Care of Patients with Common Environmental Emergencies

The nurse is educating a patient on safety regarding lightning strikes. Which patient statement requires further teaching?

"I should use a computer to warn my friends about lightning." Using a computer or any other electrical equipment may result in a lightning surge because lightning current can travel through power cords; therefore the nurse should tell the patient to stay away from computers. Water is a conductor of electricity, so being in the water during an electrical storm can result in injury or death. Metal objects are also good conductors of electricity. Standing under an isolated tree or metal pole in an open area is dangerous because lightning strikes the highest points.

At what core body temperature does the nurse stop cooling interventions for a patient with heat stroke?

102° F (39° C) Interventions to cool a patient with heat stroke continue until the core body temperature is 102° F. Core temperature is continuously monitored using a rectal or esophageal probe, or a temperature-monitoring urinary catheter to prevent hypothermia. If aggressive cooling interventions continue beyond 102° F, hypothermia may set in.

At what body temperature is a person said to have moderate hypothermia?

Between 82° F to 90° F (28° C to 32° C) A person is said to have moderate hypothermia when the body temperature is between 82° F to 90° F (28° C to 32° C). A person with a body temperature between 90° F to 97° F (32° C to 36° C) is said to have mild hypothermia. A person with a body temperature below 82° F (28° C) is said to have severe hypothermia.

Which body systems are most profoundly affected by lightning injuries?

Cardiopulmonary and central nervous systems The body systems most profoundly affected by lightning injuries are the cardiopulmonary and central nervous systems. The most lethal initial effect of massive electrical current discharge on the cardiopulmonary system is cardiac arrest. Prolonged respiratory arrest from impairment of the medullary respiratory center can produce hypoxia and subsequently a second cardiac arrest. Although the endocrine, renal, and integumentary systems may be secondarily affected, they are not as profoundly compromised as the cardiopulmonary and central nervous systems.

What is the cause of classic heat stroke?

Chronic exposure to a hot, humid environment Classic, or non-exertional, heat stroke occurs over a period of time following chronic exposure to a hot, humid environment. A home without air conditioning in the summer heat can cause classic heat stroke in older adults. Strenuous physical activity in hot, humid conditions causes exertional heat stroke. Inadequate fluid and electrolyte intake and heavy perspiration causes dehydration and depletion of essential salts in the body, which can cause heat exhaustion during heat exposure.

A patient is admitted to the emergency department after prolonged exposure to extreme cold. Both feet are numb, cold, and nonblanchable. The skin over the feet is red and blue. Both feet are swollen. The nurse recognizes that the patient is experiencing what complication?

Compartment syndrome The patient's feet are numb, cold, and nonblanchable. The skin over his feet is red and blue, and both feet are swollen. These symptoms indicate severe frostbite . The nurse anticipates that the patient is at risk for compartment syndrome, which is a limb-threatening complication caused by severe vascular impairment. The nurse anticipates the possibility of acute renal failure if the patient is stung by a bee or wasp. The nurse anticipates the presence of Lichtenberg figures if the patient has been struck by lightning. The nurse anticipates the presence of intravascular coagulation if the patient has been bitten by a brown recluse spider.

Which environmental injury can cause elevations in creatinine kinase (CK) levels from muscle breakdown and myoglobinuria?

Coral snake bite Coral snake venom contains nerve and muscle toxins and can cause elevations in CK levels from muscle breakdown and myoglobinuria. The black widow spider venom is neurotoxic, producing a syndrome called latrodectism in which the venom causes neurotransmitter release from nerve terminals affecting breathing, airway, and circulation. Scorpions inject venom via stinging apparatus on the tail and causes neurotoxic effects. Brown recluse spider venom causes cellular damage and impaired tissue integrity.

An athlete participating in a marathon presents to the emergency department after collapsing due to dehydration and overexposure to the sun. What interventions does the emergency nurse perform? Select all that apply.

Draw blood for serum electrolyte analysis. Place cold packs on the neck, chest, abdomen, and groin. Remove any constrictive clothing and spray water on the skin. The nurse should place cold packs on the neck, chest, abdomen, and groin to cool the body. Constrictive clothing must be removed and water sprayed on the skin to reduce body temperature. The nurse should draw blood for serum electrolyte analysis to identify any electrolyte imbalances. The patient should be given an oral rehydrating sports drink and not coffee to replace lost electrolytes. The patient should not be given salt tablets as they may cause nausea, vomiting, and irritation to the stomach.

