The Joint Commission National Patient Safety Goals

  • CHAPTER 10,11,12,13,14 ATI FUNDAMENTS
  • In patient safety, critical thinking is an ongoing process.
  • Standards have been developed by American Nurses Association and The Joint Commission.
  • Use of the nursing process when planning care promotes safety.


Safety in Health Care Organizations
A Safe Environment

  • Includes meeting patients’ physical and psychosocial needs
  • Applies to all places where patients receive care
  • Includes patients’ and health care providers’ well-being
  • Reduces risk of injury and transmission of pathogens
  • Maintains sanitation and reduces pollution
Environmental Hazards

  • Physical hazards:
  • Lighting
  • Obstacles
  • Bathroom hazards
  • Motor vehicle accidents
  • Poison
  • Fires

Transmission of pathogens

Fire Safety

  • Keep open spaces (e.g., hallways) free of clutter.
  • Make sure fire exits are clearly marked.
  • Know the locations of all fire alarms, exits, and extinguishers.
  • Know the telephone number for reporting fires.
  • Know the agency’s fire drill and evacuation plans.
  • Never use the elevator in the event of a fire.
  • Turn off oxygen and appliances in the vicinity of a fire.
  • In the event of fire, maintain the respiratory status of a client on life support manually with the use of an Ambu-bag (resuscitation bag) until the client can be moved away from the fire.
  • Use the RACE mnemonic to set priorities in the event of a fire.
  • Use the PASS mnemonic to remember how to use a fire extinguisher.
Evacuation Procedures

  • Ambulatory clients may be directed to walk on their own to a safe area and may be able to help move clients in wheelchairs.
  • Bedridden clients are generally moved from the scene of a fire on stretchers, in their beds, or in wheelchairs.
  • Appropriate transfer techniques must be used to carry a client from the area of a fire.
  • Fire department personnel at the scene of a fire can help evacuate clients.
Safety – The Primary concern when caring for clients
All employees need to know:
the institution’s fire evacuation routine
the location of fire alarms
the location of fire extinguishers
how to use the fire extinguisher
the location of fire exits
The “hang tag“ (ON FIRE EXTINGUISHERS) should be checked for date of last inspection (usually annually)
List the phone number for reporting fires close to all phones in the facility
facility rescue plans:
The most common water extinguishers are suitable for class A fires only. Never use water to extinguish  class C  fires due to the risk of electrical shock.
Dry chemical extinguishers come in a variety of types and are suitable for a combination of  class A, B, and C  fires (liquids and electrical fires)
filled with foam or powder and pressurized with nitrogen
may leave a harmful residue that reduces the likelihood of re-ignition
Carbon dioxide (CO2) extinguishers
used for  class B and C  fires
do not work well on  class A  fires because they may not be able to displace oxygen to put the fire out and the fire may re-ignite
do not leave a harmful residue
Electrical Safety

  • Electrical equipment must be maintained in good working order and should be properly grounded.
  • Inform the client that any electrical equipment that the client brings into the healthcare facility must be inspected for safety before it is used.
  • Check electrical cords and outlets for exposed, frayed, or otherwise damaged wires and loose or missing parts.
  • Do no overload electrical circuits.
  • Read warning labels on all equipment; never operate unfamiliar equipment.
  • Use safety-type extension cords only when absolutely necessary, and secure them to the floor with the use of electrical tape.
Electrical Safety

  • Never run electrical wiring under a carpet.
  • Never pull a plug by the cord; always grasp the plug itself.
  • Never use electrical appliances near sinks, bathtubs, or other water sources.
  • Always disconnect a plug from the outlet before cleaning equipment or appliances.
  • If a client sustains an electrical shock, turn off the electricity before touching the client.
  • A malfunctioning piece of equipment must be removed from the client’s vicinity, and the appropriate hospital maintenance personnel must be notified
Electrical Safety
Electrical safety overview for home settings
To reduce the risk of electric shock, make sure that ground fault circuit interrupter (GFCI) protection is provided for outlets at kitchen counters, in bathrooms, and at outdoor receptacles; test GFCIs regularly
Check the wattage of light fixtures and lamps to make sure they are the correct wattage; incorrect wattage can cause overheating that can lead to a fire
Use safety closures to “child-proof” electrical outlets
Many avoidable electrical fires can be traced to misuse of electric cords, e.g., overloading circuits or extension cords, running cords under rugs
Handling Hazardous and Infectious Materials
Nursing Responsibilities
Identify situations that involve the potential for exposure to hazardous or infectious materials (e.g., radiation, infectious wastes, contaminated needles). Follow agency protocols for handling biohazardous and infectious materials. Ensure that nursing staff understand and follow these protocols. Handle all infectious materials as hazards. Dispose of waste in designated areas only, using the proper containers for disposal. Ensure that infectious material is labeled properly. Dispose of all sharps immediately after use in a closed puncture-resistant disposal container that is leak proof and labeled or color coded.
Radiation Safety Precautions

