temperature as quickly as poss
directly related lo the duration of hypertherm ible, because mortality is
ia.
Simultaneous treatment focuses on stabilizing
basic life support. oxygenation using the ABCs (airway, breathing,
and circulation) of
·
This includes establishing IV acce ss for fluid
administration.
After the patient's clothing is removed, the core
(Internal) temperature is reduced lo 39·c (102"
possible, preferably within 1 hour . F) as rapidly as
One or more of the following methods may be
usE:Jd as prescribed :
o Cool sheets and towels or continuous
sponging with cool water
o Ice applied to the neck , groin , chest, and
axillae while spraying with tepid water
o Cooling blankets
o Immersion of the patient in a cold-wate
r bath (if possible)
During cooling procedures , an electric fan is
positioned so that it blows on the patient to augm
by convection and evaporation. ent heat dis.-sipation
The patient's temperature is constantly moni
tored with a thermistor placed in the rectum,
to evaluate core temperature. bladder, or esophagus
Caution is used lo avoid hypothermia an9 to
prevent hyperthermia, which may recur spon
hours . taneously within 3 to 4
, ------- ~
The cooling process should stop at 38.a·c
(1 02"F) in order to avoid iatrogenic hypotherm
Throughout treatment, the patient's status is ia.
monitored carefully;-irrclUdlflg\ 'ltal-s i-grrs-;-e:e<
myocardial ischemia, myocardial infarction, ;;iindings (for possible
and dysrhythmias), central venous pressure
responsiveness . all of which may change with (CVP), and level of
rapid alterations in body temperature.
A seizure may be followed by recurrence of hype
rthermia.
To meet tissue needs exaggerated by the _h
ypermetabolic condition, 100% oxygen is admi
Endotracheal intubation and mechanical venti nistered.
lation to support failing cardiopulmonary syste
IV infusion therapy of normal saline or lacta ms may be required .
ted Ringer's solution is initiated as directed
maintain adequate circulation . to replace fluid losses and
Fluids are administered carefully because of
the dangers of myocardial injury from high body
poor renal function. temperature and
Cooling redistributes fluid volume from the
periphery to the core Urine output is also meas
because acute tubular necrosis may occur ured frequently ,
as a complication of heat stroke from rhabd
the urine). omyolysis (myoglobin in
Blood specimens are obtained for serial testin
g to detect bleeding disorders , such as disse
coagulation (OIC), and for serial enzyme studi minated intravascular
es to estimate thermal hypo xic injury to the
tissue. liver, heart, and muscle
Permanent liver, cardiac, and CNS damage
may occur.
Additional supportive care may include dialy
sis for renal failure, antiseizure medications
for hypokalemia, and sodium bicarbonate to control seizures, potassium
to correct metabolic acidosis. Benzodiazepine
s (e.g., diazepam [Valium]) or

document is the prop erty of !"Ym.,.ww.--1.. 77

..,...,,..., • ~ -
 162

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic· Lecture
Module #21 Student Activity Sheet

Class number: _ __
l\Jam e:
- - - - - - - - - -- - - -- - - - - - - - - - - - -
Schedule : _ _ _ _ _ _ _ _ _ _ _ _ __
Date: _ _ _ _ _ __
Section ·

regarding the prevention of

chlorpromazine (Thorazine) may be prescribed to suppress seizure activity. Patient education
heat stroke is also important to prevent a recurrence
~n the
FROSTBITE is trauma from exposure to freezing temperatures and freezing of the ~
- -- - - - - --.____
mtescellular spac;es. thrombos is. Body parts most
✓ It results in cellular and vascular damage. Frostbite can result in venous stasis and
frequently affected by frostbite include the feet, hands, nose, and ears.
tissue destruction).
✓ Frostbite ranges from first degree (redness and erythema) to fourth degree (full-depth

Assessment and Diagnostic Findings

or ottl ·1e. The
A frozen extremity may be hard, cold, and insensitive to IO\JC nd may appear white
extent of injury from exposw1f l5cold-is nof always initially kn6wn.
humidity, and the presence
- - The patient history ~hould include environmental temperature, duration of exposure ,
of wet conditions.

Management: The goal of management is to restore normal body temperature.

Constrictive clothing and jewelry that could impair circulation are removed.
patient should not be
Wet clothing is removed as rapidly as possible. If the lower extremities are involved, the
allowed to ambulate .
to 40"C (98.6"F to
Controlled yet rapid rewarming is instituted . Frozen extremities are usually placed in a 37"C
104 · F) circulating bath for 30- to 40-minute spans.
to decrease the
- This treatment is repeated until circulation is effectively restored. Early rewarming appears
amount of ultimate tissue loss.
g process may be
During rewarming, an analgesic for pain is administered as pr~ cribed, because the rewarmin
veiypainful. - - - - - - - -
To avoid further mechanical injury, the body part is not handled.
is elevated to help
Massage is contraindicated,_pnce'rewarmed7 he part is protected from further injury and
control swelling.
dressing is
--- .:?~u,ze or cotton is ~ced _!:~en affected fingers or toes to prevent maceration, and a bulky
placed on the extremity.
agic blebs, which
A foot cradle may be used to prevent contact with bedclothes if the feet are involved. Hemorrh
may develop 1 hour to a few days after rewarmin g, are left intact and not ruptured.
the blister fluid.
Non-hemorrhagic blisters are debrided to decrease the inflammatory mediators found in
g to observe for r.oncomil ant injury, such as soft tissue injury,
A physical assessment is conducted with rewarmin
dehydration. alcohol coma, or fat embolism .
and hypovolemia, which
Problems such as hyperkalemia (e.g., from release of potassium in the damaged cells)
occur frequently in people with frostbite, are corrected .
changes, and tetanus
Risk of infection is also great; therefore, strict aseptic technique is used during dressing
prophylaxis is administered as indicated.
and to control pain.
Nonsteroidai anti-inflammatory medication is prescribed for its anti-inflammatory effects

Addition al measures that may be carried out vvhen appropriate include the following:
tissue to help prevent
Whirlpool bath for the affected body parts to aid circulation and debridement of necrotic
'iiiTecii ofr--
normal circulation and to
Escharotomy (incision through the eschar) to prevent further tissue damage, to allow for '
permit joint motion

- --
Fasciotomy to treat compartment syndrome
--
This document is the property ot l'hii~MA EDUtAII U (-.
·
 163

Nursing Care of Clients with Life-Threatening Conditions/ Acutely Ill/Multi-Organ

✓
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #21 Student Activity Sheet

i\la rne :
Class number: _ __
Section : ____ _ Schedule: _ _ _ ____ ____ ____ __
Date: _ _ _ _ _ __

After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration
function and to prevent contractures. of

Discharge instructions also include encouraging the patient to avoid tobacco, alcohol, and caffeine
because of their
v8soconslrictive effects, which further reduce the already deficient blood supply to injured tissues
~j
1 HYPOTHERMIA is a condition in which the core (internal) temperature is 35 ' C (95' F) or less as a result
of exposure to
cold or an inability to maintain body temperature in the absence of low ambient temperatures.
✓ Urban hypothem1ia (extreme exposure to cold in an urban setting) is associated with a high mortality rate;
elderly
people, infants, people with concurrent illnesses, and the homeless are particularly susceptible.
✓ .Alcohol ingestion increases susceptibility because it causes systemic vasodilation .
✓ Some medications (e.g., phenothiazines) or medical conditions (e.g., hypothyroidism. spinal cord injury)
decrease
the ability to shiver, hampering the body's innate ability to generate body heat.
✓ Trauma victims are also at risk for hypothermia resulting from treatment with cold fluids, un-warmed
oxygen, and
exposure during examination. The patient may also have frostbite, but hypothermia takes precedence in
treatment.