High altitude disease (HAD) is associated with unidentified mutant forms of hypoxia-related genes. Which gene is known to cause vasoconstriction and increase blood pressure?

Endothelin ( EDN1) Genetic factors related to (HAD) have been studied in different ethnic groups found in high-altitude areas, and certain genes have been identified that may mutate and contribute to the development of HAD. Such genes include endothelin ( EDN1), which causes vasoconstriction and thus increases blood pressure. EPO regulates red blood cell production. HIF1A mediates the effects of hypoxia on body cells. NOS3 makes nitric acid in vascular tissue to maintain vessel tone and altitude adaptation.

Which intervention can lead to complications in a patient who is suspected of having heat exhaustion?

Giving salt tablets Salt tablets should be avoided in a patient who is suspected of having heat exhaustion because they cause stomach irritation, vomiting, and nausea. Spraying water on the skin may relieve heat exhaustion. Making the patient feel comfortable by removing constrictive clothing will reduce heat exhaustion. Giving oral rehydrating solutions will reduce heat exhaustion.

Which condition is a medical emergency in which the body temperature may exceed 104°F (40°C)?

Heat stroke Heat stroke is considered a true medical emergency in which the body temperature may exceed 104°F (40°C). Heat exhaustion is a syndrome resulting primarily from dehydration that may lead to heat stroke. Venom from a coral snakebite contains nerve and muscle toxins that block neurotransmission. Venom from a black widow spider bite is neurotoxic and produces a syndrome known as latrodectism in which the venom causes neurotransmitter release from nerve terminals. While serious, neither of these will cause a critical rise in body temperature to 104°F (40°C).

The nurse provides emergency care to a drowning victim who is not breathing. What is the first action the nurse should take?

Initiate airway clearance and ventilatory support. Immediate emergency care for a drowning victim who is not breathing is to initiate airway clearance and provide ventilatory support. Attempts to get water out of the victim's lungs via abdominal thrusts or back blows should not be done unless an airway obstruction is suspected. Ventilatory support and chest compressions if the pulse is absent are necessary until the AED becomes available.

An older patient informs the home nurse of plans for a vacation at the beach. What does the nurse teach the patient about preventing heat-related illness? Select all that apply.

Limit activity at the hottest time of the day. Wear lightweight, light-colored, and loose-fitting clothes. Use a sunscreen with sun protection factor (SPF) of at least 30. Lightweight, light-colored, and loose-fitting clothes should be worn for comfort. The patient should use a sunscreen for protection against ultraviolet rays of the sun; an ideal sunscreen should have at least 30 SPF. Activity should be limited at the hottest time of the day, and the patient should rest frequently in a cool place. These measures help to prevent exhaustion due to heat. Cool baths or showers help to reduce body temperature. The older patient should try to spend as much time as possible indoors in air-conditioned buildings on warm days.

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker?

Lower altitude The most effective intervention to manage serious altitude-related illness is descent to a lower altitude. Acetazolamide sodium should be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Dexamethasone can be administered during descent to help with symptoms, but is not the most effective treatment at this time. Oxygen is not the most effective treatment.

What is the first collaborative intervention that should be performed on a patient with heat stroke?

Provide high-concentration oxygen therapy. Providing high-concentration oxygen therapy is the first intervention that should be implemented. It helps to support the patient's airway and breathing. Removing clothing and wetting the patient's body with cold water is done for rapid cooling after ensuring that the patient is breathing effectively and has proper circulation. Food and liquid are not given as first aid or prehospital care in a patient with heat stroke.

What degree of frostbite presents as large, clear-to-milky, fluid-filled blisters with partial-thickness skin necrosis?

Second Second-degree frostbite presents with large, clear-to-milky, fluid-filled blisters with partial-thickness skin necrosis. First-degree frostbite is the least severe and involves hyperemia and edema of the involved area. Third-degree frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch. Fourth-degree frostbite is the most severe form in which there are no blisters or edema, and the affected body part is numb, cold, and bloodless.

What is the main characteristic of fourth-degree frostbite?

The affected part is numb, cold, and bloodless. Fourth-degree frostbite is the most severe form of frostbite in which the affected area is numb, cold, and bloodless, and the full-thickness necrosis extends into the muscle and bone. Amputation may be required if gangrene develops. First-degree frostbite involves increased blood flow in the affected area and edema formation. Large, fluid-filled blisters with partial-thickness necrosis develop in the affected area of second-degree frostbite. In third-degree frostbite, full-thickness and subcutaneous necrosis appears as well as small blisters that contain dark fluid. The affected part is cool, numb, blue, or red and does not blanch.