  • Most nuclear medicine therapy clients are treated with radioactive iodine-131 (I-131). Iodine-131 has a half-life of 8 days and emits both beta particles and gamma rays. Gamma rays have properties like x-rays and present a potential external hazard. Some clients may be undergoing implant therapy, where a sealed source of radioactive material (usually a gamma emitter) is placed in a body cavity close to the tumor.
  • Use these simple techniques to reduce the hazards associated with gamma rays:
Radiation Safety Precautions
Mark the client’s room with appropriate signage
Place client in a private room
Place wristband on client indicating that the client is receiving internal radiation therapy
Put on shoe covers and protective gloves before entering the client’s room; remove equipment before exiting the room
Internal Radiation Implant Safety
Organize nursing tasks to minimize exposure to the radiation source. Rotate nursing assignments Do not allow a pregnant nurse to care for the client. Do not allow pregnant women or children visit the client. Limit visitors to 30 minutes per day and warn them to remain at least 6 feet from the source of radiation. Keep all bed linens and dressings in the client’s room until the implant is removed. Keep a lead container in the client’s room.
Radiation Safety Precautions
Wear gloves
When handling secretions/excretions of a client receiving systemic isotopes; flush toilet twice
When changing linens of clients receiving systemic isotopes
Plan care to minimize time at the client’s bedside
Work quickly, but effectively and courteously
Maintain the greatest distance possible from the client consistent with effective care
Restrict care to a maximum of 30 minutes to one (1) hour every eight (8) hours
Prepare meal trays outside the room
Radiation Safety Precautions
Position items within client’s reach so as to facilitate as much self-care as possible
Schedule only one radioactive client to a nurse at a time
Ensure a long handled forceps and a lead container are in the client’s room in case of implant dislodgement
In the event that a source becomes dislodged, notify the Radiation Oncologist
Do not attempt to handle the dislodged implant unless trained to do so
Radiation Safety Precautions
Wear a dosimeter film badge to measure radiation exposure while caring for client to monitor exposure; have it checked per agency policy
Wear a lead shield to reduce the transmission of radiation.
No pregnant nurses, visitors, or children should be allowed near the client
Read more about radiation safety on the Occupation Safety & Health Administration (OSHA) Web site.
Poison control

  • High risk groups are young children and older adults
  • Goals of therapies

before the body absorbs poison, remove it, (either through vomiting or gastric lavage) or neutralize it (using activated charcoal, for example)
give supportive care, i.e., manage shock, seizures, aspiration
give the correct antidote to neutralize poison
speed the elimination of any absorbed poison

Points to remember-Poisons

  • Never induce vomiting unless instructed to do so by a poison center or health care provider.
  • If you suspect someone has taken poison, take the poisonous substance with you to the emergency room.
  • Call the local poison control center to determine appropriate treatment for the specific poison.
Fall prevention

  • Assesses client for risk factors
  • Use Guidelines to prevent client falls
  • Use the mnemonic FRAIL MOM & DAD for assessing the geriatric client in the primary care setting:
    F alls
    R elative or caregiver strain
    A ctivities of daily living
    I ncontinence
    L iving situation
    M emory Impairment
    O culo-otic impairment (visual and auditory problems)
    M alnutrition
    D rugs
    A dvance directives
    D epression

  • To prevent injury, the nurse needs to use good body mechanics and observe ergonomic principles when providing care.
  • When planning to move a client, the nurse must assess the client’s ability to stand, balance, transfer, and use assistive devices to move about.
  • The nurse needs to ensure that staff members understand the principles of good body mechanics and use proper body mechanics.
  • The nurse needs to arrange for adequate help and use mechanical lifting aids as much as possible.
  • The nurse should provide information to the client about the lift or move and encourage the client to assist as much as possible.
When moving the client, the staff person with the heaviest load coordinates efforts of the team involved by counting to three.
The staff person positions self close to the client (or object being lifted).
The staff person keeps the back, neck, pelvis, and feet aligned and avoids twisting; the arms and legs (not the back) are used, and the knees are kept flexed and the feet kept wide apart.
The staff person sets (tightens) abdominal and gluteal muscles in preparation for the move.
When transferring a client onto a stretcher, a slide board should be used.
Ergonomic Principles for Healthcare Workers
Protect self from falls and injuries using correct body mechanics
When moving objects, avoid pulling; push instead
When moving clients or objects
arrange for help
lift simultaneously with assistance or, better yet, use mechanical aids
flex the knees
keep back, neck, pelvis, and feet aligned
widen the base of support, keeping feet apart
avoid twisting of the body
use arms and legs for lifting and moving, not the back
balance load and keep it centered on the
Incident Reports
An incident report is a form that is completed after an unanticipated occurrence.

