Med-Surg Patient 3 PDF

**Ch. 68 - Terrorism, Mass Casualty, and Disaster Nursing, pg. 5826** **Emergency Operations Plan (EOP)** - Emergency Operations Plan: means of standardizing planning, protocols, procedures already in place for major events. - **Mass Casualty:** situation in which the number of casual...

**Ch. 68 - Terrorism, Mass Casualty, and Disaster Nursing, pg. 5826** **Emergency Operations Plan (EOP)** - Emergency Operations Plan: means of standardizing planning, protocols, procedures already in place for major events. - **Mass Casualty:** situation in which the number of casualties exceeds/overwhelms the number of available resources - Healthcare Facilities must be prepared for any type of disaster - Need to maintain constant state of "preparedness" - Planning ensures appropriate and timely response within shortest possible time frame - **Community Characteristics:** a part of an EOP, they look at resources, **population** (especially vulnerable populations) distribution/location of resources, weather emergencies, timely responses, most likely hazards, the ability to respond (ex: how many ambulances you may need for the situation) - These plans need to be based on the community \[different needs based on location\] - Pharmaceutical Stockpile: stock of supplies in case of emergency evaluated also -- specific chemical or biological agent - Especially antidotes for chemical & biological agents - Federal Emergency Management Agency (FEMA): essential for EVERY community and facility - **The National Incident Management System (NIMS)** - Guides all levels of government, nongovernmental organizations and the private sector to work together to prevent, protect against, mitigate, respond to and recover from incidents - NIMS guidelines are also followed for any other disaster situation, including natural disasters, outbreaks, epidemics, and pandemics \[book\]. - Follow through with recover from an event - Standardized codes to improve communication - Critical Institute of Risk Management: gives staff food, lets them rest, properly clothed, masked, etc. **EOP Components \[pg. 5837\]** - Activation response: determine where, how, and when the plan is activated - Ex: major weather event - Internal/External communication plan: clear communication is essential, must know whats going on - Ex: Parkwest gets 20 pt, UT Med gets 20 pts; ambulances are diverted to other hospitals (not PW or UTMC) - Coordinated patient care plan - Security plans: National Guard, KPD (local, state, federal) - Identification of external resources - Chart 68-1: FEMA, American Red Cross - A plan for people management and traffic flow - Coordinate media, extra personnel, center, equipment staging - **Data management strategy:** management if computers die and backup plans, must be able to track staffing - **A data management plan** for every aspect of the disaster will save time at every step. A backup system for documenting, tracking, and staffing is developed if the facility utilizes an electronic health record (book) - Demobilization response: must be a stated plan, resources shouldn't be unnecessarily exhausted, person making decision is clearly identified, residual effects considered before decision made - Corrective plan: a "hotwash", discuss all aspects of care/plan; essentially a debrief to update plan - Practice plan (organization should have regular drills to practice), Anticipated resources (food, water) - MCI plan \[mass casualty incident\]: planning for mass casualties and morgue readiness - Personnel must be educated for every part of the EOP **Initiating the EOP, pg. 5839** → ID pts, triage, communicate w/ media & family, and manage internal problems - **Triage, table 68-2 pg. 5842**: (do the most good for the most people in disaster triage, utilitarian) - **Red**/Immediate -- Life threatening but survivable with minimal intervention (priority \#1) - Ex: Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, 15-40% burns on body surface (book) - **Yellow**/delayed -- Injuries are significant and require medical care but can wait hours without threat to life or limb (priority \#2) - Ex: soft tissue injuries, fractures requiring open reduction, débridement, and external fixation (book) - **Green**/minimal -- Injuries are minor and treatment can be delayed hours to days (priority \#3) - Ex: Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding (book) - **Black** (deceased/expectant) -- Injuries are extensive, and chances of survival are unlikely even with definitive care (book) - Ex: Patients who are unresponsive with penetrating head wounds, high spinal cord injuries, no pulse, **cardiac arrest,** 60% burns on body