Western Mindanao State University COLLEGE OF NURSING Graduate Program

Course Module On

NCM 106
(CARE OF CLIENTS ACROSS THE LIFESPAN WITH PROBLEMS IN

INFLAMMATORY AND IMMUNOLOGIC REACTIONS, CELLULAR ABERRATIONS, ACUTE BIOLOGIC CRISIS, INCLUDING EMERGENCY AND DISASTER NURSING)

Submitted to: Josefa Andrea C. Pizarro, R.N.,M.N. (course professor)

In Partial Fulfilment of the Requirements in NED 204 (Development of Instructional Support Material)

Submitted by: Amor Mei Candido Ochoa, R.N. Jobel Aringo-Nuval, R.N. Maynard K. Baird, R.N. MN/MAN Students
Second Semester S.Y. 2010-2011

Table of Contents

Content

Page

Unit I (Inflamatory/Immunologic)

Unit II ( Cellular Aberrations)

Unit III (Acute Biologic Crisis)

Unit IV (Emergency & Disaster Nursing)

NCM 106 CARE OF CLIENTS ACROSS THE LIFESPAN WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC REACTIONS, CELLULAR ABERRATIONS, ACUTE BIOLOGIC CRISIS, INCLUDING EMERGENCY AND DISASTER NURSING

Course Description It deals with the principles and techniques of Nursing Care Management of sick clients across lifespan in varied settings with alterations/problems in inflammatory and immunologic reactions, cellular aberrations, acute biologic crisis including emergency disaster nursing and IV therapy.

Course Credit:

8 units lecture, 8 units RLE

Contact hours/sem

144 lecture hours, 408 RLE hours

Prerequisite

NCM 105

Placement

4th year, 1st Semester

Terminal Competency: Given actual clients with problems in inflammatory and immunologic reactions, cellular aberrations, acute biologic crisis and emergency, the student should be able to: 1. Utilize the nursing process in the care of individuals and families in selected setting: y Assesses with client/s/his/her/their condition/health status through interview, physical examination, interpretation of laboratory findings y Identifies actual and potential nursing diagnosis y Plans appropriate nursing interventions with client/s and family for identified nursing diagnosis y Implements plan of care with client/s and family y Evaluates the progress of his/her/their clients condition and outcomes of care 2. Ensure a well organized and accurate documentation system. 3. Relate with client/s and their family and the health team appropriately

4. Observe bioethical concepts/principles, core values and nursing standards in the care of clients. 5. Promotes personal and professional growth of self and others.

By: Amor Mei Candido Ochoa, R.N. MAN Nursing Education

A. Care of Clients with Infection 1. Overview of the Immune System

Definition Immune System composed of many interdependent cell types that collectively protect the body from bacterial, parasitic, fungal, viral infections and from the growth of tumor cells. is an intricate network of specialized cells, tissues, and organs designed to allow us to exist in an environment that often includes hostile microorganisms. Function  Evolved to protect and defend the body against invasion by bacteria, viruses, fungi and parasites.  Seeks out and destroy malignantly transformed cells.  Can engulf bacteria, kill parasites or tumor cells, or kill viralinfected cells. -

1.1.

Immune System Components

Organs of the Immune System

1. Bone Marrow -- All the cells of the immune system

are initially derived from the bone marrow. They form through a process called hematopoiesis. During hematopoiesis, bone marrow-derived stem cells differentiate into either mature cells of the immune system or into precursors of cells that migrate out of the bone marrow to continue their maturation elsewhere. The bone marrow produces B cells, natural killer cells, granulocytes and immature thymocytes, in addition to red blood cells and platelets. 2. Thymus -- The function of the thymus is to produce mature T cells. Immature thymocytes, also known as prothymocytes, leave the bone marrow and migrate into the thymus. Through a remarkable maturation process sometimes referred to as thymic education, T cells that are beneficial to the immune system are spared, while those T cells that might evoke a detrimental autoimmune response are eliminated. The mature T cells are then released into the bloodstream. 3. Spleen -- The spleen is an immunologic filter of the blood. It is made up of B cells, T cells, macrophages, dendritic cells, natural killer cells and red blood cells. In addition to capturing foreign materials (antigens) from the blood that passes through the spleen, migratory macrophages and dendritic cells bring antigens to the spleen via the bloodstream. An immune response is initiated when the macrophage or dendritic cells present the antigen to the appropriate B or T cells. This organ can be thought of as an immunological conference center. In the spleen, B cells become activated and produce large amounts of antibody. Also, old red blood cells are destroyed in the spleen. 4. Lymph Nodes -- The lymph nodes function as an immunologic filter for the bodily fluid known as lymph. Lymph nodes are found throughout the body. Composed mostly of T cells, B cells, dendritic cells and macrophages, the nodes drain fluid from most of our tissues. Antigens are filtered out of the lymph in the lymph node before returning the lymph to the circulation. In a similar fashion as the spleen, the macrophages and dendritic cells that capture antigens present these foreign materials to T and B cells, consequently initiating an immune response.

The Cells of the Immune System

1. T-Cells -- T lymphocytes are usually divided into two

major subsets that are functionally and phenotypically (identifiably) different. The T helper subset, also called the CD4+ T cell, is a pertinent coordinator of immune regulation. The main function of the T helper cell is to augment or potentiate immune responses by the secretion of specialized factors that activate other white blood cells to fight off infection. Another important type of T cell is called the T killer/suppressor subset or CD8+ T cell. These cells are important in directly killing certain tumor cells, viral-infected cells and sometimes parasites. The CD8+ T cells are also important in down-regulation of immune responses. Both types of T cells can be found throughout the body. They often depend on the secondary lymphoid organs (the lymph nodes and spleen) as sites where activation occurs, but they are also found in other tissues of the body, most conspicuously the liver, lung, blood, and intestinal and reproductive tracts.

2. Natural Killer Cells -- Natural killer cells, often

referred to as NK cells, are similar to the killer T cell subset (CD8+ T cells). They function as effector cells that directly kill certain tumors such as melanomas, lymphomas and viral-infected cells, most notably herpes and cytomegalovirus-infected cells. NK cells, unlike the CD8+ (killer) T cells, kill their targets without a prior "conference" in the lymphoid organs. However, NK cells that have been activated by secretions from CD4+ T cells will kill their tumor or viral-infected targets more effectively. 3. B Cells -- The major function of B lymphocytes is the production of antibodies in response to foreign proteins of bacteria, viruses, and tumor cells. Antibodies are specialized proteins that specifically recognize and bind to one particular protein that specifically recognize and bind to one particular protein. Antibody production and binding to a foreign substance or antigen, often is critical as a means of signaling other cells to engulf, kill or remove that substance from the body.

4. Granulocytes

or Polymorphonuclear (PMN) Leukocytes -- Another group of white blood cells is collectively referred to as granulocytes or polymorphonuclear leukocytes (PMNs). Granulocytes are composed of three cell types identified as neutrophils, eosinophils and basophils, based on their staining characteristics with certain dyes.

These cells are predominantly important in the removal of bacteria and parasites from the body. They engulf these foreign bodies and degrade them using their powerful enzymes. 5. Macrophages -- Macrophages are important in the regulation of immune responses. They are often referred to as scavengers or antigen-presenting cells (APC) because they pick up and ingest foreign materials and present these antigens to other cells of the immune system such as T cells and B cells. This is one of the important first steps in the initiation of an immune response. Stimulated macrophages exhibit increased levels of phagocytosis and are also secretory.

6. Dendritic Cells -- Another cell type, addressed

only recently, is the dendritic cell. Dendritic cells, which also originate in the bone marrow, function as antigen presenting cells (APC). In fact, the dendritic cells are more efficient apcs than macrophages. These cells are usually found in the structural compartment of the lymphoid organs such as the thymus, lymph nodes and spleen. However, they are also found in the bloodstream and other tissues of the body. It is believed that they capture antigen or bring it to the lymphoid organs where an immune response is initiated. Unfortunately, one reason we know so little about dendritic cells is that they are extremely hard to isolate, which is often a prerequisite for the study of the functional qualities of specific cell types. Of particular issue here is the recent finding that dendritic cells bind high amount of HIV, and may be a reservoir of virus that is transmitted to CD4+ T cells during an activation event. 1.2. Non specific Inflammatory Response - Includes natural immunity or innate immunity a type of immunity which acts as the bodys first line of defense against pathogens and microorganisms. Specific Immune Response - Includes Acquired immunity or adaptive immunity which is stimulated when a pathogen gains entry to the body. Natural or Acquired Immunity (1) Natural Immunity is nonspecific and acts as the bodys first line of defense, guarding against potential pathogens

1.3.

1.4.

and preventing them from becoming established as an overt infection.

Natural Immunity

Physical barriers

Cellular defense mechanisms

Biochemicals

Potential Pathogens
(2) Acquired Immunity is stimulated when a pathogen gains entry to the body, and it produces a specific response to the invader. Normal Immune Responses

(3)

2.1. Tissue Inflammation -is the bodys response to damage that includes direct physical injury, infected cells, or other pathogens such as bacteria, allergens, viruses, and debris. Many different areas of the body can experience tissue inflammation including the skin, muscles, tendons, nervous system, immune system, and circulatory system. Depending on the trigger, tissue inflammation can either be an acute, immediate response or a chronic, long-term response. While beneficial in some cases such as wound healing and disease prevention, inflammation can also have negative consequences for the body. 2.2. Infection - is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease. Colloquially, infections are usually considered to be caused by microscopic organisms or microparasites like viruses, prions, bacteria, and viroids, though larger organisms like macroparasites and fungi can also infect. A. Care of Clients with Altered Immunity 1. Altered Immune Responses 1.1 Hypersensitivity Reactions overreaction to a substance or hypersensitivity is often referred to as an allergic response. Although allergy is widely used, the word hypersensitivity is more appropriate; this term designates an increased immune response to the presence of an antigen, the route of allergen entrance into the body, and the exposure to the allergen,

1.2

Autoimmune Disorder - any of a large group of diseases characterized by abnormal functioning of the immune system that causes your immune system to produce antibodies against your own tissues. - arise from an overactive immune response of the body against substances and tissues normally present in the body. In other words, the body actually attacks its own cells. The immune system mistakes some part of the body as a pathogen and attacks it. - a condition stemming from an abnormal immune response generated by the body against its own tissues, cells, or molecules. Tissue Transplant - An organ transplant is the moving of an organ from one body to another, or from a donor site on the patient's own body, for the purpose of replacing the recipient's damaged or absent organ. - The movement of muscle, fat and skin (composite flap) from one area of the body to another to fill a defect or reconstruct the breast, eg TRAM flap.

1.3

2. Impaired Immune Response 1.2. HIV Infection - Human immunodeficiency virus (HIV) is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS), a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections.

HIV ASSOCIATED MALIGNANCIES include kaposis sarcoma (KS) and AIDS associated lymphoma. KS, a neoplasm of the vascular endothelium, is the most common neoplasm affecting clients with AIDS. AIDS associated KS is often aggressive and disfiguring. Ks is most common in homosexual and bisexual men, compared with other high risk groups. Non Hodgkins lymphoma, Burkitts-like lymphomas and malignant lymphomas of the central nervous system can be classified as AIDS associated malignancies. HIV NEUROLOGIC DISEASE can involve the central and peripheral nervous system. AIDS DEMENTIA COMPLEX is characterized by cognitive, motor, and behavioural dysfunction. HIV WASTING SYNDROME is characterized by progressive weight loss (greater than 10 per cent of body weight), cachexia, persistent levers, and diarrhea.

E. Nursing Process of Clients with Infection/Altered Immune Response

1. Diagnoses y Infection (any body organ), High Risk for R/T cellular immunodeficiency y Breathing Pattern, Ineffective R/T PCP, CMV infection, pulmonary KS, MAC infection, tuberculosis, pneumonitis, pneumothorax y Nutrition Altered: Less than Body Requirements R/T persistent diarrhea, malabsorption, increased metabolic rate, anorexia, stomatitis, infection y Skin Integrity, impaired R/T malnutrition, KS, immobility, infection(HSV, histoplasmosis, CMV, varicella zoster, candidiasis) y Social Isolation R/T stigma, fear, cultural and religious mores, risk for HIV transmission y Diarrhea R/T infection, diet, medications y Sleep Pattern Disturbance R/T anxiety, depression, withdrawal from drugs (heroin, cocaine, methadone), pain, night sweats, side effects of medications y Pain R/T side effects of medications, infections, immobility, lymphadenopathy, lymphedema secondary to KS, lymphoma, headaches due to central nervous system infection, peripheral neuropathy, severe myalgias, psychogenic pain related to anxiety and fear of death y Activity intolerance R/T fatigue, weakness, arthralgia, myalgia, side effects of medications, dyspnea, fever, malnutrition y Thought Process, Altered R/T central nervous system disease (toxoplasmosis, cryptococcosis), CMV infection, KS lymphoma, HIV infection y Body Image Disturbance R/T diagnosis, KS lesions, alopecia from chemotherapy or HIV infection, weight loss, depression, social stigma, change in sexuality y Grieving, Anticipatory R/T multiple losses, including health, independence, friends, social activities, job, housing, life, and loss of control y Anxiety R/T HIV diagnosis, fear of death, fear of disclosure y Knowledge Deficit R/T disease progression, treatment options, transmission, and methods of preventing transmission y Sexual Patterns, Altered R/T safer sex practices, abstinence, fear of transmission, impotency secondary to medications y Injury, High Risk for R/T weakness, HIV encephalopathy and cognitive changes, neuromascular changes y Sensory/ Perceptual Alterations: Auditory/Visual R/T hearing loss secondary to medications and visual loss related to infection (CMV) y Role Performance, Altered R/T parenting, childbearing, supporting y Individual Coping, Ineffective R/T the diagnosis of HIV disease 1. Intervention y Assess the pre illness activity tolerance in order to establish the clients usual energy level. y Assess the clients need for sleep and rest. y Assist the client with ADLs. y Encourage the client to engage in regular exercise and rest as tolerated.

y y

y y y

y y y

Teach the client energy conservation measure and evaluate response to instructions. Establish a time with the client and family or significant others for rest while the client is hospitalized and educate other staff about this protected time. Encourage the client to eat and maintain an adequate dietary intake during periods of activity intolerance. Administer ordered treatment of underlying infections, pain, anxiety, sleeplessness, or malnutrition. Perform pain assessment that includes assessing for location, onset, duration, time of day of occurrence, precipitating factors, alleviating factors, characteristics and frequency of pain. Provide alternative measures for pain relief such as massage, visualization, and touch. Assess the effectiveness of any therapy that is administered and monitor for side effects. Teach patient or s/o on ways on how to reduce the risk of transmission which includes safe sex counselling, avoidance of sharing of needles or instructions on cleaning the works (paraphernalia used in injection of drugs) or both, care of household items, and proper disposal of items soiled with body fluids.