  • This type of report is used as a tool for identifying risk situations and improving client care.
  • Other terms for “incident” include unusual event, irregular occurrence, and variance.
Nursing Responsibilities

  • Be aware of the situations that require completion of an incident report.
  • Follow specific agency guidelines for documentation.
  • Fill out the report completely, accurately, and factually.
  • Contact the client’s physician to report the incident; the physician will need to complete the incident report and sign the report.
  • Ensure that the incident report form is not copied or placed in the client’s record and that no reference to completing an incident report form appears in the client’s record.
  • Document a complete entry in the client’s record regarding an incident. The incident report is not a substitute for documentation of the event.
  • When a client injury occurs or an error in care is made, assess the client frequently.
Home Safety

  • Nursing Responsibilities
  • Assess the home environment, taking into consideration the client’s condition and limitations; look for fire alarms, adequate lighting, stair and bathroom handrails, and safe appliances.
  • Initiate modifications to the client’s home as necessary.
  • Teach the client about safety related to the client’s condition and with regard to any equipment that the client is using (e.g., disposal of insulin syringes).
  • Teach parents about safety measures for the child; the toddler, the preschooler, and the young school-age child must be protected from accidental poisoning.
Home Safety
Ensure that parents understand car safety and the use of car seats for the infant and child.
Ensure safety for older adults. Diminished eyesight and impaired memory may result in accidental ingestion of poisonous substances or an overdose of a prescribed medication; a medication organizer will help prevent such errors.
The phone number for a poison control center should be displayed on the telephone itself; the number should be called in any case of suspected poisoning.
The nurse needs to provide instructions to laypersons about interventions to take in the event of an accidental poisoning.
Nursing diagnoses for patients with safety risk:
Risk for falls
Impaired home maintenance
Risk for injury
Deficient knowledge
Risk for poisoning
Risk for suffocation
Risk for trauma
An infection is the result of an interaction between a susceptible host and an infectious agent (bacteria, viruses, fungi, parasites) ; a clinical syndrome caused by the invasion and multiplication of a pathogen in the body.

  • A. Types of infections
  • 1. Community acquired
  • 2. Hospital acquired (also called nosocomial infections)
Health Care–Associated Infection

  • Types of HAI infection:
Health Care–Associated Infection
Risk factors
Number of health care employees with direct contact with the patient
Types and numbers of invasive procedures
Therapy received
Length of hospitalization
Major sites for HAI infection
Surgical or traumatic wounds
Urinary and respiratory tracts
Nature of Infection

  • Communicable disease is the infectious process transmitted from one person to another.
  • If pathogens multiply and cause clinical signs and symptoms, the infection is symptomatic.
  • If clinical signs and symptoms are not present, the illness is termed asymptomatic.
  • Hand hygiene is the most important technique to use in preventing and controlling transmission of infection.
Stages of an infectious process
Incubation period
The time between entrance of the pathogen and the first symptoms
Incubation periods vary with host and organism
If host defenses are successful, an infection may disappear without progression to next stage
Examples of incubation periods for specific diseases
Mumps: 18 days
Varicella (Chicken Pox): 2 to 3 weeks
Stages of an infectious process
Prodromal stage
Time from onset of nonspecific findings, i.e., fatigue, malaise, to more specific findings
The pathogen is multiplying
The host is most contagious

  • Not all diseases have prodromal periods
Stages of an infectious process
Invasive phase (or period of illness)
When a person exhibits the specific findings of the disease
the host is trying to fight off the disease
Given unsuccessful host defenses, the invasive phase can progress to death
Examples of findings for specific diseases
Mumps: swelling of the parotid gland

  • Common cold: sore throat, congestion
Stages of an infectious process
Convalescence: when the acute findings begin to disappear and the body returns to normal health
Complications of infection
Relapse – some infections may reactivate, often because they were not treated thoroughly or the client did not comply with treatment
Local complications – local infections may form abscesses
Systemic complications – pathogen may enter bloodstream and cause septicemia
Defenses Against Infection