surface (book) - **White**/Involved -- no obvious injuries - **SALT: S**ort, **A**ssess, **L**ifesaving interventions, **T**reatment/**T**ransport - Developed to allow for rapid evaluation and sorting of patients of any age, injured in any type of event **Nurse's Role in Disaster Response Plans** - Maybe asked to do things outside their scope of practice - Exact role can be decided by facility based on needs - May question decisions regarding care of patients - Issues the nurse must deal with: - Rationing care, Consent, Duty, Confidentiality, Resuscitation, Assisted suicide - **Question ethics, chart 68-1, pg. 5848** **Short-term and Long-term Psychological Effects Post Disaster** - Listen and provide emotional support - Provide information as necessary and appropriate - Refer to outside resources for counseling - Talk to them about media coverage and exposure - Encourage them to return to normal activities - **Common effects, pg. 5852**: anxiety, depression, compassionate fatigue, interpersonal conflicts, impaired performance, PTSD, migraine HA, abdominal pain, SUD **Critical Incident Stress Management, pg. 5853 (CISM)** - Preventing and treating the emotional trauma that can affect emergency responders as a consequence of their job - Components of CISM - Education (preparedness before the incident occurs), Defusing, Debriefing, Demobilization, Follow-up - Field support: ensuring that staff get adequate rest, food, and fluids, and rotating workloads **Preparedness and Response** - Healthcare provider should have a heightened awareness of possible attack with toxic or infectious agents - **Onset of outbreak, epidemic, and pandemic:** - An unusual increase in the number of people seeking care for fever, respiratory, or gastrointestinal symptoms - Clusters of patients who present with the same unusual illness from a single location. - A large number of fatalities **Personal Protective Equipment, 5856 (PPE)** - Purpose → shield healthcare workers from the chemical, physical, biologic and radiologic hazards that may exist when caring for contaminated patients - **EPA (environmental protection agency) divided protective wear into four Levels A-D** - **Level A:** highest level of resp, skin, eye, and mucous membrane protection - Fully encapsulated, vapor tight, chemical-restraint suit, gloves & boots, self-contained breathing apparatus (SCBA). - **Level B:** highest level of respiratory protection, but a lesser level of of skin & eye protection - Self-contained breathing apparatus (SCBA) and chemical-restraint suit but suit not vapor tight - **Level C:** for airborne - Air purifying respirator (which filters or sorbent material to remove harmful substances), chemical-restraint coverall & gloves, splash good, and boots - TYVEK suit - **Level D:** everyday wear/scrubs/uniform, other PPE such as gloves or mask may be required based on situation - **Chart 68-4, pg. 5857 (just talks abt the whole-process training ot improve use of PPE)** - **Decontamination**: the process of removing accumulated contaminants or rendering them harmless, is critical to the health and safety of health care providers by preventing secondary contamination. - Decontamination is vital for all patients/personnel prior to entering ED - First step: removal of the patients clothing and jewelry and then rinsing the patient with water - Second step: soap-and-water wash and rinse - Something you may have to worry about when decontaminating patients: is RUN off (water contains the contaminating agent) in the water **Natural Disasters, pg. 5861** - Natural disasters: tornadoes, hurricanes, floods, avalanches, tsunamis, earthquakes, and volcanic eruptions - Fire department or EMS are not consulted in tornadoes or hurricanes anymore - Potential Issues - Loss of communication, lack of drinkable food/water, exposure to elements (heat/cold), loss of medication, lack of sanitation/waste removal, vector control, loss of utilities/electricity, potentially dangerous animals (snakes, alligators), hypothermia, and removal of human and animal remains **Weapons of Terror, pg. 5864** - **Blast Injury**: Bombs used pipe bombs (MC), Molotov cocktails, fertilizer and dirty bombs - Pipe bombs: contain low-velocity explosives and may also contain nails or other implements - Molotov cocktail: flammable liquid (gas) in a glass bottle and source of ignition such as a rag - Fertilizer and dirty bombs: include a radioactive source that spreads radiation after the initial blast - **Blast waves have four effects. Table 68-4:** - **Primary injury:** results form initial blast of air wave - **Secondary injury:** results from debris from the scene or shrapnel from the