Assessment and Diagnostic Findings: Hypothermia leads to physiologic changes in all organ systems.
There is
progressive deterioration with:
apathy
poor judgment
ataxia
dysarthria
drowsiness
pulmonary edema
base abnormalities
coagulopathy
eventual coma
Shivering may be suppressed at a temperature of less than 32.2C (90F), because the body's self-warmin
g
mechanisms become ineffective.
The heartbeat and blood pressure may be so weak that peripheral pulses become undetectable. Cardiac
clysrhythmias may also occur. Other physiologic abnormalities include hypoxemia and acidosis.

Managem ent consists of removal of wet clothing, continuous monitoring, rewarming . and supportive
care.
Monitoring the ABCs of basic life support is a priority.
The patient's vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (blood
urea
nitrogen, creatinine, glucose, electrolytes), and chest x-rays are evaluated frequently.
Body temperature is monitored with an esophageal, bladder, or rectal thermistor.
Continuous ECG monitoring is performed, because cold-induced myocardial irritability leads to conduction
disturbances, especially ventricular fibrillation .
An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling.

Rewarmin g
·- Rewarming methods include active internal (core) rewarming and passive or active external (spontaneo
us)
rewarming .
 - ! i @ P tlfll8E

Nursing Care of Clients with Life Threatening Conditions/Acutely 111/Multl-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic. Lecture
Module #21 Student Activity Sheet

Class number:

~ ::inion _____ _____ Sche du Ie: Date:

- -- - - -

--- Active internal (core) rewarming-methods are used for moderaje .to_seyere_bypotbe.rrnia_(les a '
y
[82.5"F to 90' F]) and include cardiopulmonary bypass, warm fluid administration, warm humidified oxygen
ventilator, and warmed peritoneal lavage.
- Monitoring for ventricular fibrillation as the patient's temperature i~ cre "es-fro~ 1·c to 32'C (88' F to
90' F) is
essential.
- _!:fil;si'1'.e_m acti1Le__e_~~I ~~arming is used for mild hypothermi (32.2'C lo 35· c O' F to 95'F]).
Passive active rewarming usesover-the-bed heaters to the extremities and increases blood flow to the acidotiG,
anaerobic extremities .
a
T~ cold blood ~rom peripheral tissues has high lactic acid levels. As this blood returns to the core, it causes
s1gmficant-drop m the core temperature (i.e. co,e-iemperatur-e after drop) and can potentially cause cardiac
dysrhythmias and electrolyte disturbances.
Active external rewarming uses forced air warm blankets. Care must be taken to prevent extremity burn from
these devices, because the patient may not have effective sensation to feel the burn.

Supportive Care during rewarming includes the following as directed:

31 ' C
External cardiac compression (typically performed only as directed in patients with temperatures higher than
[88 ' FJ).
Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32 ·c (90' F] experiences
es
spontaneous ventricular fibrillation if moved or touched. Defibrillation is ineffective in patients with temperatur
lower than 31 ' C (88'F); therefore, the patient must be rewarmed first.
Mechanicai ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain
tissue oxygenation.
, as
Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming
described previously .
.Administration of sodium bicarbonate to correct metabolic acidosis if necessary.
Administration of antiarrhythmic medications.
Insertion of an indwelling urinary catheter to monitor urinary output and renal function.

Check for Understanding

the rationale for
1\fter studying the main lesson, you may now answer the following multiple choice questions and provide
each item.

1. The following clients are presented with signs and symptoms of heat-related illness. Which
of them needs to be
attended first?
manifest
A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who
fatigue, hypotension, tachypnea, and profuse sweating.
to view a parade.
8 . An elderly person who complains of dizziness and syncope after standing in the sun for several hours
n , and hot, dry ashen
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordinatio
skin- and whose duration of heat exposure is unknown.
A diaphoresis, and
D. marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor,
tachycardia.
Answer: _ __
Rationale :

... ' ' ·r; ;~ ~ ~~ ~<!'(,J·-:'i'.'\:~ ' :Pl?'Y'f "'.-~ ~-~ ts,·.

f.1is document is the property of PHINl'vlA EDUCATION

 1
lf;IJ

i condi tions/Acutely Ill/Mu lti-Org an

Life Threaten ng Acute & Chronic - Lecture
Nursing Care of Clients with
. d ncv Situat Ions, .
Modu le #ll stude nt Activity Sheet
I Problems/High Acuity an Emerge
I
l Class numb er: _ _ __
I Date: _ _ _ _ _ __

I
Name .
____ _ _ __
_ _ _ _ _ Sched ule: _ _ _ _ __ ___
'-<?c t io n:

. . • · t ntions in the correc t order.

. the followi ng 1n erve
with frostbi te on the feel. Place
2. You are caring for a client
1. Immer se the feet in warm water 100° F to 105°
F (40.6° C to 46.1° C).

'J
>,

.,.~
'
2. Remov e the victim from the cold environ
3. Monitor for signs of compartment syndrome.
4 . Apply a loose, sterile, bulky dressing.
5. Administer a pain medication.
.A 5. 2. 1 3, 4
8. 2. 5. 1, 4, 3
C. 2,1, 5, 3, 4
ment.

D. 3. 2. ·1, 4, 5
,,
Answer: _ _ __
t' Rationale:

~
<
nsive and
~ the emerg ency depart ment unresp onsive , hypote
3. You are caring for a patien t who was brough t into is 106 "F. You suspe ct heat stroke . What
~ that the patien t's tempe rature
~ tachypneic. Upon furthe r asses sment, you realize
J would your priority nursin g intervention be?
j
A Obtain a history from the patient.
of treatm ent.
8 . Take oral tempe rature to monito r effecti venes s
C. Call the family for conse nt to treat.
towels and place a fan on the patient.
D. Take off the patien t's clothing, wrap him or her in wet
Answer; _ _ __
Ration ale:

winter. Which studen t

n how to preven t injurie s from cold expos ure in the
4. An eleme ntary schoo l nurse is teachi ng childre
effecti ve?
statem ent demon strate s that the teachi ng has been
A "Dressing in layers is import ant."
8 . "I will drink lots of water when I exerci se."
C. 'Takin g freque nt breaks will help me rest."
D. "Wearing three pairs of cotton socks is very important."
Answ er: _ _ __
Ration ale:

5. Wtuch client is at greate st risk for heat exhau ztion?

A. 24-yea r-old constr uction worke r
B 34-yea r-old police man
C . 42-yea r-old swimm ing instruc tor
D. 78-yea r-old garde ner
Answer:
Ration ale:·

_.i,j
 166

-Organ
Nursing Care of Clients with life Threatening Conditions/Acutely Ill/Multi
ns, Acute & Chronic - Lecture
Problems/High Acuity and Emergency Situatio
Module #21 Student Activity Sheet

f\Ja me· Class numbe r: _ __

- - -- - - - -
__ Date: _ _ _ __ _ _
<; ectio n· _ _ ___ _ Schedule: _ _ _ __ _ _ __ _ _ _ __

nurse is instructing the student on hovv

G. /J, 16-year-old high school athlete recently suffered heat exhaustion. The school
trates that the teaching is effective?
to PrHvenl a recur rence of this situation . Which student statement demons
.!\ ··1should try to exercise between noon and 3 PM."
8 "I will lirnit my fluids to drinking 'sports' drinks after I exercise ."
'.=: 'Taking frequent rests is impor1ant when working in a hot environm
ent."
D "Wearing dark-colored clothing to defiect the sun away from me will help rne stay cooler "
An swer:
Rationafe_:_ __

nt floor, agitated and confused. After

7. On a hot summer day, an older adult is found by a neighbor lying on the apartme
Upon arrival at the hospital , which action
calling 911 , the neighbor places ice bags to the client's groin area and armpits.
does the emergency department (ED) nurse perfom1 first?
A Administers 2 acetylsalicylic acid tablets (aspirin) orally
B. Checks the client's airway, continuing oxygen by mask
C. Monitors the client's vital signs
D Places a cooling blanket on the client
Answer: _ _ __
Rationale:

ion and a diminished level of consciousness

8. While at a soccer match, a player drops to the ground with heat exhaust
fl_OCj What does the team nurse do first?
A Gives sa!t tablets
B. Moves the player to the shade
C. Places ice packs under the arms
D. Provides a cool electrolyte fluid drink
Answer : - - - -
Rationa le:

who is suffering from a fever?

