NR442 -COMMUNITY HEALTH CMS (EXTRA BITS) questions and answers + rationales for student success

HOSPITAL INCIDENT COMMAND SYSTEM (HICS)

assists hospitals to improve their emergency management planning, response, and recovery capabilities for planned and unplanned events

DEPARTMENT OF HOMELAND SECURITY (DHS)

Mission of the DHS

prevent terrorism and enhance security

secure and manage U.S. borders

enforce and administer immigration laws

safeguard and secure cyberspace

ensure resilience to disasters

OFFICE OF EMERGENCY MANAGEMENT (OEM)

involves representatives from all official and unofficial agencies in:

developing the community disaster plan

developing scenarios to test the plan through drills

assessing the scope, intensity, and number of casualties once an incident has occurred in order to initiate the proper response

FEDERAL EMERGENCY MANAGEMENT AGENCY (FEMA)

FEMA's Mission

to support citizens and first responders to ensure that as a nation, everyone works together to build, sustain, and improve the capacity to prepare for, protect against, respond to, recover from, and mitigate all hazards

FEMA - RECOMMENDATIONS FOR BASIC DISASTER SUPPLY KIT

3 day supply of non-perishable food

3 day supply of water

- 1 gallon/per person/per day

portable, battery powered radio/television

with extra batteries

flashlight with extra batteries

first aid kit w/manual

sanitation/hygiene items

matches/waterproof container

whistle

kitchen accessories/utensils/can opener

photocopies of ID Cards/credit cards

cash/coins

medications

infant supplies (diapers, formula, bottle, etc)

warm clothes (if in a cold climate)

AMERICAN RED CROSS (ARC)

a nonprofit, humanitarian organization led by volunteers and guided by its Congressional Charter that provides relief to victims of disasters

SURVIVOR'S GUILT

when a person has feelings of guilt because they survived a life-threatening situation when others did not

a common reaction to traumatic events

a symptom of post traumatic stress disorder (PTSD)

PTSD - PREVENTION

During the incident, be aware of need for breaks, rest, adequate water, and nutrition

provide emotional support for those involved in the incident

encourage staff to support each other

debrief with others following the incident

encourage expression of feelings by all involved

use offered counseling resources

RISK MAP

geographic map of an area that is analyzed for the impact of a potential disaster on the population and buildings in the area that would be involved

examples

- an area in a flood plain

- area covered if a nuclear explosion would occur

- area involved in an explosion of an industrial site

DISASTER MANAGEMENT - DISASTER RESPONSE

assess extent of disaster

- how many people affected?

- how many injured/dead?

- how much fresh water/food available?

- what are areas of risk/sanitation concerns?

perform triage and direct those affected

coordinate evaluations/quarantines

RESOURCE MAP

geographic map that outlines the resources that would be available in or near the area affected by a potential disaster

examples

- potential shelter sites

- potential medical sources

- location of equipment that might be needed

MITIGATION

actions taken to reduce loss of life and property by lessening the impact of disasters

primary prevention = aimed at preventing the occurrence of a disaster or limiting consequences when the event cannot be prevented

NON-DISASTER STAGE

the period before the disaster occurs

ETHICAL PRINCIPLES IN COMMUNITY HEALTH NURSING

respect a client's right to autonomy

non-maleficence

beneficence

distributive justice

PREVENTIVE ACTIONS DURING THE NON-DISASTER STAGE

assessing communities to determine potential disaster hazards

developing disaster plans at local, state, and federal levels

conducting drills to test the plan

training volunteers and health care providers

providing educational programs of all kinds

AUTONOMY

respect a client's right to self-determination

individuals select actions that fulfill their goals

example

a client refusing chemotherapy

FIRST RESPONDERS

responsible for incident management at the local level

includes:

- police dept

- fire dept

- public health

- public works

- emergency medical services

NON-MALEFICENCE

do no harm

example

developing plans of care that include a system for monitoring/evaluating outcomes