2. Client, family, community education teaching needs to include information on any medications, access to follow up care, location of local support networks, knowledge about transmission of HIV or any coexisting infections (i.e., tuberculosis) and care of any central or peripheral intravenous lines when appropriate.

Clients with Cancer Cancer - a class of diseases characterized by out-of-control cell growth. There are over 100 different types of cancer, and each is classified by the type of cell that is initially affected. A. Incidence and Mortality 1. Risk factors
o o o o o o o o

Chemicals Diet and exercise Infection Radiation Heredity Physical agents Physical trauma and inflammation Hormones

2. Causes Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth,

division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.

B. Pathophysiology 1. The Cell Cycle

C. Etiology 1. Theories of Carcinogenesis y General Theory of Carcinogenesis - is proposed consisting of the following features: (1) It is suggested that all cells possess multiple structural genes (Tr) capable of coding for transforming factors which can release the cell from its normal constraints on growth. (2) In adult cells they are suppressed by diploid pairs of regulatory genes and some of the transforming genes are tissue specific. (3) The Tr loci are temporarily activated at some stage of embryogenesis and possibly during some stage of the cell cycle in adult cells. (4) Spontaneous tumors, or tumors induced by chemicals or radiation, arise as the result of a double mutation of any set of regulatory genes releasing the suppression of the corresponding Tr genes and leading to transformation of the cell. (5) Autosomal dominant hereditary tumors, such as retinoblastoma, are the result of germ-line inheritance of one inactive regulatory gene. Subsequent somatic mutation of the other regulatory gene leads to tumor formation. (6) The Philadelphia chromosome produces inactivation of one regulatory gene by position effect. A somatic mutation of the other leads to chronic myelogenous leukemia. (7) Oncogenic viruses evolved by the extraction of host Tr genes with their conversion to viral transforming genes. As a result, in addition to the above mechanisms, tumors may also be produced by the reintroduction of these genes into susceptible host cells. y Quantitative Theories of Carcinogens attempt to relate the frequency and time of occurrence of detectable tumors to the

concentration and potency of carcinogen, the age and susceptibility of the host and duration of exposure to the carcinogen. 2. Known Carcinogens Carcinogens Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. Theses free radicals damage cells and affect their ability to function normally. 3. Types of Neoplasms A neoplasm can be benign, potentially malignant (pre-cancer), or malignant (cancer).
y y

Benign neoplasms include uterine fibroids and melanocytic nevi (skin moles). They do not transform into cancer. Potentially malignant neoplasms include carcinoma in situ. They do not invade and destroy but, given enough time, will transform into a cancer. Malignant neoplasms are commonly called cancer. They invade and destroy the surrounding tissue, may form metastases and eventually kill the host.

4. Characteristic of Malignant Cells When the malignant tumor expands, it presses against surrounding cells and tissues, showing two dangerous characteristics: its invasive nature, or its tendency to invade outlying tissues, and its metastatic nature, or its tendency to travel to other parts of the body through blood or lymphatic channels and grow there. 5. Tumor invasion and metastasis

D. Psychophysiologic Effects of Cancer y Sexual Dysfunction: Some cancer patients and survivors, may experience a level of sexual dysfunction. This can happen to both males and females and there are ways around it. Chronic Pain: The cancer patient may experience consistent, chronic pain after prolonged cancer treatment. Infertility: Both male and female patients and survivors may experience infertility.

y y

y y

y y

Constant Fatigue: Patients and survivors may feel like they are constantly tired and do not have the motivation or energy to complete simple, everyday tasks. Numbness: Numbness is caused by a condition called 'Neuropathy'. The numbness is most common in the patients hands and feet. Osteoporosis: Is a condition which causes your bones to become very fragile and weak. Making the cancer patient more susceptible to broken bones and fractures. Incontinence: Uncontrollable urination is an effect some patients may experience. Multiple Cancers: It is possible to get a second cancer, other then the one diagnosed for. It is best to find this out through your doctor, as soon as possible. Hair Loss: Hair loss is common during the treatment of cancer. If this is a problem, consult with your doctor on ways to deal with the hair loss. Ostomies: An Ostomy is a surgical opening, with a tube connecting to a bag on the outside of the body.

Psychological Effects of Cancer. y y Stress: A high level of stress is often attributed to cancer and can be a common side effect. Low Confidence: Due to the physical and mental changes cancer and cancer treatment can have on the patients, it can often result in low self esteem and confidence. Depression: Depression is commonly found in cancer patients and survivors. This could be attributed to the physical effects of the cancer treatment

Unit Exam Inflammatory and Immunologic Name: ___________________ Yr./Section:_______________ Date:____________ Score:___________

I. Multiple Choice Directions: Encircle the letter of the best answer . NO ERASURES OR SUPERIMPOSITIONS. 1. . Which of these are the most abundant in circulation?

a. dendritic cells b. neutropils c. basophils d. mast cells 2. Which of these is a professional antigen presenting cell (APC)? a. erythrocytes b. eosinophils c. mast cells d. dendritic cells

3. Which of these is a secondary lymphoid organ? a. Spleen b. Heart c. Kidney d. Brain 4. T cells require two signals to be activated. One signal is the binding of the antigen presented by the antigen presenting cell (APC). The other is the binding of a. co stimulators b. partner molecules c. helper molecules d. interfering molecules 5. What kind of cells produce antibodies? a. T cells b. neutrophils c. NK cells d. B cells 6. The client suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which pre-procedure instruction to the client? a. eat a light breakfast only b. maintain an NPO before the procedure c . wear comfortable clothing and shoes for the procedure d. drink six to eight glasses of water without voiding before the test

7. A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder? a. altered red blood cell production

b. altered production of lymph nodes c. malignant exacerbation in the number of leukocytes d. malignant proliferation of plasma cells within the bone

8. The oncology nurse specialist provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which of the following is a characteristic of the disease? a .presence of Reed-Sternberg cells b. occurs most often in the older client c .prognosis depending on the stage of the disease d. involvement of lymph nodes, spleen, and liver 9. The community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer? a . alopecia b. back pain c. painless testicular swelling d. heavy sensation in the scrotum 10. The client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: a. dyspnea b. diarrhea c. sore throat d. constipation

Unit II

Nursing Care of Clients with Cellular Aberration

By: Jobel Aringo-NuvaL, R.N. MAN- Management 1. Assessment A. Nursing History Health History chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors) Cancer signs: CAUTION US!

-Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss Risk Factors:  Heredity,Age,Gender,Poverty, Stress, Diet, Occupation, Alcohol use, obesity B. Physical Assessment y Inspection skin and mucus membranes for lesions, bleeding, petechiae, and irritation Assess stools, urine, sputum, vomitus for acute or occult bleeding Scalp noting hair texture and hair loss y Palpation Abdomen for any masses, bulges or abnormalities Lymph nodes for enlargement y Auscultation of lung sounds, heart sounds and bowel sounds 2. Nursing Diagnosis y y y y Risk for Infection as evidenced by tissue trauma or impaired immune response Risk For trauma as evidenced by high risk personal behaviors Ineffective Protection as evidenced by impaired immunity related to cancer therapy or HIV disease Ineffective Health Maintenance by lack of preventive care or health screening C. Planning 1. Planning for Health Promotion & Maintenance Cancer Prevention and Control: i. Primary Prevention = Nurses play a key role in Cancer Prevention by: y Assisting patients to avoid carcinogens. y Adopting dietary and various lifestyle changes Secondary Prevention = involves prevention programs such as breast and testicular self-examination and Papanicolaou (PAP) tests.

ii.

Screening Tests for Cancer Prevention: i. AMAS - Anti-malignant antibody screen test- designed to pick up cancers well in advance of other signs and symptoms, months before conventional medical tests can detect it. Endoscopic ultrasound- another test being used to detect tumors and help in diagnosing GI cancers. Mammography/Thermography - Mammograms can detect many breast cancers, but there is concern over false results and the hazards of radiation exposure that result from the tests. There are two new forms of mammography: Computed Tomography Laser Mammography and Full Field Digital Mammography. Hemoccult Test for colorectal cancer tests for blood in the stool. A positive finding warrants having further tests, like a colonoscopy or sigmoidoscopy to detect polyps and tumors. Pap Smears/PAPNET - examine cells from the mucous membrane of the cervix for pre-cancerous changes in cells. Digital Rectal Exam (DRE) -checks the prostate gland for any bumps or abnormalities, but it only checks the back of the prostate, so again, it must be used with other tests. PSA - Prostate Specific Antigen - Prostate Specific Antigen may help detect prostate cancer early. An elevated level may indicate cancer before the tumor is large enough to raise a bump that a doctor can feel during a check-up.

ii. iii.

iv.

v. vi.

vii.

2. Planning for Health Restoration  Surgery- surgical removal of the entire cancer remains the ideal and most frequently used treatment method. TYPES: 1. Diagnostic Surgery - such as biopsy, usually performed to obtain a tissue sample for analysis of cells. Types of Biopsy Methods: i. Excisional Biopsy = most frequently used and most accessible method for tumors of skin, breast, upper and lower gi tract and upper respiratory tract. y Incisional Biopsy = is performed if the tumor mass is too large to be removed. y Needle Biopsy = are performed to sample suspicious masses that are easily accessible such as growths in the breast, thyroid, lung, liver & kidney. 2. Prophylactic Surgery = involves removing nonvital tissues or organs that are likely to develop cancer.

3. Palliative Surgery = is performed in attempt to relieve complications of cancer such as ulcerations, obstructions, hemorrhage and malignant effusions.  Radiation Therapy ionizing radiation is used to interrupt cellular growth. Types: y External Radiation = accelerates subatomic particles ( neutrons, pions, heavy ions) through body tissue. = Also known as HIGH LINEAR ENERYGY TRANSFER RADIATION. Internal radiation = also known as BRACHYTHERAPHY. It delivers a high dose of radiation to a localized area.

 Chemotherapy- use of antineoplastic agents to destroy tumor cells by interfering w/ cellular functions & reproductions.

Chemotherapy can:
y

Cure cancer - when chemotherapy destroys cancer cells to the point that your doctor can no longer detect them in your body and they will not grow back. Control cancer - when chemotherapy keeps cancer from spreading, slows its growth, or destroys cancer cells that have spread to other parts of your body. Ease cancer symptoms (also called palliative care) - when chemotherapy shrinks tumors that are causing pain or pressure.

Chemotherapy may be given in many ways.

y

y y

y y y

Injection. The chemotherapy is given by a shot in a muscle in your arm, thigh, or hip or right under the skin in the fatty part of your arm, leg, or belly. Intra-arterial (IA). The chemotherapy goes directly into the artery that is feeding the cancer. Intraperitoneal (IP). The chemotherapy goes directly into the peritoneal cavity (the area that contains organs such as your intestines, stomach, liver, and ovaries). Intravenous (IV). The chemotherapy goes directly into a vein. Topically. The chemotherapy comes in a cream that you rub onto your skin. Orally. The chemotherapy comes in pills, capsules, or liquids that you swallow.

Common Side Effects of Chemotheraphy:

y y y y y y y y y y y y y y y y

Fatigue Nausea & Vomiting Pain Hair Loss Anemia Infection Blood Clotting Problems Mouth, Gum and Throat Problems Diarrhea and Constipation Nerve and Muscle Effects Effects on Skin and Nails Radiation Recall Kidney and Bladder Effects Flu-Like Symptoms Fluid Retention Effects on Sexual Organs and Sexuality

 Immunotherapy- the use of the immune system to reject cancer. The main premise is stimulating the patient's immune system to attack the malignant tumor cells that are responsible for the disease. Types of Immunotherapy: 1. Active immunotherapies = stimulate your body's own immune system to fight the disease. 2. Passive immunotherapies = do not rely on your body to start the attack on the disease; instead, they use immune system components (such as antibodies) made in the lab.

Side Effects of Immunotherapy:  Like other cancer treatments, immunotherapy can cause side effects that occur during treatment or soon after. Side effects include flu-like symptoms such as fever, chills, headache, and increased tiredness or fatigue.