9 Which of the following nursing interventions is appropriate for a client
~.. Av0id giving the client food
8. Increase the client's fluid volume
C. Provide oxygen
D. All of the above
E. Both B and C
Answer : _ _ __
Rationa le:

'J"(l~ -' 1'9';--r,~ ("(I'~-.. -,. '·'

l'hi ~ ducurnen l is the propeIty of P~1IMVJA EDUCA'IIOf•l

-r .
ti

'I 1

~ Ufl' af C5ffltt wkl\ Hft- Th,utOft"'t Condltfon,/Ac\lttly ID/Mi.lltf .()tp.n

r; - ~ , ,ww.,.,,,
A:t'Ufff ~ (1"C,l tn<Y Situ~tlom. •<U'lt I Cllronl:c • Lt<tute-
Modut. J1 L Scuct.nt Actlvftv $hut

(l,n., numbN

' •11
Date

10 fl c••~t hs~ 91.Sr'!Vi swsabl'lg profusely due to rrte""\se tieat Hi:s overall Mutd volume ,slow and he has devt.!lop.ed
.-t~ r-ltolvt" 1rn!iiil1J'lC!" This cl1en1 ,s m:><-1 lrlte'y s.t",.rr,.g fTOCT'
A f\1_,.1,i1""-.n1 hVP"'r1h9'ffllEI
0 l-tpgJ • "'18 •J!;I IO"
C 4!'BI titrol<!?
C Hn~l C'i'mt'!I
Ani,wttt _ _ _ _
Rationale

C LESSON WRAP-UP

Thinking about Leam ing

MIN UTE PAPER

1 h,r; oltalcyy prov,dea feedback on whether or 11ot you understand the lesson. Use the space provided in this activity
,.:,12,,1lo clrti,w':!r tho following quesllon& Make sure to net miss a tiny detail'

IMHJI w11:, tha most useful or tile most meaningful /h,ng you havo teamed this session?

, Wi:Rt q1mst1011(s) do you have as we end this session'

,lt) \.I\ ~ }\I 1-~1\Jt,. • ! \.l f l- 1•t• \ • -

I fill

1II/Multi-Organ
Nursing Care of Clients with Life Threatening Conditions/Acutely • ct re
Problems/High Acuity and Emergency Situations, Acute & Chronic." ~h~et
Module #22 Student Activity

Class numbe r: _ __
f\l ;i fTIP

Date: ___ ____

~cct irrn: - - -- - Schedule : - - - - -- - - - - - - - - - -

Materials:
Lesson title: STING AND BITES
Electronic gadget, pen, & notebook
Leaming Targets :
Al the end of tho module, students will be able to:
Reference:
1 Define anaphylactic shock;
2 Describe the pathophysiologic process of anaphylactic
Hinkle, J. L., & Cheever, K. H. (2018).
shock ;
Brunner & Suddarth's textbook of
3. Explain the clinical manifeGtation of anaphylactic shock;
and,
medical-surgical nursing (14th ed.).
Philadelphia, PA: Lippincott Williams
4 Discuss the nursing management process of anaphylactic
shock. &Wilkins .

A. LESSON PREVIEW/REVIEW
Kindly answer the posted task on the
Lei us have a quick review of what you have learned from the previous session.
the task:
c,pace provided . You may use the back page of this sheet, if necessary. Here is

Enumerate and briefly explain all the environmental emergencies.

8. MAIN LESSON

STING AND BITES

Insect Stings
Hymenoptera (bees, hornets,
A person may have an extreme sensitivity to the venoms of insects in the order
yellow jackets, fire ants, and wasps). l"t1Ul'lrilolt ob< ~11,rqic r,~cti11n~
an acute emergency. Although stings
~ Venom allergy is thought lo be an lgE!rned1ated reaction , and it constitutes
in any area of the body can triggerin'a°phylaxis, stings of the IJ§~d and neck or multiple stings are especially
~e..dru.l~ - - --
s_th_e_ ~..Q!Q g_nosi s.
Generally, tb_e sh2!1erJbe.tirne-between the sting and the ODset of se,'.ILe. (e sy.rnptom

Clinical manifestations range frorn generalized:

urticaria
itching
malaise
anxiety due to laryngeal edema to severe bronchospasm, shock, and death

Management
is associated with sacs
Management includes stinger removal if the sting is from a bee because the venom
around the barb of the stinger itself.
The stinger is removed with one quick scrape of a fingerna il over the site.
-
~
Wound care with soap and water is sufficient for stings. _§.cmtching is avoided because
· -
it results in a histamine
169

, . h L'f Threatening conditions/Acutely Ill/Multi-Organ

Nursing Care of Chents wit I e . . h •
I . h Acuity and Emergency s,tuat1on s, Acute & C romc · Lecture
Problems Hig Module #22 Student Activity Sheet

Name: _ _ _ ___ _ _ _ _ _ __ _ _ __ __ __ Class number:

---
Schedule· _ _ _ _ _ _ _ _ __ __ __ Date: - - - - - -
-

Ice application reduces swelling and also decreases venom absorption .

.
An oral antihistamine and analgesic will decrease the itching and pain. In the case of an anaphylac
t1c or severe
allergic response , the patient is treated as discussed previously in Chapter 53.
Desensitization therapy should be given to people who have had systemic or significant local
reactions. Patient
and family education is an important measure in preventing exposure to stinging insects (Chart
71-10).

ANIMAL AND HUMAN BITES

Bites are a common reason for visits to the ED. Dog bites constitute 90% of these bites and
are responsible for
lhe majority of deaths from bites by a nonvenomous animal.
Cat bites have a high risk of intection because of the presence of Pasteurella in their saliva.
All animal bites must be reported to public health authorities, which must provide follow-up screening
offending animal for rabies. of the
lf_the animal cann~t-be located and rabies vaccination verified, rabies prophylaxis for the person
who has been
bitten must be instituted. Human bites are frequently associated with rapes, sexual assaults,
battery. or other forms of
The human mouth contains more bacteria than that of most other animals, so a high risk of
bite-related infection
exists.
Depending on the circumstances surrounding the event, the victim may delay seeking treatment
. The ED nurse
should inspect any bitten tissue for pus. erythema, or necrosis.
- j~ health care provider-Should take photographs, which can be used as evidence in criminal and legal
proceedings.
Cleansing with soap and water is then necessary, followed by the administration of antibiotics
and tetanus toxoid
as prescribed

Snake Bites
Venomnus (poisonous) snakes cause 7000 to 8000 bites in the US each year and result in 10
to 15 deaths.
Children between 1 and 9 years of age are the most likely victims. The greatest number of bites
occurs during the
daylight hours and early evening of the summer months.
The most frequent poisonous snake bite occurs from el!.YiPer.s-fCrotalidae).
The most common site is the upper extremity.
Of these bi[es-:Only 20% to25'1/o resulUne nvenomation (injection of a poisonous material by
sting, spine, bite, or
other means). .
Venomous snal<e bites are medical emergencies. Nineteen different species of venomous snakes
are found in
various regions within the US.
Nurses should be familiar with the types of snakes common to the geographic region in which
they practice.
Clinical Manifestations
Snake venom consists primarily of proteins and has a bread range of physiologic effects.
•- It may atfect multiple organ systems, especially the neurologic , cardiovascular, and respiratory
systems.
Classic clinical signs of envenomation are edema, ecchymosis and hemorrhagic bullae leading
to necrosis at the site of
envenomation

Symptoms include:
lymph node
tenderness
nausea
---!Jt111:11:li"l..,<>(t>'' ,. ·• ., . '1:.1 •,; I
Thi~ document is the p1operty 01 F'hlNMA EOUCJi.HOlll

J
 Nursing Care of Cl'ient5 with Life Threatening Conditions/Acutely Ill/Multi-Organ
, Acute & Chronic · Lecture
Problems/High Acuity and Emergency Situations
Module 1122 Student Activ ity Sheet

Class num ber : _ __

'•r·cti on . - - -- Schedult" : Date :

vomiting
11umbness
;;i motallic taste in the mouth

n , hypotension, paresthesia.
h festations may progress to include fasciculatio
Wi! cut decisive treatment, these clinical mani
i;e12.ures . and coma .

