Risk of aspiration
Since the development and refinement of the process of nursing care, it has come to be the principal scientific method for nursing practice, provide care that enables effective and efficient goal-oriented. It is a strategy based on resolution of problems based on a reflection that requires cognitive, and interpersonal skills to meet the needs of the patient, family and community. A challenge for nurses is to identify specific nursing diagnoses, by applying a specific assessment and then develop individualized care plan.
The poisoning is now a public health problem that is aggravated every day. However, patients with organophosphate poisoning, become critically ill patients, which must be addressed as quickly, and more importantly, should be managed taking into account scientific bases that lead to physiologically restore damaged body, so evidenced the need for highly qualified personnel in their performance, with cognitive, attitudinal and procedural, to enable it to provide a safe and timely care.
For the above, it is necessary to define, which are chemicals organophosphates preventing the transmission of nerve impulses in the brain, causing disturbances in sensory, motor function, behavior and breathing rate. From there then, that the neuro-physiological changes that occur in the individual ranging from mild intoxication to death himself. The formalization and standardization of nursing diagnosis and intervention allow the unification of criteria, reduced time for care and the possibility of evaluating the results of the nursing activity to ensure the quality and efficiency of care.
Risk of aspiration in patients with organophosphate poisoning case report: A 26-year-old male patient admitted at the hospital Emergency stretcher, brought by his sister, who relates that patient has ingested poison diluted in approx. 1 hours ago. Patient with a tendency to sleep, confused, in MEG, respiratory distress, with mitotic pupils with diaphoresis, cramps, twitching eyelids and face multiple, abdominal pain, vomiting, explosive and relaxation of sphincters.
P / A = 90/50 mmHg
FC = 50 x min.
FR = 30x min.
T ° = 35.8 ° C
Sat.O2 = 90%
LABORATORY ANALYSIS:
Electrolytes: k 3.0 mEq / L hypokalemia
CBC and sedimentation where there is leukocytosis with neutrophilia.
Hgt: 195 g / dl hyperglycemia
Erythrocyte and serum cholinesterase. 20% decreased.
Arterial gases: metabolic acidosis (pH 7.20, HCO3: 18 mEq / L
PCO2: 36 mmHg. PO2: 96 mmHg. SO2: 90%)
BUN and creatinine: On the possibility of developing pre-renal failure
dehydration and / or low cardiac output.
EKG: sinus tachycardia.
Chest Rx: for the presence of chemical pneumonitis and / or
aspiration.
DX. Definitive proof positive for atropine.
OTHER:
HEPATIC TRANSAMINASE
Examination of gastric juice or in search of toxic metabolites.
I. NURSING ASSESSMENT BY BASIC NEEDS.
GENERAL INFORMATION
Patient: E.T. E Sex: M Edad_26
Place of current residence: Villa el Salvador
Reason for hospitalization: organophosphate poisoning
NEEDS ASSESSMENT
1. BREATHING
Frequency: 25/min.
Cough: present. Feelings of choking: If Dyspnea: Yes.
Bronchial constriction
Stridor
Bronchorrhoea
Rhinorrhea.
Rales present.
Bronchial
Chest tightness.
2. DRINKING AND EATING
Difficulty swallowing: If Nausea: If vomiting: If Sialorrhea: YES.
Breath: garlic.
Current weight: 70kg.
Size: 1.72
Good condition of the oral mucosa: Yes
Good condition of the tongue: Yes
3. DELETE
Pattern Bowel incontinence, loose stools
Abdominal distension: Yes
Bowel sounds: Augments
Pattern Urinary Incontinence
Diaphoresis: Yes
4. MOVE
Mode of arrival: stretcher
Weakness: Generalized
Muscle twitching in eyelids and facial muscles
Force Extremities: Decreased
P.A. 90/50 mmHg.
Pulse: Frequency: 50/min. Regularly:
5. SLEEP AND REST
No relevant data
6. Dressing and undressing
Able to dress / undress only: No
Factors impeding it: weakness
7. KEEP THE BODY TEMPERATURE WITHIN NORMAL LIMITS
Temperature: Axillary: 35.8 º C
Skin temperature: cold
8. Be clean and neat, and protect the integument
Needing assistance with care: Yes
Skin condition: Integra
9. AVOIDING THE HAZARDS
State of consciousness, mental confusion
Risk of violence to others: No
Falling: Yes
Use of medication at home (name and dosage): No
10. COMMUNICATE WITH SIMILAR
Able to understand what is said: NO.