D. Implementation y Pharmacological Therapy and antineoplastic drugs:

Commonly used Antineoplastic Drugs: 1. Alkylating agents- Alkylating agents are so named because of their ability to alkylate many nucleophilic functional groups under conditions present in cells. Ex: Cisplatin and carboplatin, oxaliplatin 2. Antimetabolites- become the building blocks of DNA. They prevent these substances from becoming incorporated in to DNA during the "S" phase (of the cell cycle), stopping normal development and division. Ex: azathioprine, mercaptopurine , pyrimidines 3. Vinca alkaloids - bind to specific sites on tubulin, inhibiting the assembly of tubulin into microtubules (M phase of the cell cycle). They are derived from the Madagascar periwinkle. Ex: Vincristine, Vinblastine, Vinorelbine, Vindesine y VEGETABLES Vegetables contain fibers and important phytonutrients which help your body fight cancer. Include generous amounts of raw and cooked vegetables in your diet. Vegetables in the brassica family (i.e., cabbage, broccoli, cauliflower, brussels sprouts, turnip, rutabaga, kale) help keep thyroid activity in check which is often beneficial for cancer patients. On the other hand, if you have hypothyroidism (low thyroid function), FRUITS Fruits contain important phytonutrients which help your body detoxify and fight cancer. Even though fruit are sweet, they contain fibers which modulate sugar uptake and therefore do not pose the same concern as eating refined sugar. Use fresh or frozen fruits; avoid canned fruits. Small amounts of dried berries may also be used. Fruit juice is high in sugar and lacking fiber and should therefore be avoided unless specifically prescribed. BROWN RICE Brown rice is a good source of vitamins, minerals, protein and fiber. It is a valuable gluten free grain which contains important phytonutrients such as lignans which are converted into cancer protective substances by the friendly flora in our intestines. Nutrition & Diet Therapy to Prevent Cancer:

FISH Fish and shellfish are low in saturated fat and contain high quality protein and other essential nutrients. Salmon, sardines, anchovies, flounder, sablefish, halibut, cod, pollock, shrimp and oysters have been shown to generally contain low levels of mercury.

FOODS TO LIMIT OR AVOID MEATS Animal proteins are readily used as nutrition for rapidly developing tumors. The cholesterol content can also be a concern. DAIRY PRODUCTS Dairy products contain proteins which can unleash the production of immunoglobulins and provoke an inflammatory reaction. FRIED FOODS Fried foods are typically high in saturated fat. Frying also causes formation of acrylamide, a cancer causing chemical. Strictly limit fried foods in your diet.

FOOD ADDITIVES Food additives such as artificial flavors, colors, sweeteners, hydrogenated (trans) fats, and preservatives contain toxic substances, allergens, and/or place a strain on the organs of elimination. Avoid them as diligently as possible.

Common Approaches to Complementary Cancer Therapy 1. Religious and spiritual approaches such as prayer, laying on of hands, or beliefs about the religious and spiritual realm. Some studies suggest that religious practices are associated with better health outcomes. Other literature discusses the benefits of intercessory prayer and other forms of faith-based healing. 2. Psychosocial approaches which may address both mental and emotional aspects of cancer. Psychological approaches include support groups, individual psychotherapy, hypnotherapy,

imagery, art therapy, and types of self-analysis and selfexpression such as structured journal writing. 3. Nutritional approaches, including special diets and nutritional supplements. These therapies range from following a basic, healthy vegetable-based diet to adopting highly restrictive diets and supplement programs. 4. Physical approaches, designed to relax, align, energize and strengthen the body. These include exercise; progressive deep relaxation; massage; chiropractic or osteopathic therapies. 5.Herbal treatments for cancer, some contemporary and some derived from traditional medicines. There is a large and growing mainstream research literature on herbal therapies. Some herbs hold clear promise for cancer treatment and others may be harmful. 6. Electromagnetic therapies, which represent an intriguing approach to cancer treatment. Therapies range from the simple use of magnets, as an adjunct to Traditional Chinese Medicine.

CHAPTER TEST
1. The nurse is caring for a client following a radical neck dissection and creation of a tracheostomy performed for laryngeal cancer and is providing discharge instructions to the client. Which statement by the client indicates a need for further instructions? a) I will protect the stoma from water b) I need to keep powders and sprays away from the stoma c) I need to use an air conditioner to provide cool air to assist in breathing d) I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking 2. What is the purpose of cytoreductive ("debulking") surgery for ovarian cancer? a) cancer control by reducing the size of the tumor b) cancer prevention by removal of precancerous tissue c) cancer cure by removing all gross and microscopic tumor cells

d) cancer rehabilitation by improving the appearance of a previously treated body part 3. Hormone therapy is prescribed as the mode of treatment for a client with prostate cancer. The nurse understands that the goal of this form of treatment is to: a) increase testosterone levels b) increase prostaglandin levels c) limit the amount of circulating androgens d) increase the amount of circulating androgens 4. The nurse is caring for a client with cancer of the prostate following a prostatectomy. The nurse provides discharge instructions to the client and tells the client to: a) avoid driving the car for 1 week b) restrict fluid intake to prevent incontinence c) avoid lifting objects heavier than 20 lb for at least 6 weeks d) notify the physician if small blood clots are noticed during urination 5. The oncology nurse is providing a teaching session to group of nursing students regarding the risks and causes of bladder cancer. Which statement by a student indicates a need for further teaching? a) bladder cancer most often occurs in women b) using cigarettes and coffee drinking can increase the risk c) bladder cancer generally is seen in client older than 40 d) environmental health hazards have been attributed as a cause 6. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching related to colorectal cancer is necessary if the client identifies which of the following as an associated risk factor? a) age younger than 50 years b) history of colorectal polyps c) family history of colorectal cancer d) chronic inflammatory bowel disease 7. The nurse is performing an admission assessment on a client diagnosed with a right colon tumor. The nurse asks the client about which characteristic symptom of this type of tumor? a) rectal bleeding b) flat, ribbon-like stool c) crampy, colicky abdominal pain d) alternating constipation and diarrhea 8. The nurse is reviewing the preoperative orders of a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the physician has prescribed neomycin (Mycifradin) for the client. The nurse determines that this medication has been prescribed primarily: a) to prevent immune dysfunction b) because the client has an infection c) to decrease the bacteria in the bowel d) because the client is allergic to penicillin

9. Overweight and obesity are major risk factors for diseases such as: a)Colin Cancer b)Diabetes c) Lung disease d) Thyroid Cancer 10. This test is being used to detect tumors and help in diagnosing GI cancers. a) Endoscopic ultrasound b) Mammogram c) Pap Smear d)Digital Rectal Exam

Unit III Shock, Sytemic Inflammatory Response syndrome, and Multiple Organ Dysfunction By: Maynard K. Baird, R.N. MN- Medical-Surgical Nursing A. SHOCK Inadequate tissue perfusion resulting to the failure of one or more of the following: (1) the Heartpump failure, (2) blood volume, (3) arterial resistance vessels, and (4) the capacity of the venous beds. 1. Classification: A. Hypovolemic Shock : lost of fluid resulting to inadequate tissue perfusion B. Cardiogenic perfusion Shock: pump failure causes inadequate tissue

C. Neurogenic Shock: rapid vasodilation blood within the

and subsequent pooling of

peripheral vessel D. Anaphylactic Shock: caused by allergic reaction causes release of histamine and vasodilation E. Septic Shock: reaction to bacterial toxins results in leakage of plasma into tissue 2. Stages: 1: Initial Stage it is reversible and no signs of shock can be identified. 2: Compensatory Stage- body tries to reverse the result of the initial stage. Physiological, neural, hormonal, & biochemical reactions are employed to correct the imbalances. 3: Progressive Stage- if initial cause is not corrected, damages become more severe and can be irreversible. 4: Refractory Stage- at this stage, organs failure and death can occur. 3. Diagnostic Studies: A. Assessment of Level of Consciousness B. Monitoring of Arterial Blood Pressure C. Pulse Quality and Rate change D. Assessment of Urinary output E. Assessment of Capillary Perfusion F. Also Assess for: I. Subjective Feeling of impending doom II. Metabolic Acidosis due to anaerobic metabolism within cells III. Excessive Thirst IV. Hyperthermia, if Septic Shock 4. Collaborative Care 4.1. General Measures 4.1.1. Oxygen and Ventilation- Administer O2 to maintain the PaO2 at 80 to 100 torr. This will augment oxygen-carrying capacity of arterial blood A. One hundred per cent oxygen by nonrebreather face mask B. Intubation if the patient is unable to manage secretions or is ventilating poorly C. If intubated, the patient may be hyperventilation to help control the acidosis

4.1.2. Fluid Resuscitation. A. Two large-bore IV lines should be established. B. Ringers lactate is the initial fluid choice. Normal saline is the second choice. C. Rate of infusion depends on severity of blood loss and clinical evidence of hypovolemia. D. Fresh whole blood is infused when there is massive blood loss E. Additional platelets and coagulation factors are given when large amounts of blood are needed 4.1.3. Drug therapy A. Inotropes are used in Cardiogenic shock. i. ii. iii. i. ii. iii. Isoproterenol Digoxin Dobutamine Dopamine Norepinephrine Metaraminol

B. Vasopressors

C. Antibioticsbroad spectrum for septic shock D. Nutritional TherapyA. Enteral Feeding B. Parenteral Feeding

4.2. Specific Measures 5. Nursing Management 5.1. Nursing Assessment A. Rapid recognition and prompt intervention B. Initial priorities in the assessment are the same for all types of shock. i. ii. iii. C. i. ii. iii. iv. v. Is the airway open? Is the patient breathing? Is there a circulation problem? Confusion Irritability Anxiety Agitation Inability to concentrate

Assess level of consciousness

D. Monitor arterial blood pressure.

E. F.

Pulse quality and rate change Assess urinary output

G. Assess capillary perfusion H. Also assess for: i. ii. iii. iv. Subjective feeling of impending doom. Metabolic acidosis Excessive thirst Hyperthermia if septic shock

5.2. Nursing Diagnoses A. Fluid volume deficit r/t loss of fluid B. C. Altered tissue perfusion: cardiopulmonary r/t arterial venous blood flow exchange problems Risk for injury r/t prolonged shock resulting in multiple organ failure 5.3. Planning 5.3.1. Health Promotion client and family be instructed of about strategies to prevent further episodes of shock by identifying the factors implicated in the initial episodes. 5.3.2. Restoration and Maintenance A. Acute Intervention i. Initiate immediate interventions as indicated. a. Resuscitate as necessary b. Administer oxygen to augment oxygen-carrying capacity of arterial blood. c. Start cardiac monitoring d. Control hemorrhage B. Ambulatory and home Care i. Keep client warm,place in supine position with legs and ii. iii. iv. v. arms elevated (modified trendelenburg position) Monitor hemodynamics status and vital signs Allay clients anxiety Administer intravenous fluids as ordered Monitor oxygen saturation and provide oxygen therapy as indicated. 6. Evaluation

A. Reduces blood/fluid loss B. Restores normal circulating volume C. Maintains a urine output of 30 mL or more per hour D. Remains oriented to time, place, and person E. Maintains adequate cardiac output

B. Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome Systemic Inflammatory Response Syndrome (SIRS): overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissue perfusion. Mutliple Organ Dysfunction Syndrome (MODS): altered organ function in acutely ill patients that requires medical interventions to achieve homeostasis.

1. Etiology

SIRS: immune response related to infection MODS: infection, injury (accident, surgery), hypoperfusion, and hypermetabolism

2. Pathophysiology SIRS y Stage I: Following an insult, local cytokine is produced with the goal of inciting an inflammatory response, thereby promoting wound repair and recruitment of the reticular endothelial system. Stage II: Small quantities of local cytokines are released into circulation to improve the local response. This leads to growth factor stimulation and the recruitment of macrophages and platelets. This acute phase response is typically well controlled by a decrease in the proinflammatory mediators and by the release of endogenous antagonists. The goal is homeostasis. Stage III: If homeostasis is not restored, a significant systemic reaction occurs. The cytokine release leads to destruction rather than protection. A consequence of this is the activation of numerous humoral cascades and the activation of the reticular endothelial

system and subsequent loss of circulatory integrity. This leads to end-organ dysfunction. y The end stage of Systemic Inflammatory Response Syndrome results to Multiple Organ Dysfunction Syndrome.

3. Clinical Manifestation of SIRS & MODS

A. SIRS y Temp >38 C or <36C y Heart rate >90 bpm y Respiratory rate >30 breaths/min y PaCO2 <32 mmhg y WBC count >12, 000 cells/mm3 ,<4000 cells/mm3, or >10% immature WBC (bands) B. MODS y Cardiovascular: Hypotension & hypoperfusion y Respiratory: hypoxia, hypercabia, adventitious breath sounds y Renal: increased creatinine, decreased urine output y Hematologic : thrombocytopenia, bleeding y Metabolic: lactic acid academia, metabolic acidosis y Neurologic: altered Level of consciousness y Hepatic: Elevated Liver function test

3. Nursing and Collaborative Management 4.1. Prevention and control of infection Nursing caring for patients in any setting must keep in mind the risks of sepsis and high mortality rate associated with sepsis, sever sepsis, and septic shock. A. Invasive procedures must be carried out wit aseptic technique after careful hand hygiene. B. IV line, arterial and venous punctures sites, surgical incisions, traumatic wounds, urinary catheters, and pressure ulcers must be monitored for signs of infection and sepsis. C. Elevated body temperature may not be treated unless they reached dangerous levels (more than 40C) or unless patient is uncomfortable D. Administers prescribed IV fluids and medication including antibiotic agents and vasoactive medications, to restore vascular volume. E. Monitors hemodynamics status, fluid intake and output, and nutritional status F. Daily weights and close monitoring of serum albumin levels help determine the patients protein requirement

4.2. Maintenance of tissue Oxygenation A. Supplemental oxygen is administered via nasal cannula at a rate of 2- 6 L/min to achieve an oxygen saturation exceeding 90% B. Monitoring blood gas values and pulse oximetry values 4.3. Nutrition and Metabolic Demands A. Nutritional supplementation should be started within the first 24 hours B. Continuous insulin should be used to control hyperglycemia C. Enteral feedings are preferred than parenteral route because of increased risk of infection associated with IV catheters D. But if decreased perfusion to the GI tract and decreased persitalsis thereby decreasing absorption, parenteral route is the management. 4.4. Support of failing Organ

A. Assisting with Cardiac support y y y Intraaortic ballon pump (IABP) Medical anti-shock trouser (MAST) Modified Trendelenburg position

B. Assisting with respiratory support y y y y Oxygen therapy Mechanical ventilation (positive end-expiratory pressure for ARDS) Deep breathing, coughing exercises Suction as necessary

C. Assisting with renal support y y Monitor hourly urine output, BUN, s. creatinine Diuretics: furosemide, urea, mannitol

D. Assisting with G.I. Support (prevent/ stress ulcer) y NGT to suction y Histamine blockers y Antacids

Respiratory Failure and Acute Respiratory Distress Syndrome A. Respiratory Failure

1. Etiology and Pathophysiology Oxygen Failure Characterized by a decreased in PaO2 and normal or decreased PaCO2 A. Primary problem is inability to adequately oxygenate the blood, resulting in hypoxemia. B. Hypoxemia occurs because damage to the alveolar-capillary membrane causes leakage of fluid into the interstitial space or into the alveoli and slows or prevents movement of oxygen from the alveoli to the pulmonary capillary blood. i. Typically, this damage is widespread, resulting in many areas of the lung being poorly ventilated or nonventilated. Consequences are severe ventilation-perfusion imbalance and shunt.

ii.