  • Normal flora: helps to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms.
  • Innate Defenses(born with): skin, mucous membranes, WBCs(phagocytosis), interferon, etc
Chain of transmission
Causative agent (pathogen)
Portal of exit – way to get out of reservoir of host
Transmission route – way to reach susceptible host
Portal of entry – way to gain entrance
Susceptible host
After the pathogen enters the host, illness depends on 4 factors
Number of pathogen organisms
Duration of the exposure
Health status of host, including age, physical, mental, and emotional health
Genetic status of host’s immune system
Medical Asepsis
Referred to as “clean technique”
Any therapy, protocol or medical procedure used to reduce the number and spread of microorganisms
Practices that reduce pathogens include:
Hand washing – the single most effective and important way to prevent the spread of microorganisms
Friction – loosens the microorganisms so they can be removed
Soap – non-antimicrobial soap and water -or- with antimicrobial soap and water if contact with spores, e.g., Clostridium difficile  or  Bacillus anthracis
Medical Asepsis
No artificial fingernails or extenders, particularly if duties include direct contact with individuals at high risk for infections, e.g., ICU or operating rooms
Use of disinfectants and antiseptics on people and objects
Disinfectant – a substance that reduces the number of microorganisms (but does not eliminate them)
Bleach solutions
Zephirin (and other quaternary ammonium compounds)
Medical Asepsis
Antiseptic – a substance that can be applied to skin to reduce the number of microorganisms
Practices that interrupt transmission
Use of personal protective equipment (PPE)
Mask with shield or goggles
Equipment, i.e., 1-way valve in CPR mask
Surgical Asepsis
Surgical asepsis includes the practices that destroy all microorganisms and their spores
Steam under pressure
Surgical Asepsis
Sterile technique involves procedures that keep an object or area free from living organisms
A sterile object remains sterile only when touched by another sterile object, or, in other words, sterile touching sterile remains sterile
The skin cannot be sterilized and is, therefore, non-sterile
Surgical Asepsis
Surgical asepsis is used for many procedures, including
Care of surgical wounds, i.e., dressing changes
Tracheostomy care
Surgical Asepsis
Principles of surgical asepsis
Only sterile objects may be placed on a sterile field
Always hold your hands above the level of your elbows
Do not reach over the sterile field
The edges of a sterile field or container are considered contaminated (depending on the resource, this is approximately 1 to 2 inches surrounding the border)
Surgical Asepsis
A sterile object becomes contaminated under the following conditions:
Sterile touching clean becomes… contaminated
Sterile touching contaminated becomes… contaminated
Sterile touching questionable is… contaminated
A sterile object or sterile field that is not in the range of vision is… contaminated
An object held below a person’s waist is… contaminated
When a sterile object comes in contact with a wet, contaminated surface, it is considered contaminated (through capillary action)
A sterile object becomes contaminated with prolonged exposure to air
Standard precautions
used for care of all clients
used to prevent the spread of microorganisms
synthesizes the major features of universal precautions and body substance isolation
universal (blood and body fluid) precautions – designed to reduce the risk of transmission of bloodborne pathogens
body substance isolation – designed to reduce the risk of transmission of pathogens from moist body substances
Standard precautions
Apply to
all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood
non-intact skin
mucous membranes
Hand hygiene includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub.
Handwashing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds.
Standard precautions
Personal protective equipment (PPE) – designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in health care settings
protective eyewear
head covering
Transmission-based precautions
Contact: direct and indirect
direct contact transmission: microorganisms are transferred from one infected person to another person without a contaminated intermediate object or person
indirect contact transmission: transfer of an infectious agent through a contaminated intermediate object or person (especially contaminated hands of health care workers)
gown and glove for all contact
examples of opportunities for contact transmission: epidemiologically important organisms, e.g., VRE; excessive wound damage; fecal incontinence
Transmission-based precautions
Droplet precautions: transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganisms generated from someone who either exhibits a disease or who is a carrier of the microorganism
requires close contact (typically within 3 feet or less) between the source client and a susceptible person
use of a standard surgical mask within 3 feet of the client is required
respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during procedures such as suctioning, endotracheal intubation, cough induction by chest physiotherapy and cardiopulmonary resuscitation
examples of infectious agents transmitted through droplet route: group A streptococcus (for the first 24 hours of antimicrobial therapy), adenovirus, rhinovirus, Neisseria meningitis, pertussis, influenza virus
Cough Etiquette
Cover your nose/mouth with a tissue when you cough, and promptly dispose of the contaminated tissue.
Place a surgical mask on a patient if it does not compromise respiratory function or is applicable; this may not be feasible in pediatric populations.
Perform hand hygiene after contact with contaminated respiratory secretions
Maintain spatial separation greater than 3 feet from persons with respiratory infection
Transmission-based precautions
Airborne transmission: microorganisms dispersed over long distances that remain infective over time and distance
infectious agents remain active in the air over a long period of time and are dispersed over long distances by air currents, which are inhaled by susceptible individuals
preventing the spread of airborne pathogens requires
the use of special air handling and ventilation systems
wearing respiratory protection with NIOSH-certified N95 or higher level respirator for all health care workers
examples of microorganisms spread through airborne route: rubeola virus (measles), varicella-zoster virus (chickenpox), Mycobacterium tuberculosis
Acquired immunity
any form of immunity that is not “innate”
obtained during life
natural or artificial
naturally acquired immunity is obtained by
the development of antibodies resulting from an attack of infectious disease
the transmission of antibodies from the mother through the placenta to the fetus or to the infant through the colostrum
Artificially acquired immunity is obtained by
injection of an antiserum, also called an immune globulin such as a hepatitis immune globulin, after hepatitis exposure
Passive or active
passive immunity results from antibodies that are transmitted through
the placenta to the fetus
the colostrum to an infant
injection of antiserum (immune globulin) for treatment or prophylaxis
Passive immunity is not permanent and does not last as long as active immunity
active immunity is when the body produces its own antibodies as a reaction to exposure to an antigen
Disease reporting

  • Reporting of nationally notifiable diseases

voluntary – to the Centers for Disease Control and Prevention
mandated (by legislation or regulation) – at the state level

  • The list of notifiable diseases varies from state-to-state, but internationally quarantinable diseases, e.g., cholera, plague, yellow fever, are reported in compliance with the World Health Organization’s International Health Regulations
Points to remember-Infection

  • Infection control with the use of standard precautions, transmission precautions and medical and surgical asepsis decreases the spread of infection.
  • The major sites for nosocomial infections are urinary and respiratory tracts, blood, and wounds.
  • All nosocomial infections that occur in hospitals must be tracked and recorded by risk management.
  • Hand washing is the most effective method of preventing infection; friction is the most important variable.
  • Standard precautions are used for contact with all body fluids (except sweat).
  • Standard precautions are used for all clients and transmission precautions are used for all clients with transmittable organisms.
  • Special (N95) respirator masks are necessary to care for clients under airborne precautions who have tuberculosis or other airborne infectious conditions.
  • Protective (neutropenic) isolation is used for clients with immunosuppression and low white blood counts.
  • Disease reporting of “notifiable diseases” is mandated at the state level (through legislation or regulation).
Points to remember-Infection
Use of isolation precautions (refer to the Centers for Disease Control’s Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings for more complete information)
Standard Precautions
Contact Precautions
Droplet Precautions
Airborne Precautions
Overview of emergency preparedness and response

  • An emergency can be brought on by a disaster, which is any event initiated by a person or by nature, or a combination of both
  • A formal emergency preparedness plan of action is required to respond to a disaster

personal and family preparedness plan
formal institutional plan


  • The Federal Emergency Management Agency (FEMA) identifies

four disaster management phases:
Three levels of disaster, ranging from minor (Level III) to major (Level I)

Various rating systems exist and nurses should know and understand the rating systems
treated first: individuals who have life-threatening injuries that are readily correctable
treated last: individuals who have no injuries, or noncritical injuries, and who are ambulatory, as well as individuals who are dying or are dead
In the health care agency – emergency department triage involves dividing those who need care into one of the following three categories:
emergent – individuals who have life-threatening injuries and need immediate attention are given the highest priority
urgent – individuals with non-life-threatening injuries
nonurgent – individuals with no immediate complications and who can wait for treatment
Specific hazards associated with disasters

