TimbySmith Introductory MedicalSurgical Nursing 11e Chapter 15 Disaster

Disaster “A threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes and injure or kill people. ” —American Red Cross • Disaster types − Natural disasters: earthquakes, floods, etc. – Human disasters: explosions, fires, acts of terrorism • Nurses’ role in intentional human disasters – Bombings, biologic disasters, chemical disasters Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bombs and Radiologic Disasters • Bombs accounted for nearly 70% of all terrorist attacks in the United States from 1980 to 2001 – Immediate loss of life and health crises • Postexplosion injuries: radioactive substances – Gamma (ionizing) radiation: can penetrate, damage, destroy body cells • Types of radiologic disasters: explosion of a dirty bomb, damage to or human error in nuclear power plant, nuclear blast Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bombs and Radiologic Disasters—(cont. ) • Dirty bomb: conventional explosive device that spreads small amounts of radiation in the form of powder or pellets – Example: dynamite • Nuclear power plant disaster: devices that initiate, control, and sustain the nuclear reactions raise concern for escape of radiation • Nuclear blast: explosion that produces intense wave of heat, light, air pressure, and radiation – Fallout: external radiologic contamination, internal radiologic contamination Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bombs and Radiologic Disasters—(cont. ) • Assessment Findings: appearance of burns, trauma, invisible gamma radiation penetrates body and eliminated in blood, sweat, urine, feces – Acute radiation syndrome (ARS) • Long-term effects – Thyroid cancer, leukemia, non-Hodgkin’s lymphoma, genetic effects in infants: congenital malformations, stillbirths, impaired growth and development, shorter life expectancies Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bombs and Radiologic Disasters—(cont. ) • Medical and Nursing Management – Limit external and internal exposure to radiation; reduce radiologic organ damage by administering substances that interfere with organ concentration (lead) or speed up removal of radioactive substance – Limit external contamination • Stay indoors, go to centrally located room or basement with few windows, turn off all fans, air conditioners, forced-air heating units, place clothing and shoes in plastic bag, shower/wash with soap and water Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bombs and Radiologic Disasters—(cont. ) • Limit internal contamination – Covering mouth and nose with scarf, handkerchief, or cloth; drink only bottled water, consume canned, dried, or packaged food products; avoid inhalation of tobacco products – Reducing radiologic organ damage: taking substances such as potassium iodide, Prussian blue, diethylenetriamine pentaacetate, filgrastim (Neupogen) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters • Biologic disaster: one in which pathogens or their toxins cause harm to humans or other living species – Indications: high outbreak of similar symptoms, increased number of sick people, atypical illness • Classified into three categories: A, B, and C according to risk to national security • Three high priority agents in bioterrorist warfare: anthrax, botulism, and smallpox – High threat: stable and simple to mass produce, easy to deliver to large population, associated with high mortality, public fear Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters—(cont. ) Anthrax – Spore-forming bacterium; causes disease when inhaled, ingested, or introduced into nonintact skin; in body, spores multiply produce toxins • Assessment Findings – Inhalation: cold or flu symptoms, progresses into severe respiratory distress, death – Ingestion: N/V, diarrhea, abdominal pain, affects GI tract, circulatory system, mesenteric lymph nodes – Skin: painless lesions on head, hands, arms may develop into black-centered blisters that ulcerate Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters—(cont. ) Anthrax—(cont. ) • Medical and Nursing Management – Diagnosed by culturing: blood, stool, wound exudate – Treated with antibiotic therapy • Cipro, Levaquin: treatment lasts 4 weeks or longer – Anthrax vaccine: military personnel, at-risk civilians Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question You are a nurse who has to care for a victim of anthrax. The assessment findings of the infectious process associated with anthrax includes: A) Painless lesion with black-centered blister B) Rash that begins on face and progresses to the arms C) Diplopia and dysphonia D) Muscle twitching and tachycardia Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Painless lesion with black-centered blister Rationale: Skin infection is the least deadly form and the only one that may be transmitted by direct contact. It is characterized by painless lesions usually on the head, hands, and arms that develop into black-centered blisters that eventually ulcerate. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters—(cont. ) Botulism − Disease that develops from neurotoxin produced by Clostridium botulinum, anaerobic bacterium; food-borne, inhalation • Assessment Findings: paralysis of motor and autonomic nerves, drooping of eyes, generalized muscle weakness, paralysis of respiratory muscles – Early signs: (4 Ds): diplopia, dysarthria, dysphonia, dysphagia • Medical and Nursing Management: initial treatment follows clinical rather than laboratory: mechanical ventilation, botulinum antitoxin Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters—(cont. ) Smallpox – Highly contagious disease caused by variola virus • Spread three ways: direct contact with infected person, contact with body fluids or contaminated objects that contain the live virus, exposure to aerosol containing the virus • Assessment Findings – Asymptomatic for first 7 to 14 days before rash develops; high fever (101° to 104° F) – Rash begins on face, progresses to extremities Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Biologic