Management rictive items such

es having the person lie down, removing const
Initial first aid at the site of the snake bito includ ing. and
ing the wound with a light sterile dress
a:. rings , providing wam,th, cleansing the wound. cover heart.

---
levet..ef the
immobilizin g the i!Jju'u id body_uad..b.elow..the
ation are the priori ties of care-
--· Airway, breathing, and circul
- Ice or a tourniquet is not applie d.
-- - -
ation in the ED is performed quickly and includ
es information about the following:
in1t1al evalu ported to the ED with
nomous; if the snake is dead , ii should be trans
Whether the snake was venomous or nonve
the patient for identification.
ling the transported snake.
However. caution should be taken when hand
the snake in a stunned, not dead, and state.
Frequently , the patient and family transport
stances of the bite
Where and when the bile occurred and the circum and nearby
and symptoms (fang punctures, pain, edema, and erythema of the bite
Sequence of events, signs
tissues)
Severity of poisonous effects
Vital signs mity that was bitten
at several points: the circumference of the extre
Circumference of the bitten extremity or area
site extre mity
is compared with the circumference of the oppo
data (complete blood count , urinalysis, and coagulation studies)
Laboratory on Iha body the
s depe nd on the kind and amount of venom injected, where
Tl1e course and prognosis of snake bite injurie
and size of the patient.
bite occurred, and the general health , age,
of snake bites.
Ttiere is no one specific protocol for treatment stage .
hepa rin, and corticosteroids a(e not used during the ac:.ite
- Generally, ice, tourniquets, bite becau se they may depress antibody
6 to 8 hours after the
Corticosteroids are contraindicated in the first and used to treat
(antitoxin manufactured from the snake venom
production and hinder the action of antivenin
snake bites) . ension, their use
ension. If vasopressors are used to treat hypot
Paren teral tluids rnay be used to treat hypot ted. Typically, the patien t is observed closely
the bite is rarely indica
should be short term. Surgical exploralion of
unattended.
for at least 6 hours . The patient is never left bites.
gh envenomation 1s rare, ii can occur with snake
Administration of Antivenin (Antitoxin) althou derin g admin istration of antivenin.
toms is essential before consi
An assessment of progressive signs and symp er than 12 hours after the snake bite.
4 hours and no great
which is most effective if adrninistP.red wiihin

Two antivenins are available:

Antivenin Polyvalent (ACP) and
(FabAV)
Crota lidae Polyvalent Immune Fab Antivenin
type of snake and the estimated i;everity of the bite.
The dose depends on the and systemic reaction .
ession of symptoms. including coagulopathy
Indications for antivenin depend on the progr

ATll)N
1hi, cJccurne nt is the property of PHIN MA EDUC

1ms aotornent 1s the prope 1ty of P! .!, 1/JIA c:u ULA, 1vr:
17 1
. C dltions/Acutely 111/Multl·Organ
Nursing Care of Clients with life lhreatenin:.t;;tions Acute & Chronic. Lecture
Problems/High Acuity and Emergency •Module ,#22 Student Activity Sheet

Cla~s number:
_ __ _ _ _ __ _ __ _ _ __ _ _
"'! cirn E." _ _ __ _ __
Date: ___ _ _
.::L,rtion _ _ _ _ _ Schedule · _ _ __ _ _ _ _ _ _ __ __
_

