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.

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