C. Hypocapnia results from hypoxemia and decrease pulmonary compliance. Fluid within the lungs makes the lung less compliant or stiffer. i. Change in compliance reflexively stimulates the increased ventilation ii. Ventilation is also increased as response to hypoxemia. iii. Ultimately, if treatment id unsuccessful, the Pa02 will increase, and the patient will experience both an increase in PaCO2 and a decrease in PaO2. D. Etiology includes: i. Cardiogenic distress syndrome (ARDS). Underlying causes of ARDS include shock of any etiology ; infectious causes such as gram-negative sepsis, viral pneumonia, bacterial pneumonia; trauma such as fat emboli, head injury, lung contusion; aspiration of gastric fluid, near drowning; inhaled toxins such as oxygen in high concentration, smoke, corrosive chemicals; hematologic conditions such as massive transfusions, post-cardiopumonary bypass; and metabolic disorders such as pancreatitis, uremia.

Ventilatory Failure with normal lungs Characterized by a decrease in PaO2, increase in PaO2, and a decrease in pH. A. Primary problem is insufficient respiratory center stimulation or insufficient chest wall movement, resulting in alveolar hypoventilation.

B. Hypercapnia occurs because impaired neuromuscular carbon dioxide removed from lungs. i. Primary problem is insufficient respiratory center stimulation or insufficient chest wall movement, resulting in alveolar hypoventilation. ii. Hypercapnia occurs because impaired neuromuscular function or chest walla expansion limits the amount of carbon dioxide removed from the lungs. a. Primary problem is not the lungs. the patient;s minute ventilation (tidal volume times the number of breaths per minute ) is insufficient to allow normal alveolar gas exchange. C. The CO2 not exceed by the lungs combines with H20 to form carbonic acid. This predisposes to academia and fall in pH. D. Hypoxemia occurs as a consequence of hypercapnia. When the PaCO2 rises , the PaO2 must fall unless increased amounts of oxygen are added to the inspired air. E. Etiology includes: i. Insufficient respiratory center activity (drug intoxication such as narcotic overdose, general anesthesia; vascular disorders such as cerebral vascular insufficiency, brain tumor; trauma such as head injury, increased intracranial pressure). ii. Insufficient chest wall function (neuromuscular disease such as Gullain-Barre, myasthenia gravis, poliomyelitis; trauma to the chest wall resulting in multiple fractures; spinal cord trauma; kyphoscoliosis). Ventilatory Failure With Intrinsic Lung Disease Characterized by a decrease in PaO2 and decreased pH A. Primary problem is acute exacerbation or chronic progesion of previously existing lung disease, resulting in CO2 retention. B. Hypercapnia occurs because damage to the lung parenchyma and/or airway obstruction limits the amount of carbon dioxide removed by the lungs. i. Primary problem is preexisting lung diseaseusually chronic bronchitis, emphysema, or severe asthma. This limits CO2 removal from the lungs. C. The CO2 not excreted by the lungs combines with H20 to form carbonic acid (H2CO3). This predisposes to academia and a fall in pH. D. Hypoxemia occurs as a consequence of hypercapnia. In addition, damage to the lung parenchyma and/or airway obstruction limits the amount of oxygen that enters the pulmonary capillary blood. E. Etiology includes:

i. ii. iii.

Chronic onstructive pulmonary disease or COPD Sever asthma Cystic fibrosis

2. Clinical Manifestations A. Hypoxemiarestless, agitation, dypnea, disorientation, confusion, delirium, loss of consciousness B. Hypercapneaheadache, somnolence, dizziness, confusion C. Tachypnea initially; then when no longer able to compensate, bradypnea D. Accessory muscle use E. Asynchronous respirations 3. Diagnostic Studies A. ABGsshow changes in PaO2, PaCO2, and pH from patients normal; or PaO2 less than 50 mm Hg, PaCO2 greater than 50 mmHg, pH less than 7.35. B. Pulse oximetrydecreasing SaO2. C. End tidal CO2, monitoringelevated D. CBC, serum electrolytes, (ECG), blood chest and x-ray, sputum urinalysis, culturesto electrocardiogram

determine underlying cause and patients condition. 4. Nursing and Collaborative Care 4.1. Nursing Assessment A. Note changes suggesting increased work of brething (diaphoresis, intercostamuscle retraction) or pulmonary edema (fine, coarse crackles). B. Assess breath sounds. i. Diminished or absent sounds indicate inability to ventilate atelectasis. ii. iii. iv. Crackles indicate ineffective airway clearance, fluids in lungs. Wheezing bronchopasm Rhonchi and crackles indicate ineffective secretion clearance C. Assess level of consciousness and ability to tolerate in creased work breathing i. Confusion, rapid swallow breathing, abdominal paradox (inward movement of abdominal wall during inspiration), and intercostals retractions indicates narrowed airways and the lungs sufficiently to prevent

suggest inability to maintain adequate minute ventilation. D. Assess for sign of hypoxemia and hypercapnia. E. Determine vital capacity (VC), respiratory rate, minute ventilation (Ve), and negative inspiratory force

4.2. Nursing Diagnoses A. Impaired gas exchange related to loss of functioning lung tissue and inadequate ventilation/perfusion ratio. B. Ineffective airway clearance related to increased tenacious secretions C. Anxiety related to oxygen deprivation D. Risk of infection related to microbial invasion E. Fear related to air hunger and mechanical ventilation 4.3. Planning 4.3.1. Prevention i. Instruct patient with preexisting pulmonary disease to seek early intervention for infections to prevent acute respiratory failure Teach patient about medication regimen Encourage patients at risk, especially the elderly and those with preexisting lung disease, to get yearly influenza and pneumococcal pneumonia (approx. once every 10 years) immunization.

ii. iii.

4.3.2. Restoration i. ii. iii. Oxygen therapy to correct hypoxemia. Chest physical therapy and hydration to mobilize secretions. Mechanical ventilation as indicated. Noninvasive positive-pressure ventilation using face mask has been tied in some patients. Bronchodilators and possibly corticosteroids to reduce brochospasm and inflammation, surfactant replacement therapy, neutrophils inhibitors. Diuretics for pulmonary congestion. Medical supportive almost always includes intubation and mechanical ventilation, circulatory support, adequate fluid volume. ARDS requires 35-45 kcal/kg per day to meet caloric requirements. Enteral feeding is the first consideration.

iv.

v. vi.

vii.

5. Evaluation A. Maintains adequate gas exchange B. Alleviation of pain and discomfort C. Maintains adequate airway clearance and effective breathing pattern D. Absence of infections and complications B. Acute Respiratory Distress Syndrome 1. Etiology and Pathophysiology A. Pulmonary and/or nonpulmonary insult to the alveolar-capilalry membrane causing fluid leakage into interstitial spaces. B. Ventilation-perfusion (V/Q) mismatch caused by shunting of blood C. Etiologies are numerous and can be pulmonary or non-pulmonary. These include (but not limited to): i. ii. iii. iv. v. Pneumonia, sepsis, aspiration Shock (any cause), trauma Metabolic, hematologic, and immunologic disorders Inhaled agentssmoke, high concentration of oxygen, corrosive substances Major surgery, fat or air embolism

2. Clinical Progression and Manifestation A. Severe dyspnea, use of accessory muscles. B. Increasing requirements of oxygen therapy. Hypoxemia refractory to supplemental oxygen therapy C. Severe crackles and rhonchi heard on auscultation. 3. Complications A. Infections such as pneumonia, sepsis B. Respiratory complications such as pulmonary emboli, barotraumas, oxygen toxicity, subcutaneous emphysema, or pulmonary firbrosis. C. Gastrointestinal complications such as stress ulcer, ilues D. Cardiac complications such as decreased cardiac output and dysrhythmias E. Renal failure disseminated intravascular coagulation (DIC). 4. Nursing and Collaborative Management 4.1. Nursing Assessment

I.

Increase in respiration

II. Dyspnea III. Retractions IV. Central Cyanosis V. Dry cough VI. Fine crackles VII. Fever VIII. Alteration in Level of Consciousness IX. ABGs : Decrease PaO2 and increase PaCO2 4.2. Nursing Diagnoses A. Impaired gas exchange related to unequal ventilation/ perfusion B. Anxiety related to fear of death

4.3.

Planning

4.3.1. Respiratory Therapy A. Positive end respiratory pressure (PEEP) is critical part in the treatment of ARDS. PEEP helps increase functional residual capacity and reverse alveolar collapse by keeping the elveoli open. 4.3.2. Medical Supportive Therapy A. Medical supportive almost always includes intubation and mechanical ventilation, circulatory support, adequate fluid volume. B. Medications are aimed at treating the underlying cause. Corticosteroids are used infrequently due to the controversy regarding benefits of usage C. Fluid management must be maintained. The patient may be hypovolemic due to the movement of fluid into the interstitium of the lung. Critical Care A. Hemodynamic Monitoring 1. Terminology 1.1. Cardiac Output and Cardiac Index the amount (volume) of blood ejected by the left ventricle into the aorta in 1 minute. The normal cardiac output is 4-8 L/min. Cardiac index is cardiac output divided by body surface are (BSA) to determine cardiac output measurement. Normal CI is 2.5-4.0 L/min/m2. 1.2. Preload the amount of blood returning to the heart

1.3. Afterload venous tone, resistance imposed on the ventricle before ejection. 1.4. Vascular resistance the resistance to flow that should be overcome to push blood for systemic circulation 1.5. Contractility intrinsic ability of the heart to contract independent of preload and afterload. 2. Principles 2.1. Referencing y The phlebostatic axis is the crossing of twon reference lines (1) a line from the 4th intercostal space at the point where it joins the sternum, drawn out to the side of the body beneath the axilla; (2) a line midpoint between the anterior and posterior surfaces of the chest y If phlebostatic axis is used you can correctly measure the CVP with the patient supine at any back rest position up to 45. Normal CVP is 0-8 mm hg with a pressure monitor system or 38 cm H2O with water manometer system. 2.2. Zeroing y The accuracy of the invasive pressure measurements is dependent upon the proper reference point. y The zero points of manometer is adjusted to midaxillary line. This is the level of the patients heart 3. Types 3.1. Invasive Pressure Monitoring 3.1.1 Arterial Blood Pressure y Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill patients who have severe hypertension or hypotension. y Arterial catheters can also be used when ABG and blood samples need to be obtained frequently.

3.1.2. Pulmonary Artery Flow-Directed Catheter y Important tool used in critical care fro assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the patients response to medical interventions (eg, fluid administration , vasoactvive medications). y Pulmonary artery pressure monitoring involves the use of a pulmonary artery catheter and pressure monitoring system. 3.2. y Non-invasive oxygenation monitoring Pulse Oximetry continuous monitoring of the arterial oxygenation or SpO2; normally 95%-100%.

4. Nursing Management in Hemodynamic monitoring

I. II. III. IV. V. VI. VII.

Assist the physician in inserting the catheter using surgical aseptic technique Observe the insertion for inflammation Observe the line for patency and air bubbles Take readings with client in supine position if possible with transcuder at the level of the clients sternal notch Provide site care Notify the physician if the wave form changes or pressure readings are altered Ensure the balloon does not remain inflated after wedge pressure dtermination

B. Circulatory Assist Devices 1. Intraaortic Baloon output. Pump-Increasing mechanical while at cardiac device the same output that time increases

increases myocardial oxygen perfusion increasing cardiac

coronary blood flow and therefore myocardial oxygen delivery. 2. Ventricular Assist Device (VAD)-- mechanical circulatory device that is used to partially or completely replace the function of a failing heart. 3. Implantable Artificial Heart-- mechanical device that replaces the heart. Artificial hearts are typically used in order to bridge the time to heart transplantation, or to permanently replace the heart in case transplantation is impossible. 4. Nursing Management in Circulatory Assist Device A. Observe patient for: Bleeding, cardiac tamponade, ventricular failure, infection, dysrythmias, renal failure, hemolysis, and thromboembolism B. Patient may be mobile and will require an activity plan C. Psychologic support for patient and family is essential D. Goals: y y y Recovery through ventricular improvement Heart transplantation Artificial heart transplantion

C. Artificial Airways

1. Endotracheal Tubes flexible tube inserted through the mouth or nose and into the trachea beyond the vocal cords that acts as an artificial airway. 2. E.T. Intubation Procedures A. Preparatory Phase 1. Assess the patients heart rate, level of consciousness, and respiratory status B. Performance Phase 1. Remove the patients dental bridgework and plates. 2. Remove headboard of bed (optional) 3. Prepare equipement a. Ensure function of resuscitation bag with mask and suction. b. Assemble the laryngoscope.make sure the light bulb is tightly attached and functional c. Select an endotracheal tube of the appropriate size (6.0-9.0 mm for average adult). d. Place the ET tube on the sterile towel. e. Inflate the cuff to make sure it assumes a symmetric shape and holds volume without leakage. Then deflate maximally f. Lubricate the distal end of the tube liberally with sterile anesthetic water-soluble jelly. g. Insert the stylet into the tube (if oral intubation is planned). Nasal intubation does not employ use of the stylet. 4. Aspirate stomach contents if nasogastric tube is in place. 5. If time allows, inform the patient of the impending inability to talk and discuss alternative means of communication 6. If the patient is confused, it may be necessary to apply soft wrist restraints 7. Put on gloves and face shield 8. During oral intubation if cervical spine is not injured, place patient head in a sniffing position 9. Spray the back of the patients throat with anesthetic spray if time is available. 10. Ventilate and oxygenate the patient with resuscitation bag and mask before intubation 11. Hold the handle of the laryngoscope in the left hand and hold the patients mouth open with right hand by placing crossed fingers on the teeth 12. Insert the curved blade of the laryngoscope along the right side of the tongue, push the tongue to the left, and use right thumb and index finger to pull patients lower lip away from lower teeth. 13. Lift laryngoscope forward to expose the epiglottis