. . ore susceptible to the toxic

8Jildren ma}' require ~ antivenin than adults because their smaller bodies are m
effects of venom . . because as many
allergy to the anlive~i~ .. fons to it.
A skin or eye test should be performed before the initial dose to detect I
rived antivenin) develop hypersen sitivity reac f nin will
as 33% of patients who are given ACP (horse serum-de
tic reaction, patients should not be tested unless an ive
Because even the skin test can cause an anaphylac
most likely occur. . th
be given If the dose exceeds 10 vials, 5erum sickness will
that results in fever, arthralgia s, pruntus, lymphade nopa Y,
Serum sickness is a type of hypersensitivity response
and proteinuria and can progress to neuropath ies.
However, FabAV
t2bAV is more potenLihan ACP, with less associated hypersensitivity and serum sickness.
yto patients receiving anticoagu lation therapy. Administr ation of FabAV may result
must be administered cautiousi
in a recurr111g coaguiopathy
before the
The dosage and administration of FabAV are different from ACP and should be reviewed carefuily
. the circumfer ence of the
medication is given Before administering antivenin and every 15 minutes thereafter
affected part is measured.
these
~ medication with dip!l_enh~ramine (Benadryl) or cirnetjdine (Tagamel) is indicated because
antihistamines may decrease the alT~rg1c response to antivenin. "'
be used.
Antivenin is administered as an IV infusion whenever possible, although IM administration can
is diluted in 500 to 1000 ml of normal saline solution.
Depending on the severity of the snake bite, the antivenin
after 1 0 minutes if there is no reaction. The total dose
The infusion is started slowly. and the rate is increased
should be infused during the first 4 to 6 hours after the bile.
The initial dose is repeated until symptoms decrease .
30 to 60 minutes for
After symptoms decrease, the circumference of the affected part should be measured every
the next 48 hours to detect symptoms
~~~~-
of.Eg.mpa rtment syndrome
-
(swelling, loss

1Jle.most..common_ca!J§~_ou 1Jergic reaction to the antivenin is too-rapid infusion, although

of pulse, increased pain, and

about 3% of patients
with negative skin test results develop reactions unrelafea 1oinfusio n rate.

Reactions may consist of a feeling of:

fullness in the face
urticaria! and pruritus
malaise
apprehension
These symptoms may be followed by tachycardia, shortness of breath, hypotension, and shock.
red. Vasopressors are
In this situation. the infusion should be stopped immediately and IV diphenhydramine administe
resuscitation equipment must be on standby while antivenin is infusing.
used fOi patients m shock, and

Spider Bites
the brown recluse
There are two venomous spiders found in the United States that typically interact with humans:
-
and the black widow.
places such as closets, woodpiles . and attics, as well as in shoes.~
Both are usually found in dark
~ sinless.
within 24 to 72 hours.
- Systemic effectSSLi"cfi"as fever & chills. nausea & vomiting malaise, and joint pain develops
Ne~rosis oc~urs in the next 2 to
The site of the bite may appear ~ i t h 1 n~ r the bite.
4 days m approximately 10% of cases. Ih,e center-of tbe6ite-may become
necrotic, and surgical debndement may be
treatments may be helpful.
necessary. Wound care consists of cleansing with soap and water, and hyperbanc oxygen
 \og \,.V' p..1.,v• \ t'\""

, 1fe ihreaten situations ,1121 studefl

~"'('I/ J .,lo

• . s/A cute IYIll/M ulti-Organ

. life Threatening Cond1t1on
, ts with
Nu rs Ing Care of Clien Chronic . lectu re
b /High Acuity and Emergen cy Situations, Acute &
Pro fems
Module #22 Student Activity Sheet

Class number: _ __
I\Jame·
Date : _ _ _ _ __
Sectirm · - - - - - Schedule : - - - - -- - - - - - - - - - -

Check for Understanding provide the rationale fer

st g the main lesso n, you may now answ er the following multiple choice questions and
After udyin
'3ach item.
. The cat is up-to-date immuniza\,ons. The
1 You are assessing a patient who has sustained a cat bite to the left hand ing diagnosis?
own. Which of the following Is the p1 iorily nurs
date of the patient's last tetanus shot is unkn
tial tendon damage.
A. Risk for Impaired Mobility related to poten
d to organisms spec ific to cat bites .
B. Risk for Infection relate
immunization status.
C. Ineffective Health Maintenan ce related to
wounds.
D. Impaired Skin Integrity related to puncture
Answer:
---
Rationale :

s calls for advice, reports parn

ned to telep hone triage . A patient who was stung by a common honey bee
2. You are assig hylaxis. Whal is the action that
local ized swelling, but denie s any respi ratory distress or other systemic signs of anap
and
you should direct the calle r to perfonn? C. Call 911 .
A. Remove the slinger by scraping. D. Apply a cool compress.
B. Take an oral antihistamine
Answer: _ __
Ration.:tfe:

he was just stung by a

health care provider and tells the nurse that
3 A client calls the office of his primary care the client's neighbor experienced such a
lebee while gard ening . The clien t is afraid of a severe reaction, because
bumb
ng action is lo:
reaction just 1 week ago The appropriate nursi
the site in hydro gen peroxide.
A Advise the client to soak
he ever susta ined a bee sting in the past.
B Ask the client if
port to the emergency room
C Tell the client to call an ambulance for trans
unles s difficulty with breathing occurs
D. Tell the client not to worry about the sting
Answer: _ __
Rationale:

following information would

of children about Lyme disease Which ol Iha
~- The camp nurs~ prep~res to instru ct a group
tne nurse include rn the mstructions?
by deer.
A. Lyme disease is caused by a tick carried
ed by contamina tion from cat feces .
8 Lyme disease is caus
contact with an in fected individual.
C Lyme disease can be contagious by skin
ation of spores from bird droppings .
D. Lyme diseast;') can be caused by the inhal
Answer: _ __
Rationale :

- - . am,:..,,.,,~ . ·,,.,, J' ""' ~-~

fOUCA r:L1,,:
Thi.s document I, tne prop euy of ~•1•1r·~ '/!/.\
 Nursing care of Clients with Life Threatening Conditions/Acutely 111/~ultl-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic· Lecture \
Module #22 Student Activity Sheet

Narne· Class number: _ __

- ---
--'b
"01h<c51' - - - - Schedule :
--- - --- ---- - Date:

Most wounds heal within 2 to 3 months. Black widow spider bites feel like pinpricks. Systemic
effects usually occur
within 30 minutes-much more rapidly than with brown recluse spider bites.

Signs and symptoms include.

abdominal rigidity
nausea and vomiting
hypertension
tachycardia
paresthesia
severe pain also develops within 60 minutes and increases over 1 to 2 days

Treatn:i~nt in~olv~s _applicaUon of ice to the site to decrease systemic toxin delivery. Cardiopulmonary
monitoring is
essent1a1. Antivenin Is effective for black widow spider bites. This antivenin is horse serum-ba
sed; therefore, testing for
sensitivity must be performed prior to administration.

Tick Bites
This is common in many areas of the US, and they usually occur in grassy or wooded areas.
It is important to learn the place where the bite occurred as well as the location of the bite on
the body.
The patient may demonstrate weakness ; joint pain; skin rash, especially on the palms and soles
of feet;
headache; and fever.
Ticks can carry diseases such as Rocky Mountain spotted fever, tularemia, and Lyme disease.
The tick bite itself is not usually the problem; rather, it is the pathogen transmitted by the tick
that can cause
serious disease.
The tick should be removed , and the patient should be informed of the signs and symptoms
of diseases carried
by ticks, especially if the patient lives in an area endemic for tick-related diseases (e.g., Lyme
disease).
Lyme disease has three stages:
Stage I presents with a "bull's eye" rash (i.e., erythema migrans) that typically can be found in
the axilla, groin, or
thigh area and that appears within 4 weeks after the tick bite, with a peak manifestation time
of 7 days after the
bite. Classically, this rash is at least 5 cm in diameter with bright red borders.
0 It is accompanied by flulike signs and symptoms that may include chills, fever, myalgia, fatigue,
and
headache. Without treatment , the rash subsides within 3 to 4 weeks.
o However, the rash and flullke manifestations can be signlficanUy reduced within days if prompt
treatment
with antibiotics is initiated. If antibiotics are not administered,
Stage II Lyme disease may present within 4 to 10 weeks following the tick bile and may manifest
with joint pain,
memory loss, poor motor coordination, and meningitis . . .
Stage Ill can begin anywhere from weeks to more than cl year after the bite and has senous .
long-term chronic
sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

~ , , . ~_,....,.....,...., , ~. ........ - ~ ·-- -·

•, . L ,_ ,• , t ; •~ 1: 1.,~ 1~ e ~ o,J~., , .. . . . :.,,, ._ .... 1.. ...... ,.~ . . . {
 - - -
-•-<'<~ • ,....,. ,___.,_.._.,. w.,_ _, _~ ~

~ /'
~

F~
I 1"

/ Nursing Care of Clients with Ufa Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic· Lecture
Module #22 Student Activity Sheet

Name.
Class number: _ __

Sect ion : Date : _______

Schedule:
- - - - - --
5 The client IS d1agn d · · · f th'