GUIDELINES FOR EARLY DETECTION OF BIOCHEMICAL TERRORIST INCIDENTS

rapidly increasing disease incidence

unusual increase in the number of people seeking care

endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern

clusters of clients arriving from a single locale

large numbers of rapidly fatal cases

- clients who die within 72 hrs after admission

client who presents with disease that is relatively uncommon (i.e. pulmonary anthrax, smallpox, plague)

BENEFICENCE

do what is best

maximize benefits

example

assessing costs, risks, benefits when planning interventions

IN THE EVENT OF A BIOCHEMICAL INCIDENT - AGENCIES TO CALL INCLUDE...

CDC Bioterrorism Emergency Response

CDC Hospital Infections Program

U.S. Army Medical Research Institute of Infectious Diseases

DISTRIBUTIVE JUSTICE

fair allocation of resources in the community

example

determining eligibility for health care services based on income and fiscal resources

NATIONAL RESPONSE FRAMEWORK (NRF)

core operational plan for domestic incident management for an all-hazards response

describes best practices for managing incidents "that range from the serious but purely local, to large-scale terrorist attacks or catastrophic natural disasters"

CHARACTERISTICS OF DISASTERS

frequency

predictability

preventability

imminence

scope/number of casualties

intensity

DISASTER PLANNING PRINCIPLES

measures usually taken are not sufficient for major disasters

plans should be adjusted to people's needs

planning does not stop with the development of a written plan

lack of information causes inappropriate responses by community members

people should be able to respond with/without direction

plans should coordinate efforts of the entire community

plans should be linked to surrounding areas

plans should be general enough to cover all potential disaster events

CHARACTERISTICS OF DISASTERS - FREQUENCY

how often a disaster occurs

example

in the United States, there are 45 states/territories that have moderate to high risk for earthquakes and earthquakes have occurred in every region of the country

CONTINUOUS QUALITY IMPROVEMENT (CQI)

approach to quality management that emphasizes the organization and its processes and systems and uses objective data to analyze and improve processes

CHARACTERISTICS OF DISASTERS - PREDICTABILITY

relates to the ability to determine when and whether a disaster event will occur

examples

floods - predictions made by monitoring snowmelt

hurricanes - predictions based on system tracking

tornadoes - predictions based on weather conditions

CQI - EFFECTIVENESS

providing services to those who will benefit

CHARACTERISTICS OF DISASTERS - PREVENTABILITY/MITIGATION

assumes that all disasters are not inevitable and steps can be taken to prevent them

some disasters are not preventable, however, some disasters can be controlled

example

flood can be controlled by the building of dams/levees

CQI - TIMELINESS

reducing waits and harmful delays in providing/receiving care

CQI - CLIENT CENTERED

ensuring client values guide decision making

CQI - EQUITY

providing equal care without discriminating against gender, race, sexual orientation, or socioeconomic status

CQI - SAFETY

avoiding injuries to clients from the care intended to help

PRE-DISASTER STAGE

the time when the disaster is pending

CQI - EFFICIENCY

avoiding waste in supplies, ideas, or energies

CHARACTERISTICS OF DISASTERS - IMMINENCE

the speed of onset of an impending disaster and relates to the extent of forewarning possible and the anticipated duration of the incident

example

weather forecasters can tell when a hurricane may be developing days ahead of its expected arrival and can give the time of arrival, the general direction it will take, and an approximate location for its landing and forward movement

CHARACTERISTICS OF DISASTERS - SCOPE AND NUMBER OF CASUALTIES

scope

indicates range of its effect

scope is described in terms of both geographic area and number of individuals affected/injured/killed

CHARACTERISTICS OF DISASTERS - INTENSITY

characteristic describing the level of destruction and devastation of the disaster event

PNEUMOTHORAX - SYMPTOMS

deviated trachea

pain on affected site

unequal movement of chest during inhalation/exhalation

air hunger

tachycardia

shallow respirations

SCABIES - NURSING CONSIDERATIONS

pruritus may last up to 4 weeks after treatment

recurrence possible if inadequately treated

CHEST TUBE SYSTEM

first chamber

- drainage collection

second chamber

- water seal

third chamber

- suction control

- can be wet or dry

CUTANEOUS ANTHRAX

when anthrax spores get into the skin, usually through a cut or scrap

happens when a person handles infected animals or contaminated animal products (i.e. wool, hides, and hair)

most common form of anthrax

least dangerous

CHEST TUBE - INDICATIONS

drains fluid, air, or blood from the pleural space

CUTANEOUS ANTHRAX - NURSING CONSIDERATIONS

cutaneous anthrax is NOT contagious

all types of anthrax have the potential, if left untreated, to spread throughout the body and cause severe illness, and in some cases, death

CHEST TUBE - POSITIONING

TUBE TIP POSITION UP

- pneumothorax

TUBE TIP POSITION DOWN

- hemothorax

- plerual effusion

CUTANEOUS ANTHRAX - SIGNS/SYMPTOMS

small blisters/bumps

swelling around the sore

skin sores with a black center that appear on the face, neck, and arms

CHEST TUBE - DRAINAGE COLLECTION CHAMBER

chart the amount/color

report drainage amounts greater than 70 mL/hr to the provider

CUTANEOUS ANTHRAX - DIAGNOSIS

measure antibodies/toxin in the blood

Bacillus anthracis can be sampled from:

- blood

- skin lesion swab

- spinal fluid

- respiratory secretions

samples must be taken BEFORE initiating antibiotic therapy

CHEST TUBE - WATER SEAL CHAMBER

add sterile fluid up to 2 cm line

check every 2 hours

chamber must be kept upright and below chest tube insertion site

tidaling expected

lack of tidaling

- lung re-expansion or obstruction

continuous bubbling in water chamber indicates air leak

CUTANEOUS ANTHRAX - ANTIBIOTIC TREATMENT

ciprofloxacin

doxycycline

levofloxacin

CIPROFLOXACIN - CLIENT TEACHING

dairy products and antacids decrease absorption of this Rx.

this Rx can be taken with meals

increase fluid intake while taking this Rx

report unusual pain/inflammation and diarrhea symptoms

CIPROFLOXACIN - ADVERSE EFFECTS

achilles tendon rupture

GI discomfort (nausea/vomiting/diarrhea)

- take Rx with meals

suprainfection

- thrush

- vaginal yeast infection

phototoxicity (severe sunburn)

- avoid sun exposure

- wear protective clothing

DOXYCYCLINE - CLIENT TEACHING

take Rx on an empty stomach with full glass (8 oz) of water

avoid milk products and antacids while taking this Rx

this Rx decreases the effectiveness of oral contraceptives; alternative birth control needed

CHEST TUBE - SUCTION CONTROL CHAMBER

-20 cm H₂O common

continuous bubbling in suction control chamber is expected

DOXYCYCLINE - ADVERSE EFFECTS

GI discomfort

- nausea/vomiting

- cramping/diarrhea

- esophageal ulceration

tooth discoloration

- do not give to children under 8 years old

- do not give to pregnant women

hepatotoxicity

photosensitivity

- wear protective clothing

- use sunscreen

suprainfection

- pseudomembranous colitis

- yeast infections

CUTANEOUS ANTHRAX - ANTITOXIN TREATMENT

raxibacumab

obiltoxaximab

IV anthrax immune globulin

anthrax vaccine adsorbed (AVA)

SUCTION CONTROL - WET SUCTION

height of sterile fluid determines amount of suction transmitted to the pleural space

suction pressure is set by a regulator on the chest tube drainage device

suction results in continuous bubbling in the suction chamber

monitor fluid level and add fluid as needed to maintain prescribed suction level

SUCTION CONTROL - DRY SUCTION

when connected to wall suction, the regulator on the chest tube drainage system is set to manufacturer's recommendation

tidaling is expected in the water seal chamber

CHEST TUBE - RESPIRATION/FLUID PATTERNS

NEGATIVE PRESSURE/SPONTANEOUS RESPIRATION: Fluid will...

- rise with inspiration

- fall with expiration

POSITIVE PRESSURE/MECHANICAL RESPIRATION: Fluid will...

- rise with expiration

- fall with inspiration

CHEST TUBES - NURSING CARE

assess chest tube insertion site for erythema, pain, and crepitus

position patient in semi/high Fowler's position

obtain chest x-ray to verify tube placement

keep 2 hemostats, sterile water, occlusive dressing at the bedside

only clamp when ordered

do not strip/milk tubing

CHEST TUBE REMOVAL

tell patient to take a deep breath, exhale, and bear down (Valsalva maneuver)

apply sterile petroleum jelly gauze dressing over the chest tube site

CHEST TUBE COMPLICATIONS - ACCIDENTAL DISCONNECTION

if drainage system becomes compromised, place end of tube into sterile water (to maintain water seal)

if chest tube is accidentally removed, place occlusive dressing over insertion site - TAPED ONLY ON THREE SIDES

CHEST TUBE COMPLICATIONS - AIR LEAK

monitor the water seal chamber for continuous bubbling (which confirms air leak)

check all connections

tighten connection or replace drainage system

TENSION PNEUMOTHORAX

tracheal deviation

absent breath sounds on affected side

respiratory distress

asymmetry of chest

RESPIRATORY EMERGENCIES

pneumothorax

tension pneumothorax

hemothorax

flail chest

RESPIRATORY EMERGENCIES - PNEUMOTHORAX

lung collapse due to air in the pleural space

key symptom

- hyperresonance w/percussion

RESPIRATORY EMERGENCIES - TENSION PNEUMOTHORAX

air enters the pleural space during inspiration, but cannot exit during expiration

trapped air causes pressure on the heart and lungs

increased pressure compresses blood vessels and restricts venous return; decreases cardiac output

key symptom

- tracheal deviation

RESPIRATORY EMERGENCIES - HEMOTHORAX

blood accumulates in the pleural space

key symptom

- dull percussion

RESPIRATORY EMERGENCIES - FLAIL CHEST

chest wall expansion limited due to multiple fractured ribs

key symptom

- paradoxical chest wall movement

RESPIRATORY EMERGENCIES - TREATMENT

oxygen therapy

medications

- benzodiazepines (for anxiety)

- opioids (for pain)

chest tube insertion

CHEST TUBE - FUNCTIONS

drain fluid, blood, or air

re-establish negative pressure

facilitate lung expansion

restore normal intrapleural pressure

LUMBAR PUNCTURE

cerebral spinal fluid (CSF) sample is taken from the spinal canal for analysis

LUMBAR PUNCTURE - INDICATIONS

used to diagnose...

- multiple sclerosis

- syphilis

- meningitis

- infection in the CSF

LUMBAR PUNCTURE/PRE-PROCEDURE

have client void

position client in "cannonball" position on their side or have client stretch over table while sitting

LUMBAR PUNCTURE/POST-PROCEDURE

patient should lay flat for several hours

if dura puncture site does not heal, CSF may leak, resulting in headache

administer pain meds

encourage increased fluid intake

epidural blood patch can be used to seal off the hole

MENINGITIS

inflammation of the meninges (membrane around the brain/spinal cord)

viral meningitis is most common

bacterial meningitis is contagious, with high mortality rate

MENINGITIS - PREVENTION

immunizations help prevent bacterial meningitis

Hib vaccine is given to infants

- @ 2 months

- @ 6 months

- @ 1 to 1.5 years

MCV4 vaccine is given to students living in dorms

MENINGITIS - SIGNS/SYMPTOMS

headache

nuchal rigidity

photophobia

nausea/vomiting

positive Kernig's sign

positive Brudzinski's sign

fever

altered LOC

tachycardia

seizures

KERNIG'S SIGN

Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

BRUDZINSKI'S SIGN

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

MENINGITIS - DIAGNOSIS

CSF analysis

Bacterial

- cloudy CSF

- decreased glucose content

Viral

- clear CSF

both types will have elevated WBC and elevated protein

MENINGITIS - NURSING CARE

droplet precautions until antibiotics are administered for 24 hours (or per facility policy)