14. Lift laryngoscope upward and forward at a 45-degree angel to expose glottis and visualize vocal cords. 15. As the epiglottis is lifted forward, the vertical opening of the larynx between the vocal cords will come into view. 16. Once vocal cords are visualized, insert tube into the right corner of the mouth and pass the tube while keeping vocal cords in constant view. 17. Gently push the tube through the triangular space formed by the vocal cords and back wall of trachea 18. Stop insertion just after the tube cuff has disappeared from view beyond the cords. 19. Withdraw laryngoscope while holding endotracheal tube in place. Dissemble mask from resuscitation bag, attach bag to ET tube, and ventilate the patient. 20. Inflate cuff with the minimal amount of air required to occlude the trachea 21. Insert bite block if necessary. 22. Ascertain expansion of both side of the chest by observation and auscultation of breath sounds. 23. Record distance from proximal end of the tube to the point where the tube reaches the teeth 24. Secure tube to the patients face with adhesive tape or apply a commercially available endotracheal tube stabilization device. 25. Obtain chest x-ray to verify tube position. 3. Nursing management of Artificial airway A. Maintaining an Endotracheal Tube 1. Every 2 hours, assess client for: a. Level of consciousness, respiratory status, vital signs, and temperature. b. Symmetry of chest excursion with inspiration and presence of breath sounds bilaterally 2. Inspect the Et tube every 2 to 4 hours to determine if it is obstructed by kinks, mucous plugs, secretions, or clients bite. 3. Check ventilator, if applicable, for high or increasing ventilation pressures. 4. Check tube holder or tape for severe odor, soiling, and stability. 5. Replace tape/holder only when needed. To replace holder, see vendors instructions. 6. Inspect area around the tube. 7. Perform oral care every 2-4 hours (suctioning, swabs, and petroleum jelly to lips). 8. Assess cuff status 9. Properly dispose of or store supplies or equipments

10. Position client for comfort with head of bed 45 degrees, side rails up, call light within reach. D. Mechanical Ventilation 1. Types A. Negative Pressure Ventilators applies negative pressure around the chest wall B. Positive Pressure Ventilators- during mechanical inspiration, air is actively delivered to the patients lungs under positive pressure. Exhalation is passive. Requires used of cuffed artificial airway. i. Pressure limited volume delivered depends on lung compliance. the lung compliance 2. Settings of Mechanical Ventilation A. Tidal Volume (Vt) amount of air, in milliliters per breath delivered during inspiration. B. Rate- number of breaths per minute administered. C. Fraction of inspired oxygen (FiO2) - percentage of oxygen in the air administered. D. Positive end-expiratory pressure (PEEP)- constant positive pressure in the alveoli that helps keep them open and prevents closing and atelactasis E. Ventilator dead space- circuitry (tubing) common to inhalation and exhalation; tubing is calibrated. 3. Modes of Volume Ventilation A. Controlled Ventilation cycles automatically at rate selected by operator B. Assist-Control (A/C) inspiratory cycle of ventilator is activated by the patients voluntary inspiratory effort and delivers preset volume or pressure C. Intermittent Mandatory Ventilation (IMV)periodically, at preselected rate and volume or pressure, cycles to give a mandated ventilator breath. A minimum level of ventilation is provided. D. Synchronized Intermittent Mandatory Ventilation (SIMV)Periodically, at a preselected time, a mandatory breath is delivered. The patient may initiate the mandatory breath with own inspiratory effort, and the ventilator breath will be synchronized with the patients efforts, or will be assisted. ii. Volume limited- delivers the predetermined volume regardless of

4. Modes of Pressure Ventilation A. Pressure Support- a positive pressure is set; during spontaneous inspiration, ventilator circuitry is rapidly pressurized to the predetermined pressure and held at this pressure. B. Positive End-Expiratory Pressure- maneuver by which pressure during mechanical ventilation Is maintained above atmospheric at end of exhalation, resulting in an increased functional residual capacity. Airway pressure is therefore positive throughout the entire ventilator cycle. C. Continuous Positive Airway Pressure (CPAP)- provides positive airway pressure during all parts of a respiratory cycle. 5. Other Ventilatory Maneuvers A. Inverse Ratio Ventilation (IRV)- I:E ratio is greater than 1 (normally, inspiration is shorter than expiration) B. Non-invasive Positive Pressure ventilation (NIPPV)- uses a nasal mask, nasal pillow,oral mask, or mouth piece attached to a standard ventilator. Delivers air through portable ventilator that is either volume cycled or flow cycled. C. High Frequency Ventilation (HFV)- uses very small tidal volumes (less that dead space volume) and high frequency 100). 6. Complications of Positive pressure Ventilation A. Decrease Cardiac Output B. Possible alveaolar rupture C. Antidiuretic hormone formation leading to decrease urine output 7. Weaning from Positive Pressure Ventilation and Extubation Weaning: A. For weaning to be successful, the patient must be physiologically capable of maintaining spontaneous respirations. Criteria for weaning: i. ii. iii. iv. Vital Capacity- patients ability to take deep breaths and should be 10-15 mL/Kg . Maximum inspiratory pressurepatients respiratory muscle strength Tidal volume- should be 3.5 mL/Kg for weaning Minute Ventilationequal to the respiratory rate multiplied by tidal volume. Normal is aout 6L/min. (ratios greater than

v. vi.

Rapid/shallow rate by tidal volume- to assess breathing pattern The underlying disease process is significantly reversed, as evidenced by pulmonary examination, ABGs, chest xray.

vii. viii. ix. x. xi.

Patient can mechanically perform ventilation. should be able to generate a negative inspiratory force (NIF) Have spontaneous respiration rate of <25 bpm without significant tachycardia Be normotensive Have optimal hemoglobin for condition Normal nutritional status

B. Assess for other factors that may cause respiratory insufficiency such as acid-base abnormality, nutritional depletion, electrolyte abnormality, fever, abnormal fluid balance, hyperglycemia, infection, pain, decrease LOC. C. Assess psychological readiness for weaning D. SIMV is indicated if the patient satisfies all the criteria fro weaning but cannot sustain adequate spontaneous ventilation for long periods E. PAV mode allows to generate pressure in proportion to the patients efforts. With every breath, the ventilator synchronizes with the patients ventilatory efforts. F. CPAP allows patient to breathe spontaneously while applying positive pressure throught the respiratory cycle. G. When patient can breathe spontaneously, weaning trials using T-piece or tracheostomy mask are normally conducted with patient disconnected from the ventilator. H. Patient is maintained in higher oxygen concentration than when receiving mechanical ventilation I. S/he is observed for signs and symptoms of hypoxia, increasing respiratory muscle fatigue, or systemic fatigue. J. If the patient appears to be tolerating T-piece trial, a second set of arterial blood gas measurements is drawn K. The patient is placed back on the ventilator every time shows signs of fatigue or deterioration develop. L. If clinically stable, the patient can be extubated within 2 or 3 hours after weaning and allowed spontaneous ventilation by means of a mask with humidified oxygen. 8. Chronic Mechanical Ventilation y There are conditions where patient would continue extended care at home while receiving mechanical ventilation with a tracheostomy tube. Conditions like neuromuscular condition or chronic obstructive pulmonary disease. y Ultimate goal is to enchance the patients quality life not simply support or prolong life.

ALTERATION IN PATTERNS OF HEALTH A. Competencies for Registered Nurses Responding to Mass Casualty Incidents

1. Core Competencies 1.1 Critical Thinking I. Use an ethical and nationally approved framework to support decision-making and prioritizing needed in disaster situations. II. Use clinical judgment and decision-making skills in assessing the potential for appropriate, timely individual care during a mass casualty incident. III. Use clinical judgment and decision-making skills in assessing the potential for appropriate, individual ongoing-care after a mass casualty incident. IV. Describe at the pre-disaster, emergency and post-disaster phases the essential nursing care for: y individuals, y families, y special groups, e.g. children, elderly, pregnant women; and y communities. V. Describe accepted triage principles specific to mass casualty incidents. 1.2. Assessment I. General a. Assess the safety issues for self, the response team, and victims in any given response situation in collaboration with the incident response team. b. Identify possible indicators of a mass exposure (i.e, clustering of individuals with the same symptoms. c. Describe general signs and symptoms of exposure to selected chemical, biological, radiological, nuclear, and explosive agents (CBRNE). d. Demonstrate the ability to access up-to-date information regarding selected nuclear, biological, chemical, explosive, and incendiary agents. e. Describe the essential elements included in a mass casualty incident (MCI) scene assessment. f. Identify special groups of patients that are uniquely vulnerable during a MCI, e.g. the very young, aged, immunosuppressed. II. Specific

a.

Conduct a focused health history to assess potential exposure to CBRNE agents.

b. Perform an age-appropriate health assessment, including: y y y y y y y y y airway and respiratory assessment, cardiovascular assessment, including vital signs and monitoring for signs of shock, Integumentary assessment, particularly a wound, burn, and rash assessment, pain assessment, injury assessment from head to toe, gastrointestinal collection, basic neurological assessment, musculoskeletal assessment, and mental status, spiritual, and emotional assessment. the the immediate long-term psychological psychological response response of of the the assessment, including specimen

c. Assess d. Assess

individual, family, or community following a MCI. individual, family, or community following a MCI. e. Identify resources available to address the psychological impact, e.g. Critical Incident Stress Debriefing (CISD) teams, counselors, Psychiatric/Mental Health Nurse Practitioners (P/MHNPs). f. Describe the psychological impact on responders and health care providers.

1.3. Technical Skills I. Demonstrate safe administration of medications, particularly vasoactive and analgesic agents, via oral (PO), subcutaneous (SQ), intramuscular (IM), and intravenous (IV) administration routes. II. III. IV. Demonstrate the safe administration of immunizations, including smallpox vaccination. Demonstrate knowledge of appropriate nursing interventions for adverse effects from medications administered. Demonstrate basic therapeutic interventions, including: y y y y y y basic first aid skills, oxygen administration and ventilation techniques, urinary catheter insertion, naso-gastric tube insertion, lavage technique, i.e. eye and wound, and; initial wound care.

V.

Assess the need for and initiate the appropriate CBRNE isolation and decontamination procedures available, ensuring that all parties understand the need.

VI.

Demonstrate knowledge and skill related to personal protection and safety, including the use of Personal Protective Equipment (PPE) for: y y y Level B protection, Level C protection, and Respiratory protection.

VII.

Implement fluid/nutrition therapy, taking into account the nature of injuries and/or agents exposed to and monitoring hydration and fluid balance accordingly.

VIII. IX.

Assess and prepare the injured for transport, if required, including provisions for care and monitoring during transport. Demonstrate the ability to maintain patient safety during transport through splinting, immobilization, monitoring, and therapeutic interventions.

X.

Demonstrate use of emergency communication equipment and information management techniques required in a MCI response.

1.4. Communication I. II. III. Describe the local chain of command and management system for emergency response during a MCI. Identify your role, if possible, within the emergency management system. Locate and describe the emergency response plan for ones place of employment and its role in community, state, and regional plans. Identify ones own role in the emergency response plan for the place of employment. Discuss security and confidentiality during a MCI. Demonstrate appropriate emergency documentation of assessments, interventions, nursing actions and outcomes during and after a MCI. Identify appropriate resources for referring requests from patients, media, or others for information regarding MCIs. Describe principles of risk communication to groups and individuals affected by exposure during a MCI. Identify reactions to fear, panic and stress that victims, families, and responders may exhibit during a disaster situation. Describe appropriate coping strategies to manage self and others.

IV. V. VI.

VII. VIII. IX. X.

2. Core Knowledge Areas 2.1. Health Promotion, Risk Reduction, and Disease Prevention

I.

Identify possible threats and their potential impact on the general public, emergency medical system, and the health care community. II. Describe community health issues related to MCI events, specifically limiting exposure to selected agents, contamination of water, air, and food supplies, and shelter and protection of displaced persons. Health Care Systems and Policy I. Define and distinguish the terms disaster and mass casualty incident (MCI) in relation to other major incidents or emergency situations. II. Define relevant terminology, including: y CBRNE, y weapons of mass destruction y Triage y chain of command and management system for emergency response, y personal protective equipment (PPE), y scene assessment, and y comprehensive emergency management. III. Describe the four phases of emergency management: preparedness, response, recovery and mitigation. IV. Describe the local emergency response system for disasters. V. Describe the interaction between local, state and federal emergency response systems. VI. Describe the legal authority of public health agencies to take action to protect the community from threats, including isolation, quarantine, and required reporting and documentation. VII. Discuss principles related to a MCI site as a crime scene, e.g. maintaining integrity of evidence, chain of custody. VIII. Recognize the impact MCIs may have on access to resources and identify how to access additional resources, e.g. pharmaceuticals, medical supplies. Illness and Disease Management I. Discuss the differences/similarities between an intentional biological attack and that of a natural disease outbreak. Describe, using an interdisciplinary approach, the short term and long term effects of physical and psychological symptoms related to disease and treatment secondary to MCIs. Information and Health Care Technologies Describe use of emergency communication equipment that you will be required to use in a MCI response. Discuss the principles of containment and decontamination.