stage? ose with stage f of Lyme disease. The nurse assesses the client for which charactenshc o is
A Arthralgias
B. Flu-like symptoms
~ - E~larged and inflamed joints
D Signs of neurological disorders
Answer:
htltionale: ---

6 A camp nurse is providing snakebite prevention tips. Which statement indicates a need for additional education?
a. "'A dead snake is a safe snake."
b. "Snakes are most active on warm nights."
c. "Snakes should be transported in sealed glass containers."
<i "Venomous snakes are not good pets."
Answer: _ _ __
Rationale:

7. A 12-year-old client comes to the emergency department (ED) after being bitten by a scorpion at a local petting zoo.
Which action does the nurse perform first?
A. Administers tetanus shot
8. Applies an ice pack to the sting site
C. Assesses the client's vital signs
D. Calls the poison control center
Answer: _ _ __
Rationale:

8 A nurse is teaching a class of park rangers-in-training about prioritizing care for clients who have received snakebites.
Which ranger's statement demonstrates a need for further clarification'?
A. "Do not allow the client to ingest any alcohol or caffeine."
B. "The extremity should be kept below the level of the heart."
C. "'The first priority is to move the client to a safe area away from the snake."
D. "You should ti rst place a tourniquet above the bite."
Answer: _ _ __
Rationale:
 i 7$

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #22 Student Activity Sheet

I Jc1nir::, Class number: - - -

_ _ _ _ Schedule: ____ ______ _ _____ Date: _______

9 While on the playground, a school child is stung by a bee, resulting in redness and swelling. The school nurse is nearby
,,hen It happens. What does the nurse do firnt?
A .l\pp!ies an ice pack to the stinger
B. Gently scrapes out the stinger with a credit card
C Injects the child with an epinephrine pen (Epi-Pen auto-injector)
D. Removes the bee and saves it for evidence of the sting
Answer: _ __
Rationale:

10. A young man is brought lo the Emergency Department after receiving multiple fire ant bites while working in his yard.
Although initially alert and oriented, he begins to develop wheezing and on itchy throat. He complains of nausea and
severe anxiety. The ED nurse should prepare to administer all of the following for initial treatment , except:
A Adrenaline C. Oxygen
B. An tibiotic D. Antihistamines
Answer: _ __
Rationale:

C. LESSON WRAP-UP

Thinking about Learning

CAT 3-2-1
This strntegy provides a structure for you lo record your own comprehension and summarize your learning. Let us see
your progress in this chapter!

Three things you teamed:

1.

2.

Two things that you'd like to learn more about:

2.

Ona question you still have:

1.

I I -~~~ ~- ~..~ , ~ - T '""'!i';P";.

~1'!{~3i#ii1ililM Si " T , l ; : ~ l \ ~ ~..., ~ r:-rr:

f his docurnen t. is the property of PHINMA EDUCATION

 rrn
Nursing Care of Clients with life Threatening Conditions/Acutely Ill/Multi-Organ
~~ -~ . . '""'""' '"",.,. . & Ch ro nic - Lecture
'114' Pl IINMA I 11UCAflON Problems/High Acuity and Emergency Situations, Acute
Module #23 Student Activity Sheet

Class number: _ __
N;ime .
- - -- - -
Date: _ _ _ _ _ __
:,Prt ,on· - -- - - Schedule:

Materials:
Lesson title: POISONING, NEAR DROWNING AND
Electronic gadget. pen. & notebook
DECOMPRESSION SICKNESS

Learning Targets:
Reference:
.LI.I the end of the module, students will be able to·
1. Describe the effects of poison lo a patient's body;
Hinkle. J. L., & Cheever. K. H. (2018).
2. Enumerate the immediate emergency treatment of poison,
Brunner & Suddarth 's textbook of
3 Define near drowning;
4 Discuss the therapeutic management goals of drowning:
medical-surgical nursing (14th ed.).
Philadelphia, PA: Lippincott Williams
and.
&Wilkins.
"''' b. Explain assessment findings of decompression sickness.

A. LESSON PREVIEW/REVIEW
task on the
Let us have a quick review of what you have learned from the previous session. Kindly answer the posted
5:pc1ce provided You may use the back page of this sheet. if necessary. Here is the task:
ij

Write the three classic clinical signs of envenomation.

8. MAIN LESSON

POISONING
the body in
✓ A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within
relatively small amounts, injures the body by its chemical action.
a major
✓ PoisQDingJro1DlD.haJgtion and inges~on of toxic materials.J:1ot~ intentional and unintentional, constitutes
,/ health hazar~ aQ_,emergency, sj t1,1atioJ1. -

Emergency treatment is initiated with the following goals:

To remove or inactivate the poison before it is absorbed
To provide supportive care in maintaining vital organ function
~ To administer a specific antidote to neutralize a specific poison
~ To implement treatment that hastens the elimination of the absorbed poison

Ingested (Swallowed) Poisons

tissue
Swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid agents that can cause
destruction after coming in contact with mucous membranes
Alkaline products include lye, drain cleaners, toilet bowl cleaners , bleach, non-phosphate detergents, oven
cleaners, and button batteries (batteries used to power watches, calculators, or cameras).
Control
Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid
renal damage, the patient's
of the airway, ventilation, and oxygenation are essential. In the absence of cerebral or
prognosis depends largely on successful management of respiration and circulation.
Measures are instituted to stabilize cardiovascular and other body functions. ECG, vital signG, and neurologic
status are monitored closely for changes.

a a +alll!.:lJ!t:'" "':. • -r'? • ·· • · •·

This document ls the property of ~,11,..,:v,A 1.LJUt.A I 11.,,,.
 177

111/MLllti-Organ
Nursing Ca " 0 f Cl' Condl tions/AcutelY nlc • Lecture
r• rents with Life Threatening
Situations, Acute & ct,roctlllit'Y Sheet
Problems/liigh Acuity and Emergency
Module #23 Stude nt A

Name :
- -- - -- Class number: - - -

SPctron: Schedule:
- --- -- - --- Date: - - - - - - -

s pooling in the lower

Shock _ dio depressant action of the substance ingested. from ven~u
rr_iay result from the car_
g from increased capillary permeability.
extremitie~, or from reduced circulating blood volume resultin
1ndwell,ng ~nnary catheter is inserted to monitor renal function. Blood specimens are obtained to determine
An
the concentration of drug or poison .
Eff?rts are made_to determine what substance was ingest ed, the amount; the time since ingestion: age and
weight of the patient: and pertinent health history.

Signs and Symptoms:

pain or burning sensations
any evidence of redness or burn in the mouth or throat
pain on swallowing or an inability to swallow
vomiting
droolin g

its absorption.
Measures are instituted to remove the toxin or decrease
can be a strong acid or alkaline substance, is given water
- The patient who has ingested a corrosive poison , which
or milk to drink for dilution.
airway edema or obstruction or if there is clinical
- However. dilution is not attempted if the patient has acute tion.
evidence of esophageal. gastric, or intestinal burn or perfora
as prescribed:
Th€! following gastric emptying procedures may be used
Syrup of ipecac to induce vomiting 111 the alert patien t (o.ever use-with-corrosLve poisons)
saved and sent to t~ ratory for testing (toxicology
Gastric lavage for the obtunded patient; gastric aspirate i5
screens)
is absorbed by charcoal
Activated charcoal administratio n if the poison is one that
Cathartic, when appropriate
te), it is administered as early as possible to
If there is a specific chemical or physiologic antagonist (antido
reverse or diminish the effects of the toxin.
If this measure is ineffective. procedures may be
initiated to remove the ingested substance.
s),
of charcoal, diuresis (for substances excreted by the kidney
These proce dures 111clude administration of multiple doses
dialysis, er hemoperfusion.
sing it through an extracorporeal circuit and an
Hemoperfusion involves detoxification of the blood by proces
the cleansed blood is returned to the patient.
adsorbent cartridge containing charcoal or resin. after which
and fluid and electrolyte balance are monitored closely .
Throughout detoxification, the patient's vital signs, CVP,
Hypotension and cardiac dysrhithmias are possible.
the poison or from oxygen deprivation. If the patient
Seizures are also possible because or CNS stimulation from
complains of pain, analgesics are administered cautiously.
on or normal physiologic functions.
Severe pain causes vasomotor collapse and reflex lnhibiU
is imminent, written material should be given to the
After the patient's condition has stabilized.and discharge
ms related to the poison ingested and signs or
patient indicating the signs and symploms of potential proble
sympioms requiring evaluatiori by a physician
attempt, a psychiatric consultation should be requested
If poisoning was determined to be a suicide or self-ha rm
before the patient is discharged.
and home poison-proofing instructions should be
In cases of inadvertent poison ingestion, poison prevention
provided to the patient and family.

I
l_
 -- - J · - - - - --

17 (l

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic· Lecture
Module #23 Student Activity Sheet

l\l ~rne Class number: _ _ _

Date: _ __ _ __ _
