SUBJECT: HEAT RELATED CONDITIONS 1. PURPOSE: COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 706 Effective Date: August 31, 2006 The purpose of this policy is to assist nursing staff in differentiating the types of heat disorders and to provide immediate assessment and intervention to protect individuals and staff from injury during times of extreme weather or when unit temperatures are too hot due to malfunction of equipment. 2. POLICY: Nursing staff shall immediately evaluate the client or staff member to determine the medical emergency status (LIFE-THREATENING call 7119; NON LIFE- THREATENING call 7119) and take appropriate action as outlined in A.D. #10.25 and NP&P #700 Medical Emergencies. An I.V. of Normal Saline or D 5 W at TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physician s order in life-threatening emergencies. A physician s order must be obtained as soon as possible thereafter. During summer months individual served health education should be provided on a continuous and ongoing basis during therapeutic community meetings and during 1:1counseling regarding methods to prevent heat related illnesses. 3. COMPETENCY/TRAINING: All Level of Care nursing staff is required to take First Aid training at time of hire and every three years thereafter as part of Mandated Training. 4. GENERAL INFORMATION: By sweating, breathing, shivering, and shifting the flow of blood between the skin and internal organs, the body can usually keep its temperature within a narrow range in hot or cold weather. However, overexposure to high temperatures can result in heat disorders such as heat cramps, heat exhaustion, and heat stroke. -1-
The risk of heat disorders is increased by high humidity, which decreases the cooling effect of sweating, by extreme weather conditions (as is typical in the San Bernardino County during the summer months), and by prolonged strenuous exertion, which increases the amount of heat produced by the muscles. People at risk for heat related illnesses are the elderly, the very obese, those who work or exercise outdoors, people with health problems, those who have had a heat related illness in the past, those with medical conditions that cause poor circulation and those who take certain medications such as antihistamines, antipsychotic drugs, and diuretics. Heat related illness in its early stages can be reversed. 5. TYPES OF HEAT RELATED CONDITIONS: Dehydration - is a decrease in the body s water level below that required for adequate circulation. A common cause of dehydration is overexertion in hot conditions so that the body loses large amounts of fluid in perspiration while fluid intake is inadequate to replace the volume. 6. 7. CLINICAL MANIFESTATIONS: The victim may appear weak, dizzy, profoundly exhausted. They can have difficulty thinking clearly. They may experience nausea and may be drenched in sweat. They can have dark urine with a strong odor. They may have cramps. Taking a pinch of skin from the back of the hand can indicate more severe dehydration. If the pinched fold stays up (the skin is no longer pliable) the victim is becoming dangerously dehydrated. TREATMENT/FIRST AID: Careful attention to adequate intake of fluids and electrolytes and recognizing individual limitations is an important step in preventing dehydration. Drink at least one quart (or liter) of fluid each hour you are doing physical activity for continuous hydration. Re-hydrate victim with plain chilled water. Do not use sweetened or salted liquids. Severe dehydration will require medical intervention with I.V. fluids. Heat exhaustion - is a condition resulting from exposure to excessive heat in which excessive loss of fluids from heavy sweating leads to fatigue, low blood pressure, and sometimes collapse. Electrolytes are lost with the fluids, disturbing the circulation and the brain s functioning. This condition may progress to heat stroke. 8. COMPETENCY/TRAINING: All Level of Care nursing staff are required to take CPR and First Aid training at time of hire and then CPR every two years and First Aid every three years thereafter as part of Mandated Training. -2-
9. DEFINITIONS: Shock - a state in which there is loss of effective circulating blood; inadequate organ and tissue perfusion ultimately resulting in cellular metabolic derangement. Shock is classified as: Cardiogenic shock - secondary to ventricular failure and inadequate blood volume. Anaphylactic shock - an acute often-explosive systemic reaction when a previously sensitized person again receives a sensitizing antigen. Electric shock - injury caused by an electric current passing through the body. Neurogenic shock - caused by neurologic insult from injury, disease, or drugs, which disrupt transmission of nerve impulses. Hypovolemic shock - results from inadequate intravascular volume. Septic shock - caused by bacterial infection Example: Toxic shock syndrome - a syndrome characterized by high fever, vomiting, diarrhea, confusion & skin rash that may rapidly progress to severe & intractable shock. The exact cause is unknown. An infection with exotoxin-producing strains of Staphylococcus aureus has been linked with 3. 