2.2.

2.3.

II.

2.4. I. II.

III. IV.

Describe procedures for decontamination of self, others, and equipment for selected CBRNE agents. Describe how nursing skills may have to be adapted while wearing PPE. Ethics Identify and discuss ethical issues related to MCI events: y Rights and responsibilities of health care providers in MCIs, e.g. refusing to go to work or report for duty, refusal of vaccines. y Need to protect the public versus an individuals right for autonomy, e.g. right to leave the scene after contamination. y Right of the individual to refuse care, informed consent. y Allocation of limited resources. y Confidentiality of information related to individuals and national security. y Use of public health authority to restrict individual activities, require reporting from health professionals, and collaborate with law enforcement. Describe the ethical, legal, psychological, and cultural considerations when dealing with the dying and or the handling and storage of human remains in a mass casualty incident. Identify and discuss legal and regulatory issues related to: y abandonment of patients; y response to a MCI and ones position of employment; and y various roles and responsibilities assumed by volunteer efforts. Human Diversity Discuss the cultural, spiritual, and social issues that may affect an individuals response to a MCI. Discuss the diversity of emotional, psycho-social and sociocultural responses to terrorism or the threat of terrorism on ones self and others.

2.5. I.

II.

III.

2.6. I. II.

3. PROFESSIONAL ROLE DEVELOPMENT I. Describe these nursing roles in MCIs: Researcher, Investigator/epidemiologist, EMT or First Responder, Direct care provider, generalist nurse, Direct care provider, advanced practice nurse, Director/coordinator of care in hospital/nurse administrator or emergency department nurse manager, On-site coordinator of care/incident commander, On-site director of care management,

II. III. IV.

V.

VI.

Information provider or educator, particularly the role of the generalist nurse, Mental health counselor, and Member of planning response team. Member of community assessment team. Manager or coordinator of shelter. Member of decontamination team. Triage officer Identify the most appropriate or most likely health care role for oneself during a MCI. Identify the limits to ones own knowledge/skills/abilities/authority related to MCIs. Describe essential equipment for responding to a MCI, e.g. stethoscope, registered nurse license to deter imposters, packaged snack, change of clothing, bottles of water. Recognize the importance of maintaining ones expertise and knowledge in this area of practice and of participating in regular emergency response drills. Participate in regular emergency response drills in the community or place of employment.

Unit Exam
1. This is the stage of shock where signs and symptoms begin to manifest due to the negative feedback of the body. a. Initial stage c. compensatory stage b. Progressive d. refractory stage

2. This is the distinctive characteristic of septic shock compared to other types of shock a. confusion c. hypotension b. tachycardia d. hyperthermia 3. This is defined as the amount of blood returning to the heart a. Preload c. contractility b. After load d. vascular resistance 4. In hemodynamic monitoring, as a nurse u are tasked to read the current CVP of your patient. Based on you knowledge, the CVP normal range is a. 20-30 cm H20 c. 3-8 mm H20 b. 3-8 cm H2O d. 8-15 cm H20 5. Maintaining Endotracheal Tube, the nurse knows that it is essential to check patency of airway every? a. 2-4 hours c. per shift b. 8-12 hours d. 48 hours 6. The definitive test in determining that ET Tube is in place is: a. Auscultation of lung fields b. Observation of rise and fall of chest c. X-ray laboratory d. non of the above

7. The Physician asked you to give your recommendation if your patient is ready for weaning from ventilator and ultimately for extubation, as the nurse you would report one of these signs that disqualifies patient to be weaned. Patient can mechanically perform ventilation & able to generate a negative inspiratory force (NIF) b. Have spontaneous respiration rate of <25 bpm without significant tachycardia c. Is normotensive d. The underlying disease process has not been significantly reversed. 8. This is part of the core competency of a Registered Nurses Responding to Mass Casualty Incidents in which you Use clinical judgment and decision-making skills in assessing the potential for appropriate, timely individual care during a mass casualty incident. a. Critical thinking b. Assessment c. Technical skills d. Communication 9. Part of the core competency of a Registered Nurses Responding to Mass Casualty Incidents in which you, as a nurse, demonstrate safe administration of medications, particularly vasoactive and analgesic agents, via oral (PO), subcutaneous (SQ), intramuscular (IM), and intravenous (IV) administration routes. a. b. c. d. Communication Technical Skills Assessment Critical Thinking a.

10. This is a type of mechanical ventilator in which it applies negative pressure to the chest wall a. Negative pressure ventilator b. Positive Pressure Ventilator c. Pressure Limited d. Volume Limited.

By: : Amor Mei Candido Ochoa, R.N. Jobel Aringo-NuvaL, R.N. Maynard K. Baird, R.N.

A. Essentials of a Disaster Planning 1. Definition of Disasters y Forces overwhelm a community. y Services are compromised. y Outside assistance is required. 2. Types of Disasters 2.1. Natural 1.1.1 Earthquakes - shaking and vibration at the surface of the earth resulting from underground movement along a fault plane of from volcanic activity.

1.1.2

Floods - the rising of a body of water and its overflowing onto normally dry land; "plains fertilized by annual inundations"

2.1.3. Torandoes and Hurricanes A rotating column of air ranging in width from a few yards to more than a mile and whirling at destructively high speeds, usually accompanied by a funnel-shaped downward extension of a cumulonimbus cloud.

1.1.3

Volcanic eruptions - the sudden occurrence of a violent discharge of steam and volcanic material.

1.1.4

Tsunamis - a cataclysm resulting from a destructive sea wave caused by an earthquake or volcanic eruption;

1.2

Man made 2.2.1. Biological terrorism - is terrorism involving the intentional release or dissemination of biological agents (bacteria, viruses, or toxins), that may be in a naturallyoccurring or in a human-modified form. 2.2.2. Biochemical terrorism - the deliberate dispersion of viruses, bacteria, and organic or inorganic toxin agents, to kill, mutilate, and create chaos. 2.2.3. Chemical spills - spill is a situation which a chemical is accidentally released. In case of non-toxic chemicals, dealing with a fungi,

in the spill

is usually very straightforward, since the spill simply needs to be cleaned up.

2.2.4.

Radiological (nuclear) events whose energy is produced by a nuclear transformation, either fission or fusion.

2.2.5. Fires - the process of combustion of inflammable materials producing heat and light and (often) smoke.

2.2.6. Explosions (Blast/Bomb) - a violent release of energy caused by a chemical or nuclear reaction.

2.2.7. Transportation Accidents - A traffic collision (motor vehicle collision, motor vehicle accident, car accident, or car crash) is when a road vehicle collides with another vehicle, pedestrian, animal, road debris, or other geographical or architectural obstacle 2.2.8. Armed Conflicts - the waging of armed conflict against an enemy.

2.2.9. Acts of War Classifications of Man Made Disasters A. Complex emergencies - are situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment. B. Technological Disasters - are usually associated with manmade infrastructure, and are typically accidental.

Phases of a Disaster Pre-disaster Warning Impact Emergency isolation rescue remedy Recovery

Immediate Physical Management of the Disaster Victim Validate what you hear Perform a thorough assessment Assess for other injuries/illnesses even when symptoms are absent Is the condition life-threatening What is past medical history? Do not ignore patient fears or complaints

Management of the Psychosocial Aspects of a Disaster Victim Pre-disaster Preparations and Warning Phase reactions: apathy to panic interventions: mock drills, leadership important goal interventions: mental health services Impact and Emergency Phase reaction: disaster syndrome Interventions: prevent isolation, rumor control Recovery Phase reaction interventions

Reactions of Children to a Disaster Developments level Familys reactions Separation anxiety School refusals Enuresis Guilt

Elderly Reactions Generally cope better Prob. related to chronic illness/resources Fear loss of independence

Interventions assistance with clean up financial, legal, and tax info. refer to a support team refer to appropriate comm. Agencies

Caregivers Reactions Same as Victim Role Strain Concerns over Personal Safety & Family Possessiveness towards victims Nurse - parent identification with pediatric victims Interventions clear disaster plans & disaster exercises

Criteria for Post Traumatic Stress Disorder The trauma is universally recognized Re-experience the trauma Demonstrate either emotional numbing or decrease in normal events

Role of the Nurse at the Disaster Site Insure safety First Aid Emergency care

Principles of Disaster Management Prevent the disaster Minimize casualties Prevent further casualties Rescue the victims First aid Evacuate Medical care Reconstruction

Phases of a Disaster Management Program:

1. Preparedness- The goal of emergency preparedness programs is to achieve a satisfactory level of readiness to respond to any emergency situation through programs that strengthen the technical and managerial capacity of governments, organizations, and communities. 2. Mitigation- eliminate or reduce the probability of disaster occurrence, or reduce the effects of unavoidable disasters. Includes

building codes; vulnerability analyses updates; zoning and land use management; building use regulations and safety codes; preventive health care; and public education. 3. Response- to provide immediate assistance to maintain life, improve health and support the morale of the affected population. The focus in the response phase is on meeting the basic needs of the people until more permanent and sustainable solutions can be found. 4. Recovery- measures both short and long term, include returning vital life-support systems to minimum operating standards; temporary housing; public information; health and safety education; reconstruction; counseling programs; and economic impact studies.

Disaster Planning Types of Measures:

1. Preventive measures - These controls are aimed at preventing an event from occurring. 2. Detective measures - These controls are aimed at detecting or discovering unwanted events. 3. Corrective measures - These controls are aimed at correcting or restoring the system after disaster or event. All- hazards Approach- a program which allows you to provide: y
y y y

Effective coordination of activities among the organizations having a management/response role; Early warning and clear instructions to all concerned if a crisis occurs; Continued assessment of actual and potential consequences of the crisis; Continuity of business operations during and immediately after the crisis.

Types of Hazards:  Natural Hazards- a form of severe weather activities such as electrical storms, ice storms, hurricanes & tornados.  Technological Hazards- fire, supply chain shortages, structural damage and hazardous material.  Human Hazards- such as terrorism, hostage situations including VIP situations, bomb threats and potential pandemics .

InternalHospital Disasters

PHASES: 1. Alert Phase- during this phase staff remains at their regular positions, service provision is uninterrupted, and faculty and staff await further instructions from their supervisors. 2. Response Phase- during which designated staff report to supervisors or the command posts for instructions, the response plan is activated, and nonessential services are suspended. 3. Expanded-Response Phase- when additional personnel are required, off duty staff are called in and existing staff may be reassigned based on patient needs.

Hospital Disaster Plan Purpose: To provide policy for response to both internal and external disaster situations that may affect hospital staff, patients, visitors and the community. Lines of Authority: The following persons, in the order listed, will be in charge: 1. Administrator. 2. Director of Nursing. 3. Nursing Supervisor on duty at time of disaster. 4. Emergency Room Supervisor. Communications: 1. A Command Center will be set up at the Security Desk to handle and coordinate all internal communications. All department heads or their designee will report to this office and call as many of their employees as needed. 2. The person in charge when the disaster happens will assign a nurse to the communications system in the E.R. This nurse will answer all radio calls from this station. 3. At least one messenger will be assigned to each radio operator to deliver messages, obtain casualty count from triage, etc. Supplies and Equipment: 1. Extra supplies will be obtained from Purchasing personnel through

runners. 2. Outside supplies will be ordered by the Purchasing Director and brought into the hospital via the loading dock. Responsibilities of Individuals and Departments: A. Administrator: In a major disaster will do the following functions: 1. Check with local authorities to verify the disaster and obtain additional information. 2. Authorize announcement of disaster to hospital personnel. B. Director of Nursing: 1. In a major disaster will do the Administrator's functions, if he is absent. 2. Is responsible for notifying all department heads or alternates. 3. In a major disaster be responsible to see that families of victims are notified as soon as possible. These calls may be made by the physician who treats the victim, the Director of Social Services, or the Director of Nursing or her designee.

c. Nursing Supervisor: 1. Is responsible for determining the extent of the disaster, whether it is a"major" or a "minor" disaster. If it is a major disaster, then the Administrator and Director of Nursing will be notified (if not present at timeof disaster). (The Director of Nursing would then notify all department heads or alternates as noted above.) 2. Will set up a Command Center - All department heads would report in tothe supervisor before going to their departments. 3. Will attempt to find adequate numbers of nursing personnel. (This can be assigned to the Unit Coordinator or another nurse but the Supervisor must be aware of the number of nurses coming in.) Have them keep a list ofthose notified.

D. Operating Room, CSR, PAR, Anesthesia, & OP 1. Supervisor or RN will supervise Operating Room and call all needed personnel after reporting to Command Center. 2. Call additional surgeons as needed. 3. Check area for supplies and equipment. 4. Ask for additional help to carry out surgery and treatments in Operating Rooms and Recovery Room. 5.Assign and direct scrub nurses and circulate. D. ICU - After notification of disaster, the ICU nurse will: 1. Evaluate patients in the Intensive Care Unit for possible discharge. Use established discharge criteria as a guide. Transfer patients out if indicated.

2. Prepare to admit more critically ill patients. 3. Send runner to Command Center or phone for help. E. OB Unit 1. Staff from OB can be used to assist in triage if department is covered. Volunteers can be used from OB to assist in disaster. 2. Patients other than OB's will be triaged by Command Center before being transferred to OB. F. Laboratory 1. Department Head or designee will call in their own personnel as needed after reporting to Command Center. 2. Call personnel from nearby hospitals and clinics as necessary. 3. Have arrangements made to obtain additional blood, equipment and supplies from area agencies. G. Pharmacy 1. Report to Command Center, then remain in department. 2. Have list of drug suppliers that can provide emergency supplies quickly (list is in Procedure Manual). 3. Keep minimum supply of emergency drugs on hand at all times. 4. Pharmacy should remain open and have a runner to deliver needed meds to areas. H. Dietary 1. Department head or designee will call in their own personnel as needed after reporting to Command Center. 2. Prepare to serve nourishments to ambulatory patients, house patients and personnel as need arises. 3. Clear hallway of all tray carts. 4. Utilize T.C. dining room and west hospital solarium for extra eating space. 5. Be responsible for setting up menus in disaster situation and maintain adequate supplies.