~-,-rtio r, - - -- -- Schedule :
- - - - - - - -- - - - - - -

. CARBON MONOXIDE POISONING

implicated in more deaths
This may occur as a result of industrial or household incidents or attempted suicide. It is
than any other toxin except alcohol
the oxygen-carrying
" Carbo_n monoxide exerts its toxic effect by binding to circulaling hemoglobin and thereby reducing
readily than it absorbs oxygen
capacity of the blood. Hemoglobin absorbs carbon monoxide 200 times more
Carbon monoxide-bound hemoglobin. called carboxyhemoglobi n. does not transport oxygen.
,/

Clinical Manifestations:
Because the CNS has a critical need for oxygen, ~ ptoms predomiAate.withJ;arbon mowxida.toxicitt_
A person with carbon monoxide poisoning may ae pe~r intoxicate d (from cerebral hypoxia).
Other signs and symptoms include headache , muscu ar weakness . palpitation . dizziness , and confusion , which
can progress rapidly to corna.
sign.
Skin color, which can range from pink or cherry-red to cyanotic and pale, is not a reliable
because the hemoglob in is well saturated . It Is not saturated with oxygen, but the
Pulse oximetry is also not valid.
carbon monoxide
pulse oximeter indicates only if the hemoglobin is saturated. in this case. ii is saturated with
rather than with oxygen.

Managem ent
Exposure lo carbon monoxide requires immediate treatment.
. Goals of management are to reverse cerebral and myocardial hypcm_a _amLto hasten eliminatio
- - -
n of car:boo._
mo.noxide.
Whenever a patient inhales a poison, the following general measures apply:
- Carry t~e patient to fresh air immediately; open all doors and windows
L0osen all tight clothing.
Initiate cardiopulmonary resuscitation if required: administer 100% oxygen.
Prevent chilling; wrap the patient in blankets.
Keep the patient as quiet as possible.
with carbon
Do not give alcohol in any form or permit the patient to smoke. In addition, for the patient
and before treatment with
monoxide poisoning, carboxyhemoglobin levels are analyzed on arrival at the ED
oxygen if possible.
hypoxia and
100% oxygen is administered at atmospheric or preferably hyperbaric pressures to reverse
accelerate lhe elimination of carbon monoxide.
. Oxygen ii; administered until the carboxyhemoglobin level is less than 5%. The patient is
visual disturban ces, and deterioration of mental
monitored continuously .
status and behavior may
Psychoses, spastic paralysis, ataxia,
persist after resuscitation and may be symptom s of permanen t brain damage.
. When unintentional carbon monoxide poisoning occurs. the health department should be
contacted so that the
if poisoning was
dwelling or building in question can be' inspected. A psychiatric consultation is warranted
r
determined to be a suicide attempt.

SKIN CONTAMINATION POISONING {CHEMICAL BURNS)

✓ Skin contamination Injuries from exposure to ch0micals are challengin
g because of the large number of possible
offending agents with diverse actions and metabolic effects .
rating strength and
., The severity of a chemical burn is determined by the mechanism of action, the penet
concentration, and the amount and duration of exposure of the skin to the chemical.
or faucet, except in the case of lye
., The skin should be drenched immediately with running waler from a shower, hose,
" -
and white ohosplJ.Prus, v,:bich should be brushed off the skin, dry.
./ f tie skin E:houfd be flushed with a constant stream of water as 11,e patient's clothing is removed.

h1J document rs the property of l'Hli'JMA ECIUCATION

 179

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Proble1\'ls/High Acuity and Emergency Situations, Acute & Chronic. Lecture
Module #23 Student Activity Sheet

Class number: _ __

_ _ __ Schedule: Date: _ _ __ __
------------- ---
✓ The skin ol health care personnel assisting the patient should be ~ppropnately protected if the burn 1s extensive or if
the agent is significantly toxic or Is still present.
" Prolonged lavage with generous amounts of tepid water is important. Attempts to determine the identity and
characteristics of the chemical agent are necessary in order to specify future treatment. .
' The standard burn treatment appropriate for the size and location of the wound (antimicrobial treatment, debndement,
tetanus prophylaxis, antidote administration as prescribed) is instituted.
✓ The patient may require plastic surgery for further wound management .
,/ The patient is instructed to have the affected area reexamined at 24 and 72 hours and in 7 days because of the nsk of
underestimating the extent and depth of these types of injuries.

FOOD POISONING
" This 1s a sudden illness that occurs after ingestiol'l of contaminated food or dnnk.
< Botulism is a serious form of food poisonin3 that requires continual surveillance.
✓ The key to tn'!atment is determining the source and type of food poisoning .
./ If possible the suspected food should be brought to the medical facility and a history obtained from the patient or
family
Food, gastric contents. vomitus. serum. and feces are collected for. examination.
The patient's respirations, blood pressure, level of consciousness. central venous pressure (CVP) lif indicated).
and muscular activity are rnorntored closely.
Measures are instituted to support the respiratory system. Death from respiratory paralysis can occur with
botulism. fish poisoning, and some other food poisonings.
Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and electrolyte status
should be assessed.
~rniling.p@uces alkalosis, and seyem-diarrhea-pr~doces-aeidosis-:-
Hypovolemic shock may also occur from severe fluid and electrolyte losses.

Thf! r:iatient in assessed for

Signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria,
anuria. hypotension, and delirium
Weight and serum electrolyte levels are obtained for future comparisons
Measures to control nausea are also important to prevent vomiting. which could exacerbate fluid and electrolyte -
imbalances

M~nag emenl:
An antiernetic medication i5 administnred parenlerally as prescribed if the patient cannot tolerate fluids er
rnP,d ications by mouth.
For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks, or tap water.
After nausea and vomiting subside, clear liquids are usually prescribed for 12 to 24 hours, and the diet is
gradually progressed to a low-residue, bland diet.

NEAR DROWNING
./ This is defined as survival for at least 24 hours after submersion that caused a respiratory arrest.
✓ The-most com~ BAGEHfr·hypoxei+lia.
✓ Drowning is the second most commQJ1 cause of unintentional death in children younger than 14 years.
o An estimated 8000arcwnings and 90,000 near drownings occur yearly in the United States.

1 n1 ~ UOl uol1 c1oc, . Lf 1t i-, ,.__ µ~1 1 y l. 1 .- , . .

 180

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic· Lecture
Module #23 Student Activity Sheet

Na me. Class number: _ __

- - - - - - - - - -- - -- - - ------ -- - --
Section: _ ___ Scheduie. ___________ _____ Date : _ __ _ _ __

J:actors assoc,aled with drow11ing and near drowning include.

alcohol ingestion hypothermia
inabilrty to swim exhaustion
diving inJuries

Tlie rriajority of drowning events occur in:

pools
lakes
bathtubs

Suicide by drowning rarely occurs in pools and rarely involves alcohol. Efforts lo save the patient should not be
abandoned premature!}'. Successful resuscitation with full neurologic recovery has occurred in near-drowning patients
after prolonged submersiol'\ in cold water. This is possible due to decrease in metabolic demands and/or the diving reflex.

The near-drowning process involves the onset of:

- hypoxia bradycardia
- hypercapnia dysrhythmias

If there is a violent struggle associated with the near-drowning episode, exercise-induced acidosis and tachypnea can
result in aspiration. Hypoxia and acidosis cause eventual apnea and loss of consciousness. When the victim loses
consciousness and makes a final effort to breathe, the terml_r.@..9.aSp_gccurs. Water then moves passively into the
airways prior to death. After resuscitation, hypoxia a nd acidosis are the Qrimary complications experienced by a person
J!'.!io h_g.5 oea~wned; immediate intervention irrihe ED is essential.

Resultant pathophysiologic changes & pulmonary injury depend on type of nuid (fresh or salt water) & volume aspirated.
- ,Fresh water aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs.
~ ,,.,.f-,,_ .ft;•!:- S ~ 1:.espiration leads to ~ _ f r o m the osmotic e~cts oJ the salt within the I~.
~ - IH!l"'person survives submersion, acute respiratory distress syndrome (ARDS). resulting in hypoxia. hypercarbia,
and respiratory or metabolic acidosis, can occur.

Management: Therapeutic goals include maintaining ~.hraLpe~ on and adequate oxygenation to prevent further
damage to vital organs.
,j Immediate cardiopulmonary resuscitation is the factor with the greatest influence on survival.
- The most important priority in resuscitation is to manage the hypoxia, acidosis, and hypothermia.

'
j
Prevention and management of hypoxia are accomplished by ensuring an adequate airway and respiration, thus
improving ventilation (which helps correct respiratory acidosis) and oxygenation.
Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. These
parameters determine the type of ventilatory support needed.