A group of people who survived a lightning strike has arrived at the hospital for medical attention. Which patient would need an immediate intervention?

The patient in cardiopulmonary arrest The cardiopulmonary system is affected from a massive electric discharge. Prolonged respiratory arrest causes hypoxia, which subsequently leads to cardiac arrest. So, cardiopulmonary resuscitation measures should be immediately provided to the patient in cardiopulmonary arrest. The unconscious patient, the patient with severe burns, and the patient with a paralyzed left leg also need medical intervention. But they can be treated after treating the patient with cardiac arrest, which is an emergency situation; the other situations are not.

What rewarming technique does the nurse use for partial-thickness to full-thickness frostbite injury?

Use a water bath set to 104° F to 108° F. A water bath set to 104° F to 108° F is used to rewarm an affected area with partial-thickness to full-thickness frostbite. If a warming tub is not available, hot towels may be used. Warm hands may be placed over the affected area when the exposed skin turns white and waxy, an early sign of frostbite. Dry heat or massage produce further tissue injury and therefore must never be applied to rewarm a frostbitten area.

What passive external rewarming method is typically applied to treat mild hypothermia?

Warm clothing Providing the hypothermic patient with warm clothing is a passive, external rewarming method. This allows the body temperature to slowly rise. Heating blankets, warm packs, and connective air heaters are active external rewarming methods, which raise the body temperature quickly.

The nurse is educating a patient on ways to prevent lightning strikes. Which statement made by the patient indicates a need for further teaching?

"I will use a computer during a storm to let others know I am well." Using a computer or any other electrical equipment during a lightning storm may lead to lightning surges as the lightning current can travel through a power cord. Therefore the statement about using a computer during the storm needs correction. Water is a conductor of electricity. So, it may lead to injury or death if the person is in water during lightning. Metal objects are also good conductors of electricity. Standing under an isolated tree or metal pole in an open area is very dangerous because lightning strikes the highest point.

The camp nurse is educating camp counselors about safety during thunderstorms. Which statement made by the camp counselor indicates a need for further teaching?

"We should move to an open field as quickly as possible to avoid flying debris." Standing in an open area increases the risk for lightning strikes, so this statement requires further teaching. During a thunderstorm, seek shelter. It is advisable to stay away from open bodies of water during storms, stay away from tent poles and wet walls, and seek shelter under trees if it isn't possible to get to a building.

Patients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which patient is most appropriately assigned to an LPN/LVN?

24-year-old with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 37° C Because the patient who has heat exhaustion is stable and is already receiving appropriate treatment, it is appropriate to assign an LPN/LVN to care for this patient. The data for the patient reporting right forearm swelling indicates a risk for hemodynamic instability and the need for ongoing assessment and intervention by an RN. The data for the patient who was hiking and the patient stung by an unknown insect indicate a risk for respiratory instability, and also require ongoing assessment and intervention by an RN.

The RN working at a long-term care facility places priority on providing interventions for which resident?

80-year-old man with congestive heart failure who is outdoors for some "fresh air" when the temperature is 94° F Evidence has shown that older adults (especially those over the age of 80) are more likely to die in the year following non-exertional heat stroke. This is especially true in those with cardiac and cancer diagnoses. The resident who is outside when it is 94° F needs to be removed from this environment. Although the 65-year-old paraplegic man has valid concerns, they are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but the resident who is at risk for heat stroke has greater importance for intervention. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

The nurse is caring for a patient who presents to the hospital with profuse sweating and a temperature of 104° F (40° C). Assessment findings include a patent airway, tachycardia, acute confusion, and anxiety. What is the priority intervention?

Applying ice packs Profuse sweating, a temperature of 104° F (40° C), tachycardia, acute confusion, and anxiety are signs of heat stroke. After ensuring that the patient has a patent airway, the nurse should use rapid cooling methods to reduce the patient's body temperature. Therefore applying ice packs to the axilla and groin helps reduce body temperature and reduce the symptoms of heat stroke. Salt tablets may cause gastrointestinal irritation and cause nausea and vomiting in the patient. The nurse should not give food or fluids by the oral route in order to prevent nausea and vomiting. The nurse will not administer oxygen as the patient has a patent airway and is not having breathing difficulty.