10. COMPETENCY/TRAINING: All Level of Care nursing staff is required to take CPR and First Aid training at time of hire and then CPR every two years and First Aid every three years thereafter as part of Mandated Training. Example: Toxic shock syndrome - a syndrome characterized by high fever, vomiting, diarrhea, confusion & skin rash that may rapidly progress to severe & intractable shock. The exact cause is unknown. An infection with exotoxin-producing strains of Staphylococcus aureus has been linked with hypotension, vertigo, headache, moderately elevated temperature (not above 100 F). -3-
11. ASSESSMENT FOR HEAT EXHAUSTION: Assess the individual for signs/symptoms of heat related illness: Heat exhaustion/heat stroke. 12. EXPECTED OUTCOME: To prevent this syndrome from progressing to heat stroke. 13. INTERVENTION FOR HEAT EXHAUSTION: NURSING ACTION A. Place the individual in a recumbent position in a cool, well-ventilated area. KEY POINTS A. Lying flat or with head lower than the rest of the body and sipping cool, slightly salty beverages every few minutes assists with rapid recovery. B. Notify physician/mod and RN. B. Assess symptoms. Obtain STAT complete set of vital signs. C. Push fluids. C. The main treatment is replacing fluids (rehydration) and electrolytes. Sometimes, fluid replacement may need to be given intravenously. D. Monitor vital signs/neurological status at least every 15 minutes until stable. D. If blood pressure remains low and the pulse remains slow for more than an hour despite this treatment, another condition should be suspected. E. Provide health teaching to high-risk individuals regarding activity level during periods of high heat (greater than 85 F). E. Document all client teaching on the Wellness and Recovery Individual/Family Health Education Record (CSH 7156). -4-
14. HEAT STROKE/SUNSTROKE: Is the most serious of the heat-related illnesses. The body generates more heat than it is able to dissipate. It is a LIFE THREATENING MEDICAL EMERGENCY and requires IMMEDIATE and AGGRESSIVE treatment. Call 7119. Heat stroke occurs when the body s heat regulating mechanism fails. The body temperature rises so high that brain damage and death may result unless the body is cooled quickly. When the body generates more heat than it is able to dissipate, heat accumulates, the body s core temperature rises, and potentially widespread physiologic dysfunction occurs. Without immediate intervention, permanent brain damage or death can happen. 15. TWO TYPES OF HEATSTROKE: Classical and Exertional: Classic heatstroke - occurs in individuals who do not sweat normally, either because of a disease or certain medications. The typical victim is an older adult who lives without air conditioning and has underlying health problems, such as heart disease or diabetes. This type can take 2 3 days to develop. Studies have shown that even a few hour of air conditioning each day can prevent the condition. Exertional heatstroke - happens quickly, often after only a few hours of exercise. The skin is able to sweat, but the body still overheats because of a combination of hot weather, extra activity, and dehydration. Exertional heatstroke victims are usually young, otherwise healthy people, such as runners and football players. Dehydration is usually the first warning sign. SIGNS/SYMPTOMS: HOT, RED, and usually DRY skin not sweating Body temperature is VERY HIGH (more than 105.0 o F) Rapid, weak pulse Rapid, shallow breathing Pulse racing over 160 BPM Pupils are very small Severe headaches Being argumentative/combative Vertigo Disorientation Delirium Coma -37-
Individual is usually unconscious 16. PRECAUTIONS: Rule out Neuroleptic Malignant Syndrome and Lithium Toxicity. Signs of heat exhaustion or heat stroke may overlap. Individuals taking Haldol, phenothiazines, and anticholinergics are at higher risk. 17. TREATMENT/FIRST AID: This is a medical emergency Rapid recognition of the signs and symptoms so rapid treatment can occur. Rapid treatment is critical since the longer the body s core temperature is elevated the greater the risks of severe organ damage and death. Severe Medical Emergency get to a hospital immediately Get victim into a cool place Cool the victim as quickly as possible in any manner possible Place the victim into a bathtub of cool water, wrap in water soaked sheets Cold bath or sponging Cold packs on the neck, in the armpits and groin Remove clothing use fans and air conditioner, ice or cold packs Place victim in a cool lake or river (supporting their head to keep it above water) DO NOT GIVE FLUIDS (if unconscious, can t swallow) DO NOT APPLY RUBBING ALCOHOL DO NOT give salt tablets (if unconscious, can t swallow or chew) Treat for shock 18. INTERVENTIONS FOR HEAT STROKE: Nursing Action A. Call physician/mod immediately. Get victim out of the heat. Bring emergency medical equipment to the scene. Notify the RN. B. Start an I.V. Begin Intake and Output record. Key Points A. Refer to A.D and NP&P #700 Medical Emergency. Dial 7119 for paramedic assistance or dial 7111 for hospital staff assistance. B. An RN may start an I.V. of Normal Saline (or D 5 W) at TKO (to Keep Open) rate without a physician order in a lifethreatening emergency. A physician s order must be obtained ASAP thereafter. -38-