Use of endotracheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects
intrapulmonary shunting and ventilation-perfusion abnormalities (caused by aspiration of water).
If the patient is breathing spontaneously, supplemental oxygen may be administered by mask However, an
endotracheal tube is necessary if the patient does not breathe spontaneou~ . Because of submersion, the patient
is usually hypothermic. '
A rectal probe is used to determine the degree of hypothermia.

This document 1s the properw of ,.i,..,,Wv\J.. t:DvL-.Uvr,

 18 1

Nursing Care of Clients with life Threatening Conditions/Acute IYIll/Multi-Organ

L cture
Problems/High Acuity and Emergency Situations, Acute & Chronic· e
It Sheet
Module #23 Student Act Iv V

Class number: - -
:rr:rtn n ·
---- Schedule: Date: _ _ _ __ _
--- - - --- ------ -
Prescribed rewarming procedures {e.g . extracorporeal warming,
warmed peritoneal dialysis, inh~lation of warm
aorosohzed oxygon, torso warming) are started during resuscitation.
The choice of wanning method is determined by the severity and
duration of hypothermia and available
resources.
lntravascular volume expansion and inotropic agents are used to
treat hypotension and impaired tissue perfusion.
ECG monitoring is initiated . because dysrhythmias frequently occur.
An indwelling urinary catheter is inserted to measure urine output.
Hypothermia and accompanying metabolic acidosis may compro
mise renal function .
Nasogastric intubation is used to decompress the stomach and to
prevent the patient from aspirating gastric
contents.

Even if lhe patient appears healthy , close monitoring continues with

serial vital signs, serial arterial blood gas values . ECG
monitoring, intracranial pressure assessments, serum electrolyte
levels, intake and output, and serial chest x-rays.
Aft~ near-drowning, the patient is al risk for complications such
as hypoxic or ischemic cerebral injury, ARDS,
pulmonary damage secondary to aspiration, and life-threatening
cardiac arrest.

DECOMPRESSION SICKNESS
✓ This is also called ~ s Rds'.', occurs in patients who have engage
d in diving (lake, as well as ocean, diving), high-
altitude flying , or flying in commercial aircraft within 24 hours after
diving.
✓ It occurs relatively infrequently in the United States, but its effects
can be hazardous. Being aware of decompression
sickness and assessing the patient properly ensures proper manag
ement and results in the least morbidity possible.
✓ Decompression sickness results from !prmation of nitr~en bu,bble
s that occur with rapid changes in atmospbe~
E,l'essure.
✓ They may occur in joint or muscle spaces. resulting in musculoskele
tal pain, numbness, or hypesthesia.
✓ More significantly, nitrogen bubbles can become air emboli In lire.blo
odstream and thereby produce stroke, paralysis,
or death.
-
✓ Taking a rapid history about the events preceding the symptoms
is essential.
•' Recompression is necessary as soon as possible and may necess
itate a low-altitude flight to the nearest hyperbaric
chamber.

Assessment and Diagnostic Findings

To identify decompression sickness. a detailed history Is obtaine
d from the patient or diving partner.
EvidencA of rapid ascent, loss of air in lhe tank, buddy breathi ng,
recent alcohol intake or lack or sleep, or jUlight
~bin.2 4 hours after diving suggests possible decompression sicknes
s. . .
Some patients describe a perfect dive yet still have the signs and
• I symptoms of decompression sickness. and they
must receive treatment for the conditi on.

Signs and symptoms include:

joint or extremity pain
numbness
hypesthesia
loss of range of motion
Neurologic symptoms mimicking those of a stroke or spinal cord
inJury can indicate an air embolus.
Cardiopulmonary arrest can also occur in severe cases and is usually
fatal.
Any neurolog1c symptoms should be rapidly assessed.
All patients with decompression sickness need rapid transfer to
a hyperbaric chamber.

I
I
l

I
182 I

Nursing Cr1re of Clients with Life Threatening Conditions/A cutely Ill/Multi-Org an

Problems/Hi gh Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #23 Student Activity Sheet

Class number: _ __

~cctron:
- -- - - Schedu le: Date.
- -- - - - -- - - -- - - - - -

Ma"lagement
A pa.t~nt airway and adequate ventilation are established, as described previously, and 100% oxygen is
admrnrstered throughout treatment and transport.
A ~hest x-ray is obtained lo identify aspiration, and at least one IV line is started with lactated Ringer's or normal
saline solution.
The cardiopulmonary and neurologic systems are supported as needed. If an air embolus is suspected, the head
of the becLshould--be•lowered..
The patient's wet clothing is removed, and the patient is kept warm.
Transfer to the closest hyperburic chamber for treatment is initiated. If air transport is necessary, low-altitude night
(below 1000 feet) is required.
However, the patient who is awake and alert without central neurologic deficits may be able to travel by ground
ambulance or by automobile, depending on the severity of symptoms.
Throughout treatment, the patient is continually assessed, and changes are documented. If aspiration is
suspected, antibiotics and other treatment may be prescribed.

Check for Understand ing

After studying the main lesson, you may now answer the following multiple choice questrons and provide the rationale for
each item.

1 Nurse Kelly is teaching the parents of a young child how tc, handle poisoning. If the child ingests poison. what should
!he parents do first?
A. Call an ambulance Immed1ately C. Punish the child for being bad.
8. Call the poison control center. D. Administer ipecac syrup.
Answer: _ _ __
Rationale:

2. A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes.
'v'l/111ch of the following nursing actions is a priority?
A Use Restasr:; (Allergan) drops ,n the eye.
B Flusl1 the eye repeatedly using sterile normal saline
C Examine the client's visual acuity.
D. Patch the eye.
Answer: _ _ __
Rationale.

3 In relation to submersion injuries, which task is mo:;t appropriate to delegate to an LPN/LVN?

A Monitor an asymptomatic near•drowning victim.
B Remove wet clothing and cover the victim with a warm blanket.
C. Talk lo a community group about water safety issues
0 . Stabilize the cervical spine for an unconscious drowning victim.
Answer: _ _ __
Rationale:

~,~ ..,-- ........~- -- . . . ...

This ducumeri t is 1he properly o/ I ,-;11•. r,IA t1J LIU.\11U,~
 183
. / t ly Ill/Multi-Organ
Nursing Care of Clients with Life Threatening Conditions Acu e . Lecture
. . • A te & Chronic -
Problems/High Acuity and Emergency S1tuat1ons, cu . ·ty Sheet
Module #23 Student Act1v1

Class number: _ __
Name
D.ite: _ _ _ _ _ __
Section· _ _ __ __ Schedule: _ _ _ _____ _____ __ _

-1 fhe nurse employed in an emergency department is assigned to triage clients coming to the e~ergency department for
treatment on the evening shift. The nurse should assign priority to which client?
A A client complaining of muscle aches, a headache, and history of seizures
B A client who twisted her ankle when rollerblading and is requesting medication for pain
C. A client with a minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that he iust ate pizza that was made with a very spicy sauce
Answer: _ _ _ _
Rationale :

5 Which of these toxic substances is more likely to cause sickness in infants and elderly adults?
A. Lead D Bleach
B Carbon monoxide E Turpentine
C Bee venom
Answer: _ _ __
Rationale:

6. How can you reduce the risk that a child will be accidentally poisoned by medicine?
A. Never say that medicine is "candy"
B Keep medicines in their original containers and in locked cabinets
C. Ma1'c ~ure you put medicines away after using them
' D. Ail of the above
Answer: _ __
Rationale:

7. How can you reduce your risk for accidental poisoning with medicine?
1 A Always turn on t11e light when tak111g medicine
B. Clean out your medicine cabinet regularly
C Carefully read the labels on your medicine
0 . All of the above
Answer: _ _ __
Rationale:

8 If your child eats or drinks a toxic substance. what should you do?
A Call tile poison control center right away C Call your child's healthcare provider
B Tri to gel }'"OUr child to throw up (vomit) D None of the above
Answer: _ _ _ _
Rationale:
 .., ~-- - ~ ~ :i.:
~~
;

~ ' t
1[ld

l-Organ
atening Conditions/Acutely 111/Mult
Nursing Care of Clien ts with Life Thre ure
cy Situations, Acute & Chronic - Lect
Problems/High Acu ity and Emergen She et
Module #23 Student Activity

Class num ber: _ __

Date: _ _ _ _ _ __
Sec t ion. Scl1edul e

rol center?
e ready when you call a poison cont
9 V\'.hal information should you hav
A T1111e the po1s0111ng occurred
B Age of your child
C Name of the product taken
D. All of the above
Answer: _ __ _
Rationale:

ucts ?
dental poison,n g by household prod
10 How can you help prevent acci
A Never mix household chemic3I
products together
a fan when using a chemical product
S. Open a window or turn on
what's inside
C Nev er sniff containers lo find out
0 All of the above
Ans wer: _ _ __
Rationale:

C. LESSON WRAP-UP

Thinking abo ut Learning

MUD DIE ST POI NT

in the main less on:
e which key points have been missed
t.J. This technique will help you determin
t clea r to you?
In toda y's session, wha t was leas