bomb that act as projectiles - **Tertiary injury:** results from pressure wave that causes the victim to be thrown - **Quaternary**: results from preexisting conditions exacerbated by the force of the blast - Blast lung - Tearing of pulmonary tissue (lead to hemorrhage), air embolism, VQ mismatch - S/sx: dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability - Tx: Require intubation & mechanical ventilation - If air embolism, prone and left lateral position and hyperbaric O2 tx - **Tympanic Membrane rupture** - Most frequent injury after subjection to a pressure wave - S/sx: hearing loss, tinnitus, pain, dizziness, and otorrhea - Majority of TM heal spontaneously - Abdominal Injury - Internal bleeding and organ damage - S/sx: bleeding, penetrating wound (cover w/ moist sterile dressing), N/V, abdominal pain, guarding, rebound tenderness, and rectal bleeding - Head injury is most common cause post-blast deaths that's usually caused by falling debris or blast itself - Special population: elderly (fractures, comorbidities), pregnant people (at risk for placental abruption), mobility disability - Ex: Warehouse explosion results in a patient who has an injury to forearm, one with BP is high, another with multiple fractures in right leg, and finally a pt with dyspnea and cyanosis, who will you see first? - Dyspnea and cyanotic pt because of ABC's **Biological Weapons, pg. 5868, table 68-5** - Biological weapons are weapons that spread disease among the general population or the military - Can be used for sabotage, such as food or water contamination with a small target area or may be used by global terrorists - **1/A:** High mortality (botulism, smallpox, ebola, plague, **Bacillus anthracis (anthrax**) - **2/B:** Low mortality but Moderate morbidity (ex: staph aureus, viral encephalitis, brucellosis) - **3/C:** Low mortality and Low morbidity, engineered agents that have potential for mass dissemination (ex: hantavirus) **Anthrax, pg. 5869** - Caused by Bacillus anthracis - Bacterium sporulates (i.e., is liberated) when exposed to air and is infective only in the spore form - Contact w/ infected animal or inhalation of spores - S/sx: three main methods of infection (skin contact, GI ingestion, and inhalation) - Cutaneous Lesion: erythema, edema, ulceration, & can develop painless eschar - **Ingestion: it can cause severe diarrhea (severe enough to reduce intravascular volume),** fever, N/V, maybe ascites - Inhalation: starts w/ flu-like sx of cough, HA, fever, vomiting, chills, weakness, dyspnea, hemoptysis, diaphoresis, cyanosis, stridor, hypoxia - Progresses after 1-3 days to severe sx of respiratory distress, hypotension & shock leading to death. - Treatment (w/in 24 hours of exposure) - Penicillin, Cirpofloxacin, Levofloxacin, Doxycycline - **Treat for 60 days** - No s/sx but exposed, OR cutaneous anthrax → Cipro/Doxy for 60 days - **Standard precautions**, does not spread person to person - After death, cremation is recommended because the spores can survive for decades and represent a threat to morticians - Mediastinum start hemorrhaging **Botulism, table 68-6** - Damages nerves ending in flaccid paralysis - Transmission: not person to person transmission; food borne - **VERY contagious (kahoot)** - S/sx: N/V/D, Dysphasia, diplopia, dysarthrias, blurred vision - Gradual paralysis in facial muscles then spreads - **Descending symmetric flaccid paralysis** - Mortality: deadliest toxin known (death due to respiratory failure) - Standard precautions, considered medical emergency - Tx: Supportive care (mechanical vent, nutrition (TPN), fluids) - Don't give aminoglycosides and clindamycin b/c they exacerbate neuromuscular blockade **Smallpox, pg. 5872** - **It is extremely contagious and spread by direct contact, by contact with clothing or linens, or by droplets** from person to person only after the fever has decreased and the rash phase has begun. it has an incubation period that ranges from 7-17 days - S/sx: fever, malaise, HA, backache & maculopapular rash (develops on face, mouth, pharynx & spreads to trunk/extremities over time, changes from vesicular to oozing pustule lesions) - Large amounts of virus in the saliva and pustules. - Tx: Isolation in negative pressure room, supportive care - **Strict airborne & contact precautions** - Linens should be autoclaved before washed, cremation is preferred for all deaths, b/c the virus can survive in scabs for up to 13 years. - Prevention: smallpox vaccine **Chemical Weapons, 5874** - Get in PPE, remove pt, Decon & don't want that water to get into the public water, then evacuate (once clean) - Agents: Nerve agents (sarin), Blood agents (cyanide), Vesicants (mustard gas), Pulmonary agents (chlorine) - Characteristics of the Chemicals - Volatility: tendency of chemical to become a vapor - Persistence: less likely to vaporize (mustard gas) - More likely to be absorbed via skin & mucous membranes - Toxicity: ability for the agent to cause harm - The **median lethal dose (LD 50)** is the amount of the chemical that will cause death in 50% of those who are exposed - Latency: time from absorption to the appearance of s/s - Prevention: limiting exposure to the agent, removal of the persons' clothing and decontamination as close to the scene as possible - **Vesicants, 5876** - Common agents: lewisite, phosgene, nitrogen mustards, and sulfur mustard - Cause blistering and result in burning - Can cause conjunctivitis, bronchitis, PNA, hematopoietic suppression, and death - Clinical Manifestations - Warm moist areas of the body will be burned, - **Skin will sting then small vesicle formation (blistering) 2-18 hours after** - Respiratory symptoms: Chest tightness, **cough, SOB, pharyngitis**, tachypnea, blurred vision, corneal ulcerations - Decontaminate with soap and water - Tx: dimercaprol administered IV for systemic toxicity and topically for skin lesions - **Nerve Agents, pg. 5877 → Sarin Gas** - MOA: a potent inhibitor of acetylcholinesterase, an enzyme that degrades the neurotransmitter acetylcholine - Sympathetic and parasympathetic nervous system are activated **\[affects nicotinic & muscarinic receptors\]** - S/sx: diarrhea, sweating, urinary, bronchospasm, emesis, salvation, pruritus, painful burning, small vesicle formation, lacrimation (leads to paralysis) - Causes respiratory issues and ACTH doesn\'t work + pt will foam at mouth + diarrhea + bronchospasm - Symptoms of nerve gas exposure include all of the following? - Visual disturbances - Flaccid muscles - Nausea and vomiting - Treat: **Atropine**, Benzos (diazepam for seizure prevention) - **Antidote: Pralidoxime 1-2 g in 100 to 150 mL of NS** **Nuclear Radiation Exposure, pg. 5881** - Exposure to radiation is affected by time, distance and shielding - Radiation exposure is cumulative - Damage is dose dependant → Lead = protective measure - **Types of radiation** - **Alpha particles:** cannot penetrate the skin - **Beta particles:** have the ability to moderately penetrate the skin - **Gamma radiation**: very penetrating (ex: medical X-ray) - **Types of radiation-induced injury:** - External: not an emergency, local reaction - Radiation dermatitis from cancer radiation - Contamination: exposure to radiation in gas form, by liquid, or solids either externally or internally - Incorporation: physical reuptake into one\'s body tissues - The organs involved are usually the kidneys, bones, liver, reproductive organs (not in book), and thyroid glands - The longer a person is within the radiation area, the higher the exposure. Also, the larger the amount of radioactive material in the area, the greater the exposure - Desire: Shortest exposure w/ furthest distance \[to decrease amount of exposure\] - Radiation Decontamination - Triage & decontamination outside of hospital is the most effective means of preventing contamination of the facility itself - Decontamination happens outside the ED, wet and naked - Monitor runoff so that it does not contaminate clean areas - Strict isolation precautions: air ducts/vents sealed,cover floors - Double bag waste & label: red goes in radiation bins (yellow & magenta), contact radiation safety officer - Staff PPE: dosimeter worn, double gloves, mask, caps, eye protection, shoe covers. - Labs needed: CBCs, blood, urine, emesis, stool, may utilize gastric lavage with chelating agents (agents that bind with radioactive substances) - **Acute Radiation Syndrome (ARS), pg. 5884, table 68-8** - The hematopoietic system is the first system affected and serves as an indicator of the severity of radiation exposure - A predictor of outcome is the absolute lymphocyte count at 48 hours after exposure bc of bone marrow suppression. - Can occur after exposure to radiation, all body systems affected - DOSE DEPENDENT - S/sx: determine predicted survival - Bone marrow suppression: pancytopenia - Phases of effects of radiation exposure - Prodromal phase, latent phase, manifest illness phase, recovery phase, death - Probable survivors have no initial symptoms or only minimal - Usually need supportive care - Possible survivors present with N/V + pancytopenia - Blood products (to replace platelets), prevent infection, supportive care - Improbable present acutely ill and have N/V/D and shock - Lethal doses → neuro symptoms and death happens quickly (dies to to increased intracranial pressure)