C. Loosen tight clothing. Apply cool, wet cloths (such as towels or sheets) to the skin. D. Monitor vital signs and neurological status at least every 5 minutes or more often if clinically indicated. E. Massage body and extremities to maintain circulation. F. Remain with the individual to allay fears and provide constant monitoring. G. Prepare for transport as soon as possible with paramedics/ambulance. C. Keep victim lying down and continue to cool the body by all available means, e.g. use of a fan. Apply cool packs especially to the wrists and ankles, groin, each armpit, and on the back of neck to cool the large blood vessels. Avoid shivering. Stop cooling when temperature reaches 102 o F. D. The heart rate increases and may quickly reach 160 to 180 beats per minute. The individual may become disoriented and confused and can quickly loose consciousness or have convulsions. E. Reduces cutaneous vasoconstriction that may occur from rapid cooling. F. Nursing staff must remain with the individual in all medical emergencies. G. Continue life saving measures until client care is taken over by the paramedics. 19. OTHER TYPES OF HEAT RELATED CONDITIONS: Heat cramps are severe muscle spasms resulting from heavy sweating during exertion in extreme heat. Heat cramps are caused by the excessive loss of fluids and electrolytes - including sodium, potassium, and magnesium - resulting from heavy sweating, as occurs during strenuous exertion. 20. CLINICAL MANIFESTATIONS: Heat cramps often begin suddenly in the hands, calves, or feet; they are often painful and disabling. The muscles become hard, tense, and difficult to relax. Muscular cramping may be evident in the large muscle groups (thighs/shoulders). The individual may also have nausea, pale, wet skin, temperature between 98-100 F, normal blood pressure. Onset is sudden. -39-
21. ASSESSMENT FOR HEAT CRAMPS: Assess individual for Heat Related Illness, refer to clinical manifestations. 22. EXPECTED OUTCOME: To prevent condition from progressing or worsening. 23. INTERVENTIONS FOR HEAT CRAMPS: NURSING ACTION KEY POINTS A. Take individual to a cool area. A. Provide rest. B. Notify physician/mod and RN. B. Follow treatment as directed by the physician/mod. C. Replace fluid and salt loss by giving the individual sips of salted water as ordered by physician/mod. D. Gently massage the cramping muscles. E. Provide health education for the individual to maintain proper nutrition with intake of fluids and salt during periods of high heat. Consult and collaborate with the dietician on effective health teaching specific to individual client needs. C. Heat cramps can be prevented or treated by drinking beverages or eating foods containing salt. D. Lightly stretch the muscle and gently massage the area. E. Strenuous exertion in a very hot environment or a poorly ventilated space should be avoided, and appropriate clothing should be worn. Fluids and electrolytes lost through sweating can be replaced by consuming salted foods and beverages, such as salted tomato juice or cool bouillon. Many commercial drinks, such as Gatorade, include extra salt. HEAT FATIGUE is caused by depletion of water and salt due to sweating. 24. SIGNS/SYMPTOMS: Feeling of weakness and tiredness 25. TREATMENT: Get out of the sun and into the shade Replace fluids with cool water -40-
HEAT SYNCOPE - presents as an orthostatic syncope (lightheadedness, fainting) episode that usually occurs with prolonged standing or sudden rising from a sitting or lying position. Predisposing factors include exercise without a cool-down period, dehydration, and lack of acclimatization. Heat syncope can result from inadequate cardiac output and postural hypotension. 26. TREATMENT: Recovery is immediate once the victim falls to the ground. Place the victim in a supine position and replace any water deficit. The victim should not engage in vigorous activity at least the rest of that day. 27. EVALUATION: Document in ID notes: 1. Date and time condition occurred 2. Problem number (temporary condition) 3. Individual's signs and symptoms 4. Vital signs 5. Nursing implementations/interventions and disposition of individual 6. Individual response to treatment -41-