A patient is exhibiting shivering, slurred speech, and clumsiness. The nurse suspects the patient has hypothermia. What steps should the nurse take according to the American Heart Association (AHA)? Select all that apply.

Initiate cardiopulmonary resuscitation (CPR) if circulation is impaired. Keep in mind that drug toxicity may occur when giving medication. Space administration of medications at longer intervals. The AHA recommends that administration of medications should be spaced at longer intervals as metabolism is irregular in cases of moderate and severe hypothermia. Health care providers should keep in mind that drug toxicity may occur due to effective rewarming in cases of moderate and severe hypothermia. According to the AHA, if the patient is showing symptoms of hypothermia and has impaired circulation, CPR should be initiated. The AHA recommends that when caring for a hypothermic patient in ventricular fibrillation, only one defibrillation attempt is required. According to the AHA, intravenous drugs, except vasopressors, should be withheld until the patient's core temperature is above, not below, 86°F (30°C).

A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue?

Initiates rescue breathing on the child Airway clearance and ventilatory support measures should be initiated as soon as possible. This child did not suffer long exposure to cold water, so hypothermia is not a risk. No attempt should be made to remove water from the lungs unless an obstruction is present. Spinal cord injury should always be considered in a water-related emergency; however, it is not likely in this scenario. Establishing an airway and beginning rescue breathing is the first priority.

A mountain climber developed fatigue and weakness on the second day of the climb. On the fourth day, the client then developed a dry cough, cyanosis of the lips and nail beds, a heart rate of 90 beats/min, and a respiratory rate of 30 breaths/min. When the patient arrives at the hospital, which medication should the nurse anticipate being prescribed by the primary health care provider?

Nifedipine The patient is diagnosed with high altitude pulmonary edema (HAPE) that occurs due to hypoxia. Nifedipine is a calcium channel blocker, which acts by decreasing pulmonary vascular resistance and is used in the treatment of HAPE. Tadalafil and Sildenafil are phosphodiesterase inhibitors. They act by increasing pulmonary vasodilation and are used to prevent progression of acute mountain sickness (AMS) associated with HAPE. Acetazolamide is a carbonic anhydrase inhibitor. It acts by increasing the respiratory rate and decreasing periodic respiration during sleep at night. It is used to prevent and treat acute mountain sickness (AMS).

The nurse assesses four patients with hypothermia. Which patient requires internal rewarming methods for effective treatment?

Patient D (80F, bradycardia, decreased neurologic reflexes, hypotension) A body temperature of less than 82° F, along with bradycardia, decreased neurologic reflexes, and hypotension indicates that patient D has severe hypothermia. Internal rewarming methods such as hemodialysis or intravascular rewarming help alleviate symptoms of severe hypothermia. A body temperature of 90° F, shivering, dysarthria, and diuresis indicate that patient A has mild hypothermia. Covering the patient with warm blankets will help alleviate the symptoms of mild hypothermia. A body temperature of 97° F, shivering, decreased muscle coordination, and impaired cognition are the clinical manifestation of mild hypothermia. Passive or active external rewarming methods will be beneficial for patient B with mild hypothermia. A body temperature of 87° F, apathy, muscle weakness, and thrombocytopenia indicate that patient C has moderate hypothermia. Core rewarming methods such as administering warm oxygen and intravenous fluids will be beneficial for patient C.

In which patient does the nurse anticipate finding "Lichtenburg figures?"

Patient struck by lightning Lichtenburg figures are an uncommon, but characteristic skin manifestation of lightning in which branching or ferning marks are seen on the skin. The central bite site in a patient bitten by a brown recluse spider appears as a bleb or vesicle surrounded by edema and erythema. The immediate reaction in a patient bitten by a wasp is a wheal-and-flare skin reaction, followed by generalized edema. A patient stung by a bark scorpion may or may not have redness or inflammation, but there is increased pain when the site is tapped gently.

What is an important clinical indication of high altitude pulmonary edema (HAPE)?

Persistent dry cough Persistent dry cough is an important finding in a patient with HAPE. Other findings include cyanosis of the lips and nail beds. Exertional dyspnea is expected as a person adjusts to high altitude. Dyspnea at rest is abnormal and may signal the onset of HAPE. A typical finding in the patient with acute mountain sickness (AMS) is throbbing headache. Ataxia or defective muscular coordination is observed in the patient with high altitude cerebral edema (HACE). HAPE often occurs in conjunction with HACE but may occur during the progression of AMS.