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3. Show at three ways nurses can prioritize first aid/prehospital interventions for patients who have thermoregulation problems, arthropod bites or stings, or venomous snake bites, affecting tissue integrity and comfort.
4. Show at three ways nurses can apply knowledge of pathophysiology to identify best practices for care of patients with environmental emergencies.
5. Show at three ways nurses can create an evidence-based plan of care for patients who have experienced an environmental emergency.
6. Show at three ways nurses can teach patients that seemingly harmless outside activities can have associated environmental risks.

Answer 1

Take the family to a private place. • Talk to the family together, so that they can mourn together. • Reassure the family that everything possible was done; inform them of the treatment rendered. • Avoid using euphemisms such as “passed on.” Show the family that you care by touching, offering coffee, and offering the services of a chaplain. • Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). • Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. • Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family to see the body. Show acceptance by touching the body to give the family “permission” to touch. • Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. • Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the emergency department. Do not challenge initial feelings of anger or denial. • Avoid volunteering unnecessary information (eg, patient was drinking).
Discharge Planning Before discharge, instructions for continuing care are given to the patient and the family or significant others. All instructions should be given not only verbally but also in writing, so that the patient can refer to them later. Many EDs have preprinted standard instruction sheets for the more common conditions. These instructions are then individualized for each patient.

Community Services Before discharge, some patients require the services of a social worker to help them meet continuing health care needs. For patients and families who cannot provide care at home, community agencies (eg, Home Care Nursing Services, Visiting Nurse Association) may be contacted before discharge to arrange services. This is particularly important for elderly patients who need assistance. Identifying continuing health care needs and making arrangements for meeting these needs can prevent return visits to the ED and readmission to the hospital

Health Promotion and Maintenance

Teach older adults before participating in any hot weather activity how to consider their risks and to take steps to eliminate or minimize them whenever possible. Ask them to have a family member, friend, or neighbor check on them several times each day to ensure that there are no signs of heat-related illness

Heat Exhaustion

Pathophysiology

Heat exhaustion is a syndrome resulting primarily from dehydration. It is caused by heavy perspiration, as well as inadequate fluid and electrolyte intake during heat exposure over hours to days. Patients feel ill, and their clinical manifestations resemble the flu. Although not a true emergency condition, if untreated, heat exhaustion can lead to heat stroke, a much more serious problem.

Patient-Centered Collaborative Care

In heat exhaustion, patients usually have flu-like symptoms with headache, weakness, nausea, and/or vomiting. Body temperature is not significantly elevated in this condition. The patient may continue to perspire despite dehydration.

Ask the person experiencing heat exhaustion to immediately stop physical activity; move him or her to a cool place, and use cooling measures. Effective cooling measures include placing cold packs on the neck, chest, abdomen, and groin; soaking the person in cool water; or fanning him or her while spraying water on the skin. Remove any constrictive clothing. Provide an oral rehydrating solution such as a sports drink. Do not give salt tablets—they can cause stomach irritation, nausea, and vomiting. If these signs and symptoms persist, call an ambulance to transport the patient to the hospital.

In the clinical setting, monitor vital signs. Rehydrate the patient with IV 0.9% saline solution if nausea or vomiting persists. Draw blood for serum electrolyte analysis. Hospital admission is indicated only for patients who have other health problems that are worsened by the heat-related illness or for those with severe dehydration.

Heat Stroke

Pathophysiology

Heat stroke is a true medical emergency in which body temperature may exceed 104° F (40° C). It has a high mortality rate if not treated in a timely manner. The victim’s heat regulatory mechanisms fail and cannot adjust for a critical elevation in body temperature. If the condition is not treated or the patient does not respond to treatment, organ dysfunction and death can result.

The two major types of heat stroke are exertional and classic. Exertional heat stroke has a sudden onset and is often the result of strenuous physical activity in hot, humid conditions. Not being used to hot weather and wearing clothing too heavy for the environment are common contributing factors. Classic heat stroke, also referred to as non-exertional heat stroke, occurs over a period of time as a result of chronic exposure to a hot, humid environment, such as a home without air-conditioning in the high heat of the summer. It generally affects ill and older adults and causes several hundred deaths in the United States every year. The risk factors for heat stroke are similar to those for heat exhaustion.

Patient-Centered Collaborative Care

Assessment

Victims of heat stroke have a profoundly elevated body temperature (above 104° F [40° C]). Although the patient’s skin is hot and dry, the presence of sweating does not rule out heat stroke—people with heat stroke may continue to perspire.