  • Bioterrorism
  • Chemical emergencies
  • Radiation emergencies
  • Mass casualties
  • Natural disasters and severe weather
  • Recent outbreaks and incidents, e.g., salmonella
Bacterial agents
causative agent: Bacillus anthracis
integumentary system (most common): direct skin contact with spores; in nature, contact with infected animals or animal products
respiratory tract: inhalation
gastrointestinal system: eating undercooked or raw infected dairy products
Bacterial agents
exposed individuals do not spread infection
clinical indicators of anthrax infection: symptoms can appear within 7 days of coming in contact with the bacterium for all types of anthrax
skin: localized itching followed by papular lesions that turns vesicular; becomes black eschar after 7 to 10 days
inhalation: initially low-grade fever, cough, malaise, fatigue, myalgias, sweating, and chest discomfort but progressing to high fever, respiratory distress, shock and death within 24 to 36 hours
Bacterial agents
remove clothing; do not pull anything over the head
decontaminate in area outside of treatment area: using large amounts of water, shower with soap or wash with soap and running water; flush eyes with running water for 15 minutes
ciprofloxacin hydrochloride (Cipro), drug of choice
penicillin G procaine (Wycillin)
doxycycline (Vibramycin)
note: do not use extended-spectrum cephalosporins or trimethoprim/sulfamethoxazole due to resistance of anthrax to these drugs
Bacterial agents
vaccine available, but not to the general public

  • Plague

causative agent:  Yersinia pestis
zoonotic infection carried on rodents and their fleas
Y. pestis destroyed by sunlight and dryness, although bacterium can survive for 1 hour after release
exposed individuals can spread infection

Bacterial agents
disease states: bubonic plague, pneumonic plague and septicemic plague
clinical indicators of pneumonic plague
rapidly deteriorating pneumonia
fever, chest pain, bloody or watery sputum
treatment: individuals with the plague need immediate treatment or death will occur within 24 hours after the first symptoms
Bacterial agents
isolate exposed individuals
treat with antibiotics
gentamycin (Garamycin)
doxycycline (Vibramycin)
ciprofloxacin hydrochloride (Cipro)
supportive treatment: oxygen, IV fluids and respiratory support are usually needed
f. vaccine: not available
Viral agents

  • Smallpox
Viral agents
causative agent: variola virus
exposed individuals can spread infection via direct contact or prolonged face to face contact
clinical indicators of smallpox disease
initially (sometimes contagious): high fever (101 to 104 degrees Fahrenheit), malaise, head and body aches
rash (most contagious): start as small, red spots on the tongue and mouth; the spots become open sores and then spread to the rest of the body becoming pustules that crust and scab-over
individuals are contagious until all scabs have fallen off
Viral agents
no specific drug treatment or cure
if the smallpox vaccine is given within 1 to 4 days after exposure to the disease, illness may be prevented or be less severe
individuals diagnosed with smallpox and everyone they have had close contact with will need to be isolated
has not been given routinely in the U.S. since 1972
it is unknown how long immunity lasts after immunization
Viral hemorrhagic fever (VHF)
used to describe a severe multisystem syndrome caused by four different families of viruses, including arenaviruses, filoviruses, bunyaviruses, and flaviviruses
the vascular system is damaged and the body’s ability to regulate itself is impaired
usually accompanied by hemorrhage, but this is not the life-threatening aspect of these diseases
disease states include: Ebola, Marburg, yellow fever, Argentine hemorrhagic fever
Viral hemorrhagic fever (VHF
Viral hemorrhagic fever (VHF
the viruses are zoonotic, residing in and totally dependent on their animal hosts
an animal reservoir host, e.g., rodents
arthropod vector, e.g., ticks, mosquitoes
Biological toxins (chemical agents)

  • Sulfur mustard or mustard gas (H, HD, or HT): a blister agent/vesicant

human-made chemical warfare agent
powerful irritant and blistering agent that damages the skin, eyes, and respiratory tract
damages DNA
may smell like garlic, onions, or mustard
effects of sulfur mustard usually last 1 to 2 days in environment, but can be present for weeks to months in a cold climate
rarely fatal but potentially long term health effects

Viral hemorrhagic fever (VHF
clinical indications of VHF
initially: high fever, muscle aches, weakness
severe disease: subcutaneous and internal bleeding, bleeding from body orifices; shock, delirium, seizures, and coma
supportive therapy
no effective treatment or cure
vaccine: vaccines only for yellow fever and Argentine hemorrhagic fever
Viral hemorrhagic fever (VHF
exposure to a vapor (released into the air), an oily-textured liquid (released into the water), or to a solid form
clinical indications of exposure
skin: redness and itching immediately after exposure eventually resulting in yellow blistering
eyes: irritation, pain, swelling, and tearing with mild to moderate exposure; severe exposure can cause light sensitivity, pain, or blindness lasting up to 10 days
respiratory tract: runny nose, sneezing, hoarseness, bloody nose, sinus pain, shortness of breath, and cough
digestive tract: abdominal pain, diarrhea, fever, nausea, vomiting
  • Post exposure treatment: remove sulfur mustard from the body

antidote: none
shower with soap or wash thoroughly with soap and running water; flush eyes with running water for 15 minutes but do not cover eyes with bandages
inhalation: leave area of exposure; get fresh air, provide oxygen, and support breathing

Sarin (GB) nerve gas

  • Sarin (GB) nerve gas

human-made chemical warfare agent
clear, colorless, tasteless liquid that can evaporate into a odorless gas
extremely toxic, acts very quickly
breaks down the enzyme acetylcholinesterase, which results in excessive concentrations of acetylcholine in nerve synapses and leads to overstimulation of parasympathetic nerves in the smooth muscles
impairs normal functioning of nervous system
can cause seizures, loss of consciousness, and respiratory failure in minutes

Sarin (GB) nerve gas
exposure via inhalation, ingestion, and/or absorption through eyes and skin
clinical indications of exposure
low to moderate doses: runny nose, watery eyes, blurred vision, drooling, cough and chest tightness, diarrhea, drowsiness, weakness, headache, changes in heart rate and blood pressure
large doses: loss of consciousness, seizures, paralysis, respiratory
Post-exposure treatment
post-exposure treatment
antidotes: soldiers typically have an antidote kit containing these two medications
atropine (Atropine): binds to one type of acetylcholine receptor on the post-synaptic nerve
pralidoxime chloride (2-PAM chloride): blocks sarin from binding to any free acetylcholinesterase
decontaminate before transport to treatment facility
flush eyes first for 15 minutes
remove clothing (without pulling over the head) and shower with soap and large amounts of water or 0.5 % solution of sodium hypochlorite (bleach), or use absorbent powders such as flour or talcum powder
Post-exposure treatment
do not induce vomiting if swallowed; administer activated charcoal
note: can contaminate rescuers by direct contact or off-gassing vapor of contaminated skin or clothing
supportive measures: maintain airway, assist ventilation, and protect client; administer diazepam for seizure activity

  • a. the primary natural source: the plant Strychnos nux vomica
  • i. a strong poison; typically used to kill rats
  • ii. white, odorless, bitter crystalline powder
  • iii. very small amount able to cause extremely serious adverse effects
  • iv. impairs functioning of neurotransmitters resulting in severe, painful muscle spasms without affecting consciousness
injection (mixed with street drugs)
ingestion (food or water contamination)
inhalation (release into air, smoked or snorted in street drugs)
clinical indications of strychnine poisoning
initially or with low level exposure:
apprehension, agitation, painful muscle spasms
the client is conscious and in extreme pain
later findings or high level exposure: uncontrollable arching of back and neck, hyperreflexia and muscle twitches, rigid extremities, seizures, difficulty breathing, brain death
Post exposure treatment: most victims die of asphyxia before reaching the hospital
no specific antidote exits
decontaminate in area outside of treatment area
remove clothing; do not pull anything over the head to remove
using large amounts of water, shower with soap or wash with soap and running water
flush eyes with running water for 15 minutes
do not induce vomiting or give fluids to drink
supportive care
IV fluid resuscitation
cooling therapy for fever
anticonvulsants (diazepam, phenytoin, Phenobarbital), antispasmodic agents and muscle relaxants
a plant protein toxin derived from the beans of the castor plant
exposure: through air, food or water
in the form of a powder, a mist, a pellet
may also be dissolved in water or weak acid
clinical indications: effects depend on whether it was inhaled, ingested, or injected; death can occur within 36 to 72 hours of exposure
inhalation: respiratory distress, fever, cough, nausea, chest tightness; pulmonary edema
ingestion: vomiting and diarrhea that may become bloody; dehydration; low blood pressure; may include hallucinations, seizures and multi-system failure
skin and eye exposure: redness and pain
post exposure treatment
treatment: get ricin off or out of the body as quickly as possible
no available antidote
shower with soap or wash with soap and running water thoroughly
flush eyes with running water for 15 minutes
leave area of exposure to get fresh air
provide oxygen and support breathing
do not induce vomiting; remain NPO
administer large dose of activated charcoal
gastric lavage
aggressive fluid resuscitation and electrolyte repletion
if necessary, medicate to control seizures and treat hypotension
Radiation emergencies

  • Causes of radiation emergencies

radioactive material contaminates food/water
a bombing or destruction of a nuclear reactor
exploding a nuclear weapon
nuclear weapon attack
radiation dispersal device (dirty bomb)

Radiation emergencies
Contamination via
Radiation emergencies
Severity of signs and symptoms of radiation sickness depends on how much radiation has been absorbed
mild radiation sickness (absorbed dose of 1-2 Gy): nausea and vomiting, headache, fatigue, weakness within 24 to 48 hours after exposure
very severe radiation sickness (absorbed dose of 3.5-5.5 Gy): nausea and vomiting less than 30 minutes after exposure to radiation, dizziness, disorientation, hypotension; usually fatal
  • Treatment

get inside and stay in an undamaged building
remove clothing and shoes
gently washing with soap and water
for damaged bone marrow:
filgrastim (Neupogen): a protein-based medication which promotes the growth of white blood cells
pegfilgrastim (Neulasta): also increases white blood cells and prevents subsequent infections
Radiation emergencies

Radiation emergencies
For internal contamination (chelating agents)
potassium iodide (KI): used to prevent absorption of radioiodine in the thyroid gland
Prussian blue: a type of dye that binds to particles of radioactive elements (cesium and thallium)
diethylenetriaminepentaacetic acid (DTPA): binds to particles of the radioactive elements plutonium, americium and curium
supportive treatment for infections, headache, fever, diarrhea, dehydration; end-of-life care
Mass casualties
Explosions or blasts can cause unique patterns of injury
primary: injury from over-pressurization force impact
secondary: injury from projectiles
tertiary: injury from displacement of victim by the blast wind
quaternary: all other injuries, i.e., burns, toxic exposures
Predominant injuries involve multiple penetrating injuries and blunt trauma

  • All bomb events have the potential for chemical and/or radiological contamination
Mass casualties
lung injuries

  • high flow oxygen sufficient to prevent hypoxemia via non-rebreather mask, CPAP or ET tube
  • ensure tissue perfusion but avoid volume overload
  • prompt decompression for clinical evidence of pneumothorax or hemothorax

abdominal injury: clinical signs can be subtle at first; observe for acute abdomen or sepsis
ear injuries: tinnitus or deafness will warrant written communication
admit 2nd and 3rd trimester pregnancies for monitoring

Mass casualties
crush injuries: sudden release of a crushed extremity may result in reperfusion syndrome (acute hypovolemia, renal failure, metabolic abnormalities)

  • IV fluid replacement (up to 1.5L/hour)
  • to help prevent renal failure: mannitol to maintain diuresis at least 300 mL/hour; dialysis may be needed
  • to treat acidosis: IV sodium bicarbonate until urine pH reaches 6.5 (to prevent myoglobin and uric acid deposition in the kidneys)
Mass casualties

  • monitor injured areas for the 5 P’s: pain, pallor, parasthesias, pain and pulselessness
  • monitor for sepsis
Natural disasters and severe weather

  • Clustered under this category are: earthquakes, extreme heat, floods, hurricanes, tornadoes, tsunamis, volcanoes, wildfires, landslides/mudslides, winter weather
  • Traumatic events following natural disasters are characterized by a sense of horror, helplessness, serious injury, or the threat of serious injury or death
  • Emergency preparedness includes being ready for any type of hazard
Mass casualties
injuries resulting in nonintact skin or mucous membrane exposure

  • hepatitis B immunization (within 7 days)
  • tetanus toxoid vaccine
  • Recent outbreaks and incidents, e.g., salmonella, E. coli , H1N1, melamine (in food products

Fire Extinguishers
Fire extinguishers are divided into four categories, based on different types of fires for which they are used.
Category Uses
Class A Ordinary combustible materials, such as paper, wood, cardboard, and most plastics
Class B Flammable or combustible liquids, such as gasoline, kerosene, grease, and oil
Class C Electrical equipment, such as appliances, writing, circuit breakers and outlets
Class D Chemical laboratories; for fires that involve combustible metals, such a s magnesium, titanium,
potassium and sodium
Infection Type Examples
central nervous
system infections
meningitis, encephalitis
childhood & vaccine-
chicken pox, diphtheria, tetanus, mumps (infectious parotitis), pertussis
(whooping cough), poliomyelitis, rubella (also known as German
measles), rubeola (measles)
staphylococcal food poisoning, botulism
acute bacterial, viral
salmonella, gastroenteritis, viral hepatitis
mononucleosis, cytomegalovirus, toxoplasmosis
respiratory infections influenza, tuberculosis, histoplasmosis, pharyngitis, scarlet fever,
rheumatic fever, pneumonia
sexually transmitted
gonorrhea, chlamydia, syphilis, genital herpes, chancroid, AIDS, genital
urinary tract infections cystitis, pyelonephritis

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