Disasters—(cont. ) Smallpox—(cont. ) • Medical Management – Strict contact transmission-based precautions (isolation) in a room under negative air pressure • Caregivers use airborne and droplet precautions, wear gloves, vaccination required – Treatment: no specific, fluid therapy, antipyretics, antibiotics • Nursing Management – Vaccinating public during potential or actual outbreak Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters • Chemical disasters: result from release of toxic manmade substances with potential for causing mass casualties – Release of chemicals • Industrial accident or transport, terrorist use as weapons: cyanide, respiratory toxins, blistering agents • Indications of chemical terrorism: dead or dying animals and/or vegetation, unexplained odor, fog-like or low-lying cloud in atmosphere, abandoned devices used for spraying chemicals Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Nerve Agent Poisoning − Most toxic of all chemical agents; cause fatal consequences by inhibiting acetylcholinesterase • Example: insecticide malathion • Assessment Findings – Nerve agent vapor—symptoms may develop within a few seconds – Liquid form—symptoms show in minutes to hours; dermal exposure symptoms appear as late as 18 hours following exposure – Death can occur within 10 minutes of inhalation if antidote is not administered. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Nerve Agent Poisoning—(cont. ) • Medical Management – Drugs administered: atropine sulfate, diazepam • Nursing Management – Supportive measures • Moving victims to fresh air; administer oxygenassisted ventilation • Clothing removed with gloves, deposited in seal container • Areas of skin exposed are washed. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Cyanide Poisoning − Solid salt or volatile liquid chemical that causes death in minutes − Used in gas chambers to execute prisoners • Assessment Findings: tachycardia, cardiac dysrhythmias, rapid breathing, low BP, restlessness, dizziness, headache, LOC, respiratory failure; victim does not appear cyanotic • Medical and Nursing Management – Wear protective garments and respirator masks – Administer cyanide antidote: amyl nitrite, sodium nitrite IV route, intravenous sodium thiosulfate Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Respiratory Toxin Poisoning − Chemicals that primarily cause pulmonary edema when inhaled − Examples: chlorine, phosgene • Assessment Findings: tearing, coughing, bronchospasm, laryngospasms, airway obstruction; produces dermal injury similar to frostbite or thermal burns • Medical and Nursing Management – Avoid fatality by assisting victims to fresh air, higher ground; remove victim’s clothing; wash skin with soap and water; remove contact lens Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Blistering Agents − Vesicants: chemicals that damage exposed skin and mucous membranes on contact; can also damage respiratory tissues; can penetrate fabric – Example: Sulfur mustard (“mustard gas”) • Assessment Findings: skin itches becomes red and blistered; blisters are dome-shaped lesions filled with clear or yellow fluid; inhalation almost sure death within 24 hours due to airway obstruction with blisters – Long-term effects: cancer, blood dyscrasias, infertility, fetal abnormalities Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chemical Disasters—(cont. ) Blistering Agents—(cont. ) • Medical and Nursing Management – Exposed person decontaminated immediately; remove all clothing, bagging all clothing – Irrigate victim’s eyes – Vesicant antidote available; care for skin lesions is similar to burn wound management – Breathing by mechanical ventilation, blood transfusions Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question A nurse manager is educating the unit staff on the indications of a chemical release. The indications of chemical terrorism includes which of the following? A) Dying vegetation B) Numerous dead animals such as domestic pets C) Vapor-like substance in the atmosphere D) Unexplained odor for the location E) All of the above Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer E) All of the above Rationale: All of the conditions listed could indicate chemical terrorism. Chemical attacks can be more difficult to detect because the agent used may vaporize quickly. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process for the Client in a Disaster Situation • Local, state, and federal disaster workers under American Red Cross, Federal Emergency Management Agency (FEMA), U. S. Department of Health and Human Services – Nurses, police, firefighters, EMT, paramedics • Assessment − Assess as many victims as possible; wear protective garments; start with closest victim − Prioritize victims’ needs for treatment by categorizing: immediate, delayed, minimal, and expectant Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process for the Client in a Disaster Situation—(cont. ) • Nursing diagnosis: Severe Hypoxia, Impaired Skin Integrity, Risk for Infection, Ineffective Coping • Interventions – Provide comfort and emotional support. – Administer first aid to victims in immediate category by keeping airway open, covering wounds, controlling bleeding, splinting fractures – Delegate the care of those with minimal health needs to volunteers with first aid skills. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question A client is exposed to a thermal burn and is at risk for impaired skin integrity. The nursing interventions related to the care of this client include: A) Applying a semiocclusive dressing over the wound B) Immunizing against smallpox or administer vaccine immune globulin C) Having victims shower and change clothes D) Restricting public access to clients who are nauseated Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Applying a semiocclusive dressing over the wound Rationale: Cleanse the wound using standard precautions; a moist wound increases the rate of epithelialization. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins