NCLEX-RN: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Introduction to Disaster Nursing

Focus topic: Disaster Nursing: Bioterrorism

 

A. Preparedness for a terrorist-caused disaster is critical for containment and protection of the population.
B. The Centers for Disease Control and Prevention (CDC) has developed a strategic plan based on five focus areas.

  • Preparedness and prevention.
  • Detection and surveillance.
  • Diagnosis and characterization of biological and chemical agents.
  • Response.
  • Communication.

C. Disaster is defined as an event of such magnitude that essential services are disrupted and current resources are overwhelmed.

  • Disasters may be natural (caused by an earthquake, hurricane, tornado, blizzard, flood, etc.).
  • Disasters may be caused by human actions such as civil disturbance, a hazardous material incident, or act of terrorism.
  • Disasters have several characteristics in common.
    a. They are unexpected with little or no warning.
    b. Lives, public health, and the environment are endangered.
    c. Emergency services and personnel must be called to action.

D. Public policy in relation to mass casualties.

  • Hospitals are the last link in community response to a mass-casualty incident and will receive most seriously injured and ill casualties.
  • Hospitals must follow federal legislation known as EMTALA (Emergency Medical Treatment and Labor Act).
    a. By federal law, a hospital is not allowed to turn away clients.
    b. EMTALA ensures that all individuals must be screened, evaluated, and stabilized before being transferred.
  • The Public Health Security and Bioterrorism Response Act of 2002 authorizes $4.3 billion to combat terrorism through detection, treatment, and containment.

E. A disaster’s impact on the infrastructure will affect transportation, electrical systems, telephone, water, and fuel supplies.
F. The Joint Commission (TJC) has focused on security management and has a developed plan.

  • Provides for designation of personnel to report and investigate security incidents.
  • Provides identification for participants.
  • Controls access to and egress from sensitive areas.
  • Provides an education program and performance standards for a mass-casualty event.

Disaster Nursing: Bioterrorism: Natural Disasters

Focus topic: Disaster Nursing: Bioterrorism

A. The type and timing of a disaster event will determine the types of injuries or illnesses that occur.

  • Disasters may have a prior warning—hurricanes or floods.
  • Disasters may occur with no warning—tsunamis or earthquakes.

B. Natural disasters include earthquakes, hurricanes, floods, tornadoes, tsunamis, typhoons, volcano eruptions, wildfires, landslides/mudslides, extreme heat, and snow or extreme cold.
C. Natural disasters affect public health.

  • Access to medical care is limited.
  • Resources (food, water, medicines) are limited or depleted.

D. Government agencies cannot always provide immediate relief. (Hurricane Katrina was an example of this situation.)
E. Develop a home disaster kit.

  • Water: 1 gallon/person/day for a minimum of 1–2 weeks.
  • Food: selection of ready-to-eat foods—nonperishable, easy-to-prepare items high in protein—for l–2 weeks.
  • Flashlight.
  • Extra batteries.
  • Multipurpose tool (e.g., Swiss army knife).
  • Family and emergency contact information.
  • Extra cash.
  • Emergency blanket (one per person).
  • Map(s) of the area.
  • Extra set of car keys and house keys.
  • Manual can opener.
  • First aid kit with bandages, gloves, soap, H2O2, over-the-counter medications for pain, stomach problems, etc.
  • Prescription drugs (with written prescriptions) essential for health (insulin, heart medications), 1-month supply.
  • Various supplies—battery-powered or hand crank radio (NOAA weather radio, if possible); oil-burning lamps; wood for heat; personal maintenance items such as contact lenses, denture needs, feminine products, sanitation and personal hygiene products.
  • Appropriate clothing and bedding supplies, rain protection gear, sleeping bags.
  • Family documents—personal identification, passports, wills, trusts, insurance records.
  • Credit cards, ATM cards, and cash.

F. Check and replenish supplies and kits once a year; update your disaster plan with the family and practice evacuation procedures.

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Weapons of Mass Destruction

Focus topic: Disaster Nursing: Bioterrorism

A. Biological agents.

  • Biological terrorism is the use of specific agents to cause harm or kill people, and includes the use of organisms such as bacteria, viruses, and toxins.
  • Agents possess unique characteristics.
    a. Easily disseminated or transmitted via person-to-person contact and can be dispersed over a wide geographical area.
    b. Cause high mortality with the potential for major public health impact.
    c. Require specific actions so that public health preparedness is secured.

B. Chemical agents.

  • Chemical terrorism is the deployment of chemical weapons with the intention of causing death.
  • Chemical weapons can be pulmonary agents (phosgene, chlorine), cyanide agents (hydrogen cyanide), vesicant agents (mustard, oxime), nerve agents (tabun, sarin, VX), or incapacitating agents (agent 15, BZ).
    a. The most dangerous of these agents are nerve gases (sarin, tabun, VX), which are extremely toxic and easy to disseminate in the air.
    b. Nerve agents are designed to kill people by binding up a compound known as acetylcholinesterase, which is the body’s “off ” switch.
Disaster Nursing: Bioterrorism

C. Radiation.

  • Radioactive substances emit radiation in the form of rays (waves) or extremely small particles.
    a. Charged particles are emitted from ionizing radiation, the most likely to be dispersed following a terrorist attack.
  • A cell that has been exposed to any type of radiation is damaged and may die.
  •  critical point of discrimination is whether
    a victim is exposed to, or contaminated by radiation.
    a. If exposed, the victim is not a hazard to others. Radiation is absorbed by or passes through the body, but does not result in radioactive contamination.
    b. Radioactive contamination resulting from spillage, leakage, deliberate dispersal, or attached to dust particles in the air can be passed on to healthcare workers.
  • Measuring radiation.
    a. A rad (radiation-absorbed dose) is a unit of measure for radiation exposure; 1 rad results in absorption of 100 ergs of energy/gram of tissue exposed.
    b. The international system measures the unit of exposure by gray (gy). 1 gy equals 100 rads.
    c. Radiation dose is a specific calculated measurement of the amount of energy deposited in the body.
    d. The unit of dose is called rem, which takes into account the type of radiation.
    e. A survey instrument measures radiation levels.
    (1) The readout is in units of R (either rad or rem), which is exposure or dose.
    (2) An instrument reading of 50 R/hr tells the healthcare worker that if he stays in the exposed area for 1 hour, he will receive a 50-rad exposure.
    (3) A radiation detection device (film badge) should be worn by personnel who come in contact with the exposed area or victims.
  • Health effects of radiation.
    a. A victim contaminated by radiation is at risk. How much risk depends on how much radiation is absorbed.
    b. Victims who absorb less than 0.75 Gy will not experience symptoms of exposure.
    c. Victims who absorb 8 Gy could die. Between 0.75 and 8 Gy, the victim could develop acute radiation syndrome (ARS).
    d. Background radiation is derived from natural sources such as radiation from outer space, industrial, academic, military, or radiation used in medicine.
    e. All of these sources combine to give us a background radiation dose of 0.360 rem per person per year.

Disaster Nursing: Bioterrorism: Bioterrorism Agents

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Smallpox: Agent of Terror

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Smallpox Disease

Focus topic: Disaster Nursing: Bioterrorism

Definition: An acute viral disease caused by the variola virus. It was eradicated in 1977, and in the early 1980s routine vaccinations were discontinued. Because there is a large nonimmune population, authorities fear it could be a bioterrorism weapon, transmitted via the airborne route as aerosol.

Disaster Nursing: Bioterrorism

Characteristics
A. Recognize clinical features.

  • Initially, symptoms resemble an acute viral illness like influenza with fever, myalgia, headache, and backache.
  • Rash appears, progressing from macules to papules (in 1 week) to vesicles, and then to scabs over in 1–2 weeks.
  • Distinguishing rash from varicella (chickenpox): smallpox has a synchronous onset on face and extremities, rather than arising in “bunches,” starting on the trunk.

B. Mode of dissemination and incubation period.

  • Smallpox is transmitted by large and small respiratory droplets; thus, both respiratory and oral secretions spread the disease, as well as lesion drainage.
  • Clients are considered more infectious if they are coughing or have a hemorrhagic form of the disease.
  • Vaccination effective if given within 3 to 4 days.
  • Incubation: 7–17 days; average is 12 days.

Assessment
A. For those clients who have contracted smallpox,
identify those in a high-risk group.
B. Assess need for smallpox vaccination.
C. Observe postvaccination reactions and compare
with adverse reactions.
D. Assess client’s understanding of postvaccination
evaluation.

Implementation
A. Manage decontamination.

  • Decontamination of clients is not indicated with smallpox.
  • Careful management using contact precautions of potentially contaminated equipment and environmental surfaces— clean, disinfect, and sterilize when possible.
  • Dedicated or disposable equipment for each client should be used.

B. Institute strict isolation precautions immediately.

  • Airborne and contact precautions in addition to standard precautions; includes gloves, gown, eye shields, shoe covers, and correctly fitted masks (very important).
  • Airborne precautions: microorganisms transmitted by airborne droplet nuclei (particles 5 microns or smaller).
    a. Respiratory protection when entering client’s room (particulate respirators, N95); must meet N1OSH standards for particulate respirators.
    b. Isolate in room under negative pressure with high-efficiency particle air (HEPA) filtration.
  • Contact precautions: clients known to be infected or colonized with organisms that can be transmitted by direct contact or indirect contact with contaminated surfaces.
    a. Perform hand hygiene using antimicrobial agent when entering and leaving room.
    b. Don gloves when entering room.
    c. Wear gown for all client contact or contact with client’s environment.
    d. Wear gown when entering room and remove before leaving isolation area.

C. Assign client placement.

  • Rooms must meet ventilation and engineering requirements for airborne precautions.
    a. Monitored negative air pressure with 6–12 air exchanges/hour.
    b. Appropriate discharge of air to outdoors, or high-efficiency filtration of air.
  • Door to room must remain closed; private room is preferred. Clients with same diagnosis may be cohorted.
  • Limit transport of clients; use appropriate mask if unavoidable.

D. Implement therapy.

  • Postexposure immunization (vaccine virus) is available.
    a. Vaccination alone if given within 3 to 4 days of exposure.
    b. Passive immunization (VIG) if greater than 3 days postexposure.
    c. VIG given at 0.6 mL/kg IM. Check with CDC for up-to-date recommendations.
  • Prophylactic care with precautions.

E. Identify clients exposed to the smallpox virus.

  • Persons who were exposed to initial release of the virus.
  • Persons who had face-to-face, household,
    or close-proximity contact (< 2 meters = 6.5 feet) with a confirmed or suspected smallpox client after client developed fever and until all scabs have separated (no longer infectious).

F. Identify healthcare workers exposed to the virus—must be evaluated for possible vaccination.

  • Personnel involved in evaluation, care, or transportation of confirmed, probable, or suspected smallpox clients.
  • Laboratory personnel involved in collection or processing of clinical specimens.
  • Other persons with increased likelihood of contact with infectious materials from a smallpox client (laundry or medical waste handlers).
  • Other persons or staff who have a reasonable probability of contact with smallpox clients or infectious materials (e.g., selected law enforcement, emergency response, or military personnel).
  • Because of potential for greater spread of smallpox in a hospital setting due to aerosolization of the virus from a severely ill client, all individuals in the hospital may be vaccinated.

G. Determine contraindications for vaccination of noncontacts.

  • Certain medical conditions (heart disease) have a higher risk of developing severe complications following vaccination.
  • Diseases or conditions that cause immunodeficiency (HIV, AIDS, leukemia, lymphoma, generalized malignancy, agammaglobulinemia).
  • Serious, life-threatening allergies to the antibiotics.
  • Persons who have ever been diagnosed with eczema or other acute or chronic skin conditions such as atopic dermatitis, burns, impetigo or varicella zoster (shingles).
  • Women who are pregnant.

H. Identify indications for vaccinia immune globulin (VIG) administration.

  • Identify postvaccination complications for which VIG may be indicated.
    a. Eczema vaccinatum is a rare severe adverse reaction to smallpox vaccination. It is characterized by serious local or disseminated, umbilicated, vesicular, crusting skin rashes of the entire body.
    b. Progressive vaccinia (vaccinia necrosum). 150 Chapter 7: Disaster Nursing: Bioterrorism

c. Severe generalized vaccinia if client has a toxic condition or serious underlying illness. d. Inadvertent inoculation of eye or eyelid without vaccinial keratitis.

  • Check physician’s orders for VIG treatment of complications due to vaccinia vaccination.
  • Administer VIG intramuscularly (IM) as early as possible after onset of symptoms.
  • Give VIG in divided doses over a 24- to 36-hour period. Doses may be repeated at 2- to 3-day intervals until no new lesions appear.

Disaster Nursing: Bioterrorism: Collecting and Transporting Specimens

Focus topic: Disaster Nursing: Bioterrorism

Implementation
A. Acquire and follow specific recommendations for diagnostic sampling of the specific agent.

  • Perform all sampling according to standard precautions.
  • Check that laboratory has capacity and equipment to handle specific sample. There are four laboratory levels.
    a. Local clinical labs for minimal identification of an agent.
    b. County or state labs.
    c. State and other large labs with advanced capacity for testing.
    d. CDC or select Department of Defense labs with bio safety level (BSL) testing capacity.

B. Wear protective gear when entering environment where potential for exposure exists.
C. Collect specimen and place in appropriate container (zip-closure plastic bag, sealed).

  • Remove original gloves handling specimen, and place in biohazard container.
  • Don new pair of gloves.
  • Place specimen bag in second zip-closure bag and seal, or if specimen is large, in trash bag.

D. Remove protective gear and place in biohazard bags.
E. Perform hand hygiene.
F. Label specimen with appropriate label outside of bag: date, person collecting specimen, location, and contact person.
G. Collect an acute phase serum sample, as well as a later convalescent serum sample for comparison.
H. Transport specimens.

  • Coordinate with local and state health departments and the Federal Bureau of Investigation (FBI).
  • Include a chain of custody form with specimen information from moment of collection, completed each time specimen is transferred to another party.

Disaster Nursing: Bioterrorism: Chemical Agent Exposure

Focus topic: Disaster Nursing: Bioterrorism

Assessment
A. Pulmonary agents (chlorine, chloropicrin or phosgene): When inhaled, produce pulmonary edema with little damage to other pulmonary tissues (with resulting hypoxemia) and hypovolemia.

  • Immediate symptoms are irritation of eyes, nose, and upper airways—often not distinctive enough to be recognized as chemical agent exposure.
  • About 2 to 24 hours later, victim develops chest tightness, shortness of breath with exertion (later, at rest).
  • Cough produces clear, frothy sputum, fluid that leaked into lungs.
  • If symptoms begin soon after exposure, death may occur within hours.

B. Cyanide agents (gases or solids, such as hydrogen cyanide or cyanogen chloride): with high concentrations, death occurs in 6 to 8 minutes.

  • Initial symptoms are burning irritation of eyes, nose, and airways, and smell of bitter almonds.
  • Victim’s skin may be acyanotic, cherry-red (oxygenated venous blood), or normal.
  • Large amount of gas inhaled: hyperventilation, convulsions, cessation of breathing (3 to 5 minutes), and no heartbeat (6 to 10 minutes).

C. Vesicant agents: Cause vesicles or blisters; common agents are sulfur mustard and lewisite. More lethal than pulmonary agents and cyanide.

  • Mustard—initial symptoms not observable; effects begin hours after exposure: erythema, burning and itching with blisters; burning of eyes; airway pain, sore throat, nonproductive cough.
  • Lewisite—oily liquid that results in topical damage; vapor causes immediate pain, burning and irritation of eyes, skin, and upper airways.
  • Cellular damage that can result in hypovolemic shock occurs.

D. Nerve agents (sarin, tabun, soman, GF, and VX): liquids or vapors that are the most toxic of all chemical agents.

  • Nerve agents block the enzyme acetylcholinesterase, so activity in organs, glands, muscles, smooth muscles, and central nervous system cannot turn off; body systems wear out.
  • Effects of nerve agent depends on route (vapor or droplet) of exposure and amount; it is felt within seconds.
    a. Felt first on face: eyes, nose, mouth, and lower airways—watery eyes, runny nose, increased salivation, and constriction of airways, shortness of breath.
    b. The most common sign of nerve vapor exposure is constricted pupils (miosis) with reddened, watery eyes.
    c. Large concentration of vapor: loss of consciousness, convulsions, no breathing.

Implementation
A. Pulmonary agents: Client with pulmonary edema must be on immediate bed rest with no exertion and receive oxygen.
B. Cyanide agents: Administer antidotes.

  • Client inhales amyl nitrite, or is given sodium nitrite intravenously (IV) (10 mL; 300 mg); frees bound cyanide from hemoglobin to allow O2 transport.
  • Sulfur thiosulfate IV (50 mL; 12.5 g); sulfur converts cyanide to form a nontoxic substance.
  • Give antidotes sequentially and slowly, titrated to monitor effects; ventilate with oxygen, and correct acidosis.

C. Vesicant agents.

  • Mustard: Immediate decontamination (within 1 minute) will minimize damage; longer will be too late. Irrigate affected skin areas and eyes frequently and apply antibiotics to skin three to four times/day.
  • Lewisite: Similar to mustard; immediate decontamination is important. An antidote for systemic lewisite is British anti-Lewisite (BAL), a drug given IV for heavy metal poisoning.

D . Nerve agents.

  • Personal protection equipment is necessary when decontaminating victims. Decontamination must take place first, before management begins.
  • Antidotes.
    a. Atropine: 2 to 6 mg (average dose 2 to 4 mg) IM. If no improvement, 2 mg more may be administered in 5 to 10 minutes. A high initial dose is necessary to block excess neurotransmitter, especially if victim is unconscious.
    b. Protopam, an oxime: 600 mg given slowlyn IV to counteract nerve agent by removing agent from the enzyme.
    c. Valium: might be used for prolonged convulsions.
  • The military has a device (Mark I Auto-Injection Kit) that holds two spring powered injectors containing two antidotes, atropine and Protopam, that can be used effectively and quickly to administer antidotes.
  • Chempacks, which include chemical weapon antidotes, are being shipped to all states from a federal stockpile. Within hours, they will be available following an emergency.
Disaster Nursing: Bioterrorism

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