Mental status changes occur as a result of thermal injury to the brain. Manifestations can include confusion, bizarre behavior, seizures, or even coma. Vital sign abnormalities may include hypotension, tachycardia, and tachypnea. Recent research demonstrates that cardiac troponin I (cTnI) is frequently elevated during non-exertional heat-related illnesses. A severe increase (>1.5 ng/mL) indicates severe myocardial damage and decreases the chance of patient survival 1 year after the event

.Interventions

Coordinate care with the health care team to recognize and treat immediately and aggressively to achieve optimal patient outcomes.Do not give food or liquid by mouth because vomiting and aspiration are risks in patients with neurologic impairment, especially those older than 65 years. Immediate medical care using advanced life support is essential.

Hospital Care

The first priority for collaborative care is to monitor and support the patient’s airway, breathing, and circulatory status. Provide high-concentration oxygen therapy, start several IV lines with 0.9% saline solution, and insert a urinary catheter. Continue aggressive interventions to cool the patient until the rectal temperature is 100° F (37.8° C) External continuous cooling methods include using cooling blankets and applying ice packs in the axilla and groin and on the neck and head. Internal cooling methods may include iced gastric and bladder lavage. Use a continuous core temperature–monitoring device (e.g., rectal or esophageal probe) or a temperature-monitoring urinary bladder catheter to prevent hypothermia.

If shivering occurs during the cooling process, give a parenteral benzodiazepine such as diazepam (Valium). Chlorpromazine (Thorazine) is an alternative agent. Because seizure activity can further elevate body temperature, be sure to have an IV benzodiazepine immediately available. Once the patient is stabilized, admission to a critical care unit is usually needed to monitor for complications such as multi-system organ dysfunction syndrome and severe electrolyte imbalances; these problems can lead to death.

Preparing for Self-Management: Snakebite Prevention

• Do not keep venomous snakes as pets.

• Be extremely careful in locations where snakes may hide, such as tall grass, rock piles, ledges and crevices, woodpiles, brush, boxes, and cabinets. Snakes are most active on warm nights.

• Don protective attire such as boots, heavy pants, and leather gloves. When walking or hiking, use a walking stick or trekking poles.

• Inspect suspicious areas before placing hands and feet in them.

• Do not harass any snakes you may encounter. Striking distance is at least the length of the snake, and often longer. Even young snakes pose a threat; they are capable of envenomation from birth.

• Be aware that newly dead or decapitated snakes can inflict a bite for up to an hour after death because of persistence of the bite reflex.

• Avoid transporting the snake with the victim to the medical facility for identification purposes, unless the snake can be placed in a sealed container.

Patient-Centered Collaborative Care

Assessment

The clinical manifestations of venom release are based on the type and amount of venom injected; the bite location; and the age, size, and health status of the victim. Puncture wounds in the skin are a key local sign of pit viper envenomation. One or more puncture wounds may be present, depending on how many fangs the snake has and how many times the snake struck the patient. Severe pain, swelling, and redness or ecchymosis (bruising) in the area around the bite are common. Hours later, vesicles or hemorrhagic bullae may form. Systemic responses to venom must be distinguished from the effects of anxiety and panic related to being bitten by a snake. Commonly reported complaints include a minty, rubbery, or metallic taste in the mouth and tingling or paresthesias of the scalp, face, and lips. Other effects include muscle fasciculations (twitching) and weakness, nausea, vomiting, hypotension, seizures, and coagulopathy (clotting abnormalities) or DIC. If the bite site does not show evidence of local tissue swelling or redness within 8 hours, systemic effects are less likely to develop.

Hospital Care

Acute care in a hospital is required as soon as possible because envenomation is a medical emergency. Supportive care includes supplemental oxygen, two large-bore IV lines, and infusion of crystalloid fluids such as normal saline solution or Ringer’s lactate solution. Apply continuous cardiac and blood pressure monitoring equipment to quickly detect clinical deterioration. Because venom can cause severe pain at the bite site, opioids are indicated. Provide tetanus prophylaxis and wound care as part of the collaborative plan of care.

Severe pit viper bites cause coagulopathy and promote hemorrhage and tissue destruction. Along with typical baseline laboratory studies, anticipate obtaining specimens for a coagulation profile, complete blood count (CBC), creatine kinase (CK), type and crossmatch for possible blood transfusion, and urinalysis. An electrocardiogram (ECG) is necessary to detect evidence of myocardial ischemia or other cardiac abnormalities.

Obtain pertinent patient history related to the event, including a full description of the snake’s appearance, the time the bite occurred, prehospital interventions, and any past incidence of snakebite or antivenom use. To accurately assess the development of tissue edema at the bite site, measure and record the circumference of the bitten extremity every 15 to 30 minutes.