Pupils: isochoric and reactive miosis.
Blurred vision
Tearing: Yes (epiphora)
Injuries: no auditory canal
11. Act on their own beliefs and values
Requirements or religious prohibitions to be respected: None (Catholic religion)
12. CARING FOR OWN CREATION
No relevant data.
13. DISTRACTING
No relevant data.
14. LEARN
No relevant data.
Nursing diagnosis.
Risk of aspiration associated with increased secretions, salivation, nausea, vomiting, absence of reflexes, and depressed level of consciousness.
Nursing Care Plan
NURSING DIAGNOSES
NURSING RESULTS
NURSING INTERVENTIONS
Risk of aspiration associated with increased secretions, salivation, nausea, vomiting, absence of reflexes, and depressed level of consciousness.
Respiratory Status: Ventilation
Scale:
Extremely committed to uncommitted
Indicators:
Respiratory ERE.
Respiratory rate ERE.
No pathological breath sounds.
Suction Control
Scale:
Never manifested constantly expressed
Indicators:
To identify risk factors.
Avoid risk factors.
Neurological State
Scale:
Extremely committed to uncommitted
Indicators:
Neurological function: consciousness.
Pupil Size
Vital DLN
Respiratory monitoring
Activities:
Monitor rate, rhythm, depth and effort of breathing steadily.
Note chest movement, watching for symmetry, and accessory muscle use, intercostal muscle retractions and supraclavicular.
Palpate to see if lung expansion is the same.
Watch for diaphragmatic muscle fatigue.
Auscultate breath sounds, noting areas of decreased / absent ventilation and presence of adventitious sounds.
Determine the need for aspiration auscultation to check for crepitus or rhonchi in the major airways.
Auscultate lung sounds after treatments and record results.
Observe for increased restlessness, anxiety or shortness of breath.
Note the changes in SaO2, CO2 and changes in the values of arterial blood gases at each control.
Check the patient's ability to cough effectively.
Record appearance, characteristics and duration of cough.
Monitor patient's respiratory secretions.
Watch for dyspnoea and events that improve and worsen.
Place the patient in lateral position to prevent aspiration.
Precautions to prevent aspiration:
Activities:
Monitoring level of consciousness, reflexes of coughing constantly.
Check the pulmonary status
Maintain an open airway
Placement left lateral position with head high, state of consciousness
Keep suction equipment available - operating.
Monitoring vital signs:
Activities:
Controlling blood pressure, pulse, temperature and respiratory status every 6 hours.
Note trends and fluctuations in blood pressure
Monitor pulse oximetry every 2 hours.
Watch for central or peripheral cyanosis.
Identify possible causes of changes in vital signs.
Regularly observe the color, temperature and moisture of the skin
Periodically check the accuracy of the instruments used to collect patient data.
Probing gastrointestinal
Activities:
Select a nasogastric No. 16, gloves Qx. No. 7, 20cc sterile syringe, saline, gauze, tape.
Insert the probe according to protocol.
To ensure correct placement of the probe.
Suction airway
Activities:
Determine need for suctioning
Auscultate breath sounds before and after aspiration
Provide universal precautions, gloves, goggles, mask, if any.
Record the type and amount of secretions obtained.
Management of vomiting:
Activities:
Measure or estimate the volume of emesis.
Identify factors that could cause or contribute to vomit.
Place the patient adequately to prevent aspiration.
Keeping the airways open.
Provide physical support during vomiting, help the person to lateralize and support the head.
Cleaning up after the episode of vomiting with special attention to eliminate odor.
Encourage rest.
Provide relief (wash face, or provide clean clothes and dry)
Monitor fluid balance and electrolytes.
Neurological monitoring
Activities:
Check the size, shape, symmetry and responsiveness of the pupil every 30 min, then every 2 hours and then every 6 hours ..
Monitor the level of consciousness.
Check the level of guidance.
Monitoring trends in the Glasgow Coma Scale.
Watch the corneal reflex.
Watch the cough reflex and nausea.
Explore muscle tone.