quiet room/low light

HOB @ 30 degrees

monitor for ICP

instruct patient to avoid coughing/sneezing

implement seizure precautions

MENINGITIS - MEDICATIONS

antibiotics

ceftriaxone or cefotaxime in combination with vancomycin

anticonvulsants

phenytoin

analgesics

acetaminophen

ibuprofen

prophylactic antibiotics (given to those in close contract with client). ABX include:

- ciprofloxacin

- rifampin

- ceftriaxone

MENINGITIS AND OPIOID MEDICATIONS - NURSING CONSIDERATION

non-opioid analgesics are preferred treatment for meningitis to avoid masking changes in level of consciousness

MENINGOCOCCAL VACCINE (MCV4)

initial dose between 11-12 years of age

booster dose at 16 years of age

MENINGITIS - COMPLICATIONS

Increased ICP

SIADH

Septic emboli

SCABIES

mite(s) penetrate the stratum corneum and deposit eggs

allergic reaction to eggs, feces, and mite parts occurs

transmission by direct physical contact

SCABIES - SIGNS/SYMPTOMS

severe itching, especially at night

usually not on the face

presence of burrows

- interdigital webs

- flexor surface of the wrists

- genitalia

- anterior axillary folds

erythematous papules with/without crusting

SCABIES - TREATMENT

5% permethrin cream

treat all family members/sexual partners

treat environment with plastic covering for 5 days

launder clothing/linen with bleach

antibiotics if secondary infections present

PPE - ORDER FOR PUTTING ON

gown

mask/respirator

goggles/face shield

gloves

(MEMORY TIP: from the bottom up, with hands above the head)

PPE - ORDER FOR TAKING OFF

gloves

goggles/face shield

gown

mask/respirator

(MEMORY TIP: these are in alphabetical order)

AIRBORNE PRECAUTIONS

smaller than 5 microns

measles

chickenpox (varicella)

disseminated varicella zoster (shingles)

pulmonary or laryngeal tuberculosis

AIRBORNE PRECAUTIONS - PROTECTIVE ACTIONS

Private room

NEGATIVE pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration

mask or respiratory protection device

N95 respirator (for TB)

DROPLET PRECAUTIONS

larger than 5 microns, within 3 feet of patient

requires surgical mask, proper hand hygiene and dedicated care equipment

DROPLET PRECAUTIONS - "SPIDERMAN"

S = Sepsis/Scarlet fever/Streptococcus pharyngitis

P = Parvovirus B19/Pneumonia/Pertussis

I = Influenza

D = Diptheria (pharyngeal)

E = Epiglottitis

R = Rubella

M = Mumps/Meningitis/Mycoplasma/Meningeal pneumonia

An = Adenovirus

DROPLET PRECAUTIONS - PROTECTIVE ACTIONS

Private room or cohort patients

mask or respirator required (depending on condition) (refer to agency policy)

CONTACT PRECAUTIONS

direct patient contact or environmental contact

requires gown & gloves

Colonization or infection with multidrug-resistant organisms such as VRE and MRSA, Clostridium difficile, shigella, and other enteric pathogens

major wound infections

herpes simplex

scabies

varicella zoster (disseminated)

respiratory syncytial virus in infants, young children, or immunocompromised adults

CONTACT PRECAUTIONS - "MRS WEE"

M = MDRO

R = respiratory infection

S = skin infections

W = wound infections

E = enteric (C. diff)

E = eye infection

CONTACT PRECAUTIONS - PROTECTIVE ACTIONS

Private room or cohort patients

gloves, gowns

Patients may leave their room for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are cleaned