I. Respiratory Therapy 1. Department Head or designee will call in their own personnel as needed after reporting to Command Center. 2. Keep adequate supply of bubblers, cannulas, masks and flowmeters available in Respiratory Therapy Department. 3. Be prepared to obtain additional respirators and equipment as needed. 4. Be prepared to assist in treatment areas. 5. Keep resuscitation equipment in good operating condition and well marked.

Nursing Personnel Assigned to Disaster Victims 1. Obtain information and fill out available information and time on disaster tags. Even if no information is available as to identity, give information as to condition, types of injuries, etc. o If top sheet on tag has already been picked up, use O.P. record

(may use ER Nurses notes) to record changes in patient's condition, additional information, etc. o Be sure to use hospital disaster tag number for identification (the tag is in triplicate). 2. BE SURE top sheet of disaster tag is made available to Medical Records with pertinent information. 3. DO NOT leave your patient unattended. Patient may be signed off to person in charge when admitted to a unit. 4. Give aggressive first aid treatment. 5. Make out the appropriate lab slips and x-ray requisitions with disaster number. It is essential that they have these slips made out. Potential Scenarios:        Loss of power, including auxiliary power Loss of medical gases Loss of water and/or water pressure Loss of compressed air and vacuum suction Loss of telecommunication systems Loss of technology systems Threats to safety of patients and staff(violence, terrorism and bombs)

C. DISASTER MANAGEMENT Levels of Disaster 1. Level I- if the organization, agency, or community is able to contain the event and respond effectively utilizing its own resources. 2. Level II- if the disaster requires assistance from the external resources, but these can be obtained from nearby agencies. 3. Level III- if the disaster is of a magnitude that exceeds the capacity of the local community or region and requires assistance from state- Level or even federal assets.

Hospital Incident Command System:  an incident command system designed for hospitals and intended for use in both emergency and non-emergency situations.  It provides hospitals of all sizes with tools needed to advance their emergency preparedness and response capabilityboth individually and as members of the broader response community.

ICS is designed to:  - Be usable for managing all routine or planned events, of any size or type, by establishing a clear chain of command  - Allow personnel from different agencies or departments to be integrated into a common structure that can effectively address issues and delegate responsibilities  - Provide needed logistical and administrative support to operational personnel  - Ensure key functions are covered and eliminate duplication The life cycle of an incident includes the following steps:              Alert and notification Situation assessment and monitoring EOP Implementation Establishing the HCC Building the ICS structure Incident action planning Communications and coordination Staff health and safety Operational considerations Legal and ethical considerations Demobilization System recovery Response evaluation and organizational learnin

TRIAGE :  process used in sorting patients or victims into categories of priorities for care and transport based on the severity of injuries and medical emergencies.  The term comes from the French verbtrier, meaning to sort, sift or select.

Triage Considerations: y y y y y y Establish triage guidelines gut reaction or sixth sense should be trusted Overtriage is acceptable Designate experienced RNs for triage Reassessment is necessary and essential Maintain emergency skills/lnowledge

Types of Triage: 1. Simple triage- used in a scene of mass casualty, in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. S.T.A.R.T. (Simple Triage and Rapid Treatment) -is a simple triage system that can be performed by lightly-trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. Triage separates the injured into four groups: The deceased who are beyond help The injured who can be helped by Immediate transportation The injured whose transport can be delayed y Those with minor injuries, who need help less urgently

In the UK and Europe, the triage process used is similar to that of the United States, but the categories are different: Dead - those who are pronounced as such by a medically qualified person or paramedic who is legally qualified to pronounce death . Immediate - patients who have a trauma score of 3 to 10 (RTS) and need immediate attention Urgent - patients who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention Delayed - patients who have a trauma score of 12 (maximum score) and can be delayed before transport from the scene PRIORITIES:  Immediate or Priority 1 (red) evacuation by MEDEVAC if available or ambulance as they need advanced medical care at once or within 1 hour. These people are in critical condition and would die without immediate assistance.  Delayed or Priority 2 (yellow) can have their medical evacuation delayed until all immediate persons have been transported. These people are in stable condition but

require medical assistance.  Minor or Priority 3 (green) are not evacuated until all immediate and delayed persons have been evacuated. These will not need advanced medical care for at least several hours. Continue to re-triage in case their condition worsens. These people are able to walk, and may only require bandages and antiseptic. 2. Advanced triage- Because treatment is intentionally withheld from patients with certain injuries, advanced triage has ethical implications. It is used to divert scarce resources away from patients with little chance of survival in order to increase the chances of survival of others who are more likely to survive.

TRIAGE CATEGORIES: FIRST PRIORITY (red tag) - immediate -victims with serious injuries that are life threatening but has a high probability of survival if they received immediate care - They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. SECOND PRIORITY (yellow tag) -intermediate Observation -victims who are seriously injured and whose life are not immediately threatened -can delay transport and treatment for 2 hours LOW PRIORITY (green tag) -Wait (walking wounded) -delayed -patients/victims whose care and transport can be delayed

until last. -hold care; can delay transport up to 3 hours -They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (broken bones without compound fractures, many soft tissue injuries). LOWEST PRIORITY Dismiss (walking wounded) -patients/victims who doesnt require care -They have minor injuries; first aid and home care are sufficient, a doctor's care is not required. Injuries are along the lines of cuts and scrapes, or minor burns. Black / Expectant They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in lifethreatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); -they should be taken to a holding area and given painkillers as required to reduce suffering.

Disaster Triage Principles: 1. 2. 3. 4. 5. Never move a casualty backward(against the flow) Never hold a critical patient for further care Salvage life over limb Triage providers do not stop treating patients Never move patients before triage, except in cases of risks due to: bad weather, impending darkness or darkness has fallen, a continued risk of

injury, medical facilities are immediately available, a tactical situation that dictates movement. 4. Management of Mass Casualty Incidents 4.1. Management of Burn Mass Casualty Incidents A. If trapped in a Burning Building y y y Smoke rises, so crawl low to the ground where the air will be cleanest. Get out quickly if it is safe to leave. Cover nose and mouth with clothe (moist if possible) Test doorknobs and spaces around doors with back of your hand. If the door is warm, try another escape route. If it is cool, open slowly. Check to make sure you rscape path is clear of fire smoke. y y Use the stairs. NEVER use an elevator during fire. Call the fire department for assistance if you are trapped. If you cannot get a phone, yell for help out the window. Wave or hang a sheet or other large object to attract attention. y Close as many doors as possible between yourself and the fire. Seal all doors and vents between you and the fire with rags, towels, or sheets. Open windows slightly at the top and bottom, but close them if smoke comes in. B. Immediate Treatment for Burn Victims y y y stop, drop, and roll to smother flames Remove all burned clothing. If clothing adheres to skin, cut or tear around burned area. Remove all jewelry, belts, tight clothing, etc., from over the burned areas and from around the victims neck. This is very important; burned areas swell immediately. C. Treatments of burn according to types of burn I. First Degree Burns Treatment y y y y y Apply cool, wet compresses, or immerse in cool, fresh water. Continue until pain subsides. Cover the burn with a sterile, non-adhesive bandage or clean cloth. Do not apply ointments or butter to burn; these may cause infection. Over-the-counter pain medications may be used to help relieve pain and reduce inflammation. First degree burns usually heal without further treatment. However, if a first-degree burn covers a large area of the body or the victim is an infant or elderly, seek emergency medical attention.

II.

Second Degree Burns Treatment

y y y y y y

Immerse in fresh, cool water, or apply cool compresses. Continue for 10 to 15 minutes. Dry with clean cloth and cover with sterile gauze. Do not break blisters. Do not apply ointments or butter to burns; these may cause infection Elevate burned arms or legs. Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches, and cover the victim with a coat or blanket. Do not place the victim in the shock position if a head, neck, back, or leg injury is suspected, or if it makes the victim uncomfortable. Further medical treatment is required. Do not attempt to treat serious burns unless you are a trained health professional.

III.

y Third-Degree Burns Treatment y y y y y Cover burn lightly with sterile gauze or clean cloth. (Do not use material that can leave lint on the burn). Do not apply ointments or butter to burns; these may cause infection Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches. Have person sit up if face is burned. Watch closely for possible breathing problems. Elevate burned area higher than the victims head when possible. Keep person warm and comfortable, and watch for signs of shock. Do not place a pillow under the victims head if the person is lying down and there is an airway burn. This can close the airway. Immediate medical attention is required. Do not attempt to treat serious burns unless you are a trained health professional.

4.2.

Management of Traumatic Injury due to Explosives and Blast Effects

A. Emergency Management Options I. II. Follow your hospitals and regional disaster systems plan. Expect an upside-down triage - the most severely injured arrive after the less injured, who by-pass EMS triage and go directly to the closest hospitals. Double the first hours casualties for a rough prediction of total first wave of casualties. Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty

III. IV.

location from police, fire, EMS, ICS Commander, regional EMA, health department, and reliable news sources. V. If structural collapse occurs, expect increased severity and delayed arrival of casualties.

B. Medical Management Options

I. Blast injuries are not confined to the battlefield. They should be

considered for any victim exposed to an explosive force. II. Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute abdomen or sepsis are advanced. III. Standard penetrating and blunt trauma to any body surface is the most common injury seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. Blast Lung is the most common fatal injury among initial survivors. IV. Blast lung presents soon after exposure. It can be confirmed by finding a butterfly pattern on chest X-ray. Prophylactic chest tubes (thoracostomy) are recommended prior to general anesthesia and/or air transport. V. Auditory system injuries and concussions are easily overlooked. The symptoms of mild TBI and PTSD can be identical. VI. Isolated TM rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries. VII. Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases. VIII. Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings. IX. Consider the possibility of exposure to inhaled toxins and poisonings (e.g., CO, CN, MetHgb) in both industrial and criminal explosions. X. Wounds can be grossly contaminated. Consider delayed primary closure and assess tetanus status. Ensure close follow-up of wounds, head injuries, eye, ear, and stress-related complaints. XI. Communications and instructions may need to be written because of tinnitus and sudden temporary or permanent deafness.

4.3.

Management of Injuries due to Chemical Spills and Environmental

Disasters A. Involves the release of a type or quantity of a chemical that poses an immediate risk to health; or B. Involves an uncontrolled fire or explosion: y Evacuate the building by activating the nearest fire alarm.

Call Emergency Response number (117, Philippines) and give details of the accident including location, types of hazardous materials involved, and whether there is personal injury.

y y y

If the accident involves personal injury or chemical contamination, follow the above steps as appropriate and at the same time: Move the victim from the immediate area of fire, explosion, or spill (if this can be done without further injury to the victim or you). Locate nearest emergency eyewash or safety shower. Remove any contaminated clothing from the victim and flush all areas of the body contacted by chemicals with copious amounts of water for 15 minutes.

Administer first aid as appropriate and seek medical attention.

4.4.

Management of Injuries due to Natural Disasters

The risk for injury during and after a natural disaster is high. Tetanus is a potential health threat for persons who sustain wound injuries. Tetanus is a serious, often fatal, toxic condition, but is virtually 100% preventable with vaccination. Any wound or rash has the potential for becoming infected and should be assessed by a health-care provider as soon as possible. These principles can assist with wound management and aid in the prevention of amputations. In the wake of a flood disaster resources are limited. Following these basic wound management steps can help prevent further medical problems. A. Evaluation y Ensure that the scene is safe for you to approach the patient, and that if necessary; it is secured by the proper authorities (police, fire, civil defense) prior to patient evaluation. y Observe universal precautions, when possible, while participating in all aspects of wound care. y Obtain a focused history from the patient, and perform an appropriate examination to exclude additional injuries.

B. Treatment y Apply direct pressure to any bleeding wound, to control hemorrhage. Tourniquets are rarely indicated since they may reduce tissue viability. y Examine wounds for gross contamination, devitalized tissue, and foreign bodies. y Remove constricting rings or other jewelry from injured body part. y Cleanse the wound periphery with soap and sterile water or available solutions, and provide anesthetics and analgesia whenever possible. y Irrigate wounds with saline solution using a large bore needle and syringe. If unavailable, bottled water is acceptable.

y y y

y y y

Leave contaminated wounds, bites, and punctures open. Wounds that are sutured in an unsterile environment, or are not cleansed, irrigated, and debrided appropriately, are at high risk for infection due to contamination. Wounds that are not closed primarily because of high risk of infection should be considered for delayed primary closure by experienced medical staff using sterile technique. Remove devitalized tissue and foreign bodies prior to repair as they may increase the incidence of infection. Clip hair close to the wound, if necessary. Shaving of hair is not necessary, and may increase the chance of wound infection. Cover wounds with dry dressing; deeper wounds may require packing with saline soaked gauze and subsequent coverage with a dry bulky dressing. Management of wound Follow tetanus prophylaxis guidelines for all wounded patients. Follow tetanus prevention guidelines.

C. Other Considerations y y y y y Be vigilant for the presence of other injuries in patients with any wounds. Ensure adequate referral, follow-ups, and reevaluations whenever possible. Dirty water and soil and sand can cause infection. Wounds can become contaminated by even very tiny amounts of dirt. Puncture wounds can carry bits of clothing and debris into wound resulting in infection. Crush injuries are more susceptible to infection than wounds from shearing forces.

D. Guidance for Management of Wound Infections Most wound infections are due to staphylococci and streptococci. This would likely hold true even in the post-hurricane setting. y For initial antimicrobial treatment of infected wounds, beta-lactam antibiotics with anti-staphylococcal activity (cephalexin, dicloxacillin, ampicillin/sulbactam etc.) and clindamycin are recommended options. Of note, recently an increasing number of community associated skin and soft tissue infections appear to be caused by methicillinresistant Staphylococcus aureus (MRSA). Infections caused by this organism will not respond to treatment with beta-lactam antibiotics and should be considered in patients who fail to respond to this therapy. Treatment options for these community MRSA infections include trimethoprim-sulfamethoxazole (oral) or vancomycin (intravenous). Clindamycin is also a potential option, but not all isolates are susceptible. Incision and drainage of any subcutaneous collections of pus (abscesses) is also an important component of treating wound infections.

E. Special Considerations Related to Contamination of Wounds by Water

Contamination of wounds with water (fresh or sea water) can lead to infections caused by waterborne organisms. Though infections with these organisms are uncommon, even after floods, this possibility should be considered in patients who fail to respond to initial therapies described above. Water-borne organisms often implicated in these infections include: Aeromonas spp., noncholera Vibrio spp. and sometimes Pseudomonas or other Gramnegative rods. Trimethoprim/sulfamethoxazole, amoxicillin/clavulanate and newer fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin) will treat Aeromonas and the fluoroquinolones will also treatPseudomonas and many other Gram-negative pathogens. Clinicians should consider Vibrio as a possible causative organism of wound infections incurred in coastal waters or from contact with shellfish or marine wildlife. Vibrio vulnificus wound infections may require extensive debridement and mortality can be high. These infections often manifest with bullous lesions that may be hemorrhagic. Persons with underlying hepatic disease or other immunocompromising illness are at highest risk of Vibrio vulnificus infection. When this infection is suspected, the recommendation is that patients be treated with a combination of ceftazidime and doxycycline.

4.5.

Management of Biological and Chemical Terrorism

Biologic Weapons A. Anthrax y Recommended gentamicin or B. Taluremia y streptomycin or gentamicin/ aminoglycosides for 10-14days. In mass casualty doxycylin or ciprofloxacin is recommended. C. Botulism y y y Supportive ventilatory therapy is necessary if respiratory infection occurs Equine antitoxin is used to minimize subsequent nerve damage. Aminoglycosides and clindamicyn are contraindicated for it exacerbate neuromuscular blockage D. Plague- Yersinia pestis y y Streptomycin or gentamicin for 10-14 days Prophylaxis is doxycyline for 7 days treatment includes penicillin, erythromycin, doxycycline. Antibiotic treatment should be started

within 24 hours to prevent death.

E. Smallpox (variola)

y y y y

Supportive care with antibiotics for any additional infection Isolation People with face-to-face contact should be vaccinated within 4 days to prevent infection and death Cremation is preferred for all death, because the virus can survive in scabs for up to 13 years

F. Severe Acute Respiratory Syndrome (SARS) y y Droplet precaution isolation Treatment is supportive

Chemical Weapons A. Nerve Agents y Sarins and Soman organophosphate soap and water; supportive care; benzodiazepine,pralidoxine and atropine B. Blood Agents y Cyanide management includes administration of sodium nitrate; sodium thiocyanate; amyl nitrate; hydroxocobalamine C. Vesicant agents y Lewisite, dry D. Pulmonary Agents y Phosgene & Chlorine management includes airway management; ventilation support and bronchoscopy. 5. Communicating with Media Communication is a key component of disaster management. Managing media request for informationalthough the media request for information repost the news and can play significant positive role in communication 6. Unique Needs of Children During Disasters 7. Understanding the Psychosocial Impact of Disasters 7.1. Psychosocial Reactions to Disaster I. II. III. 7.1.1. Experience of terror or horror when ones own life is threatened or one is exposed to grosteque or disturbing sights. Traumatic berivement, which occurs when beloved friends or family members die as result of disaster Distraction of normal living Horror, anger, panic sulfur mustard, nitrogen mustard & phosgene management includes washing of soap and water; blot; do not rub

7.1.2. Magical thinking about microorganisms 7.1.3. Fear of invisible agents or fear of contagion 7.1.4. Attribution of arousal symptoms to infection 7.1.5. Anger or terrorist or government 7.1.6. Scapegoating 7.1.7. Paranoia, social isolation, or demoralization 7.2. Common reactions to disaster survivors

7.2.1. Emotional 7.2.2. Behavioral 7.2.3. Cognitive 7.2.4. Physical

7.3.

Phases of Emotional Recovery (Red Cross)

7.3.1. The Heroic Phase y In the aftermath of the disaster, there is a strong emotional response that focuses on helping people survive and recover. People sacrificially give money and assistance to those in need and those that are most effected by the disaster often receive those helping with intense gratitude. 7.3.2. The Honeymoon Phase y As the community moved toward clean-up and recovery, people who experienced the event, draw together to talk about their shared understanding and build on new ideas to prevent or support the community on an ongoing basis. 7.3.3. The Disillusionment Phase y Disappointments over delays or unmet expectations lead to people returning to individual problem solving. This phase often begins as the media attention for a disaster begins to wane. Often intense criticism of agencies and organizations starts, especially if the disaster was a large one. 7.3.4. The Reconstruction Phase y There is a reaffirmation in the belief of ones community. This can be 7.4. associated with landmark events, such as one-year anniversaries, or the start of a major reconstruction projects. Special Needs Populations

7.4.1. Older Adults y Older adults are vulnerable to loss. Research has shown that theya re most likely to heed warnings, may delay evacuation, or resist leaving their home. y y They often lack social support, maybe financially disadvantaged and traditionally reluctant to accept offers of help. Older adults are also more likely to have preexisting medical condition that maybe exacerbated, either directly because of the emotional and psychological stress or because of disruption of their care y Older women are particularly high risk for PTSD in that they live longer than men, are most likely to be widowed, have limited social

supports, and are disproportionately victims of crime such as robbery. y Loss of irreplaceable possessions photographs, mementos, and heirloomsmay have greater meaning and value for older adults. Disasters may serve as reminder of fragility and ultimate finality of life. y Older adult may also withhold information or refuse to help due to fears of losing their independence

7.4.2. The Severely Mentally Ill y y The most psychologically vulnerable people are those with prior history of psychiatric disturbances. Exacerbations of preexisting chronic mental disorders, such as bipolar and depressive disorders are often increased in the after math of a disaster. y Those with chronic mental illness are particularly susceptible to the effects of severe stress, as they may be marginally stable and may lack adequate social support to buffer the effects of terror, bereavement, or dislocation. y Assertive Community Treatment (ACT) teams played a vital role in maintaining connections with those who were most vulnerable to the effects of stress of a disaster. 7.4.3. Cultural and Ethic Subgroups y Sensitivity to the cultural and ethnic needs of survivors and the bereaved is key not only in understanding reactions to stress and grief but also in implementing effective interventions. y Mental health outreach teams need to include bilingual, bicultural staff and translators who are able to interact effectively with survivors and the bereaved. y It is preferable to have bilingual staff or trained translators, rather than relying on the family members, because of privacy concerns and the importance of maintaining appropriate family roles and boundaries. y Availability of written material in other languages can also increase access to information for those who do not speak English. y y Understanding the local norms, history, and politics can be important in providing culturally appropriate services. Issues that should be addressed include level acculturation, gender and parental roles, religious belief systems, child-rearing practices, and use of support systems, including extended family (Cohen, 1992).

7.4.4. First Responders and other Helpers y y Victims of psychosocial impact may also include emergency personnel, piloce officers, firefighters, military personnel. Some studies of PTSD among firefighters and other first responders have found the frequency of PTSD to be 21%- 25%, and that PTSD may have comorbidity with other psychiatric disorders y Clearly, stress-induced symptoms are a hazard of disaster work and can lead to absenteeism and burnout, as well as difficulties in family, work, and social life and physical and psychiatric disorders. 7.4.5. Nurses and Hospital Personnel y Medical personnel receiving disaster victims and families at the local hospitals can also be affected by the intense emotions of those seeking help. y y Secondary traumatization is a hazard that comes with exposure to the horrific stories of the bereaved and injured. Hospital personnel are also subject to the stress of increased workload due to increased admissions and discharges and need to communicate timely information not only ot families but to the ever-burgeoning members of the media. y Nurses and other medical professional may be afraid to show their emotions during the disaster

Unit Exam Emergency Disaster Name: ___________________ Yr./Section:_______________ Date:____________ Score:___________

I. Multiple Choice Directions: Encircle the letter of the best answer. NO ERASURES OR SUPERIMPOSITIONS. 1. This is a type of natural disaster where in a cataclysm resulting from a destructive sea wave caused by an earthquake or volcanic eruption; a. Volcanic Eruption b. Earthquake c. Tsunami d. Hurricane

2. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included: a.Tertiary prevention b. Primary prevention c.Aggregate care prevention d. Secondary prevention

3. During the disaster you see a victim with a green tag, you know that the person: a. has injuries that are significant and require medical care but can wait hours with threat to life or limb b. has injuries that are life threatening but survival is good with minimal intervention c. indicates injuries that are extensive and chances of survival are unlikely even with definitive care d. has injuries that are minor and treatment can be delayed from hours to days 4. These are situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment a. Complex emergencies b. Disaster Management c. Man made Disasters d. Technological Disasters

5. It is a violent release of energy caused by a chemical or nuclear reaction; a. Radiologic (nuclear) events b. Explosion c. Acts of War d. Bilogical terrorism

Situation A disaster is a large-scale emergencyeven a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybodys business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector. 6. Which of the four phases of emergency management is defined as sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.? a. Recovery b. Mitigation c. Response d. Preparedness

7. It is usually associated with man-made infrastructure, and are typically accidental; a. Technological Disasters b. Biochemical terrorism c. Man made disasters d. Complex emergencies 8. This are forces that overwhelm a community; a. Infrastructure b. Tornadoes and Hurricanes c. Earthquake d. Disaster 9. It refers to the shaking and vibration at the surface of the earth resulting from underground movement along a fault plane of from volcanic activity; a. Volcanic eruption b. Earthquake c. Tsunami d. Flood 10. The first role of a nurse in the disaster site; a. Emergency care b. Give immediate first aid c. Ensure safety d. Call for help 11. A nursing student is studying about disasters and emergency preparedness. Which of the following statements by the nursing student depicts a correct understanding of the difference between a disaster and emergency? a. Disasters are man-made only b. An emergency is an unforeseen combination of circumstances calling for immediate action for a range of victims c. Emergencies are caused by acts of nature or emerging diseases. d. Man-made disasters are intentional only. 12. The nurse is caring for a patient with a blast injury. Which of the following nursing assessment would be most appropriate for this client? e. Assess for vasovagal hypotension f. Assess the client for confusion g. Assess for asphyxia

h. Assess for hypervolemia 13. There has been a radioactive explosion nearby. The ER nurse must triage and manage the decontamination of the clients systematically. Which of the clients would be decontaminated first? a. b. c. d. A client with severe injuries A client with minor injuries A client with least injuries A client with most injuries

14.A military nurse is working in Iraq. Because of the potential threat of hazardous gas, which of the following should be worn when working in a dangerous war zone? a. Sunglasses b. Gas mask c. Surgical mask 15. A newly graduated nurse is learning about the nurse role in disaster relief as part of an orientation to the hospital. Which of the following concepts is accurate? a. Learning about the prevention and mitigation of disasters is nice to know, but not essential. b. Nurses take a passive role in helping others to save lives and fulfill an important obligation. c. Applying advanced skills can be very helpful until help arrives.

Answer keys to Unit Exams

Answers to Unit I. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. B D A A D D D B A C

Answer to Unit II 1. A 2. A 3. C

4. 5. 6. 7. 8. 9. 10.

C A A C C D A

Answers to Unit III 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. C D A B A C D A B A

Answers to Unit IV. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. C D D A B B A D B C B D A B B

References: Books 1. Nettina, Sandra M. (2001). The Lippincott Manual of Nursing Practice (7th Ed). 2. Saxton, Dolores F., et.al. (2002). Comprehensive Review of Nursing for NCLEX-RN (6th Ed). Philippines: Elsevier Science. 3. Smeltzer, Suzane C., et.al. (2008). Brunner & Suddarths Textboook of Medical-Surgical Nusing(11th Ed). 4. Johnson, J.Y., & Temple, J.S. (2006). Nurses Guide to Clinical Procedures (5th Ed). Philippines: Library of Congress Cataloging-in-Publication Data. 5. Udan, Josie Q., (2002). Medical-Surgical Nursing: Concepts and Clinical Application (1st Ed). Philippines: Guiani Prints House. 6. Veenema, Tener, et. al. (2007). Disaster Nursing & cHemical, Biological and Radiological Terrorism and other Hazards. United States: Bang Printing 7. Smeltzer, Suzane C., et.al. (2008). Brunner & Suddarths Textboook of Medical-Surgical Nusing(11th Ed). 8. Black, Joyce M., Matassarin Jacobs, Esther, Luckmann, Joan. Medical Surgical Nursing a psychophysiologic approach 4th edition.

Electronic 1. Stanley, Joan. et.al. (August 2003). International Nursing Coalition for Mass Casualty Education. Retrieved from http://www.aacn.nche.edu 2. www.emedicine.medscape.com 3. www. wisegeek.com 4. www.surgicalcriticalcare.net 5. Environmental health in emergencies and disasters: A practical guide. WHO, 2002. 6. DisasterHelp, US Department of Homeland Security.

7. Green Paper on Disaster Management, Department of Provincial and Local Government, South Africa 8. http://www.dhfs.state.wi.us/rl_dsl/hospital/hospitaldisastrplng.htm 9. http://weathereye.kgan.com/cadet/disaster/disasterquiz.html 10. http://en.wikipedia.org/wiki/Cancer 11. http://www.medicalnewstoday.com/info/cancer-oncology/ 12. http://en.wikipedia.org/wiki/Hospital_incident_command_system 13. http://emergency.cdc.gov/disasters/emergwoundhcp.asp#guidance 14. www.redcross.org 15. www.dhs.gov