NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00037 Risk for poisoning

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 “Safety/Protection” Class 4/Environmental Hazards: Sources of Danger in the Surrounding Area

00037 Risk for poisoning

Nursing Diagnosis: Risk for poisoning
Definition: Accidental exposure to, or the likelihood of inadvertently ingesting, a drug or hazardous substance in an amount that adversely affects health, resulting in loss of health.

1. Possibly Poisoning Substances

Poisoning means that a certain kind of chemical substance enters the living body and causes disturbances in the normal activities of organs and tissues, resulting in various symptoms. Poisoning is roughly classified into chronic poisoning and acute poisoning, depending on the duration of contact with the living body of the poison and the course of development. Hazardous substances that cause poisoning include pharmaceuticals, agricultural chemicals, industrial chemicals, household chemicals, as well as animal and plant poisons and bacterial poisons. (Excerpt from Kotobank: What is addiction? Meaning and usage – Kotobank (kotobank.jp))

(1) Food (food poisoning)
・Mushroom, blowfish, aconitum, solanine (potato sprout), Clostridium botulinum (honey)
Ingestion of food infected with bacteria or viruses
・Enterohemorrhagic Escherichia coli O-157 (inadequately cooked meat, especially raw beef liver is dangerous)
・Staphylococcus aureus (Food processed with unsanitary hands (Staphylococcus aureus, a normal resident of the hands, breeds in food))
・Salmonella (meat (especially chicken), eggs, eel, soft-shelled turtle)
・ Clostridium perfringens (Anaerobic bacteria found in meat and seafood. When curry or stew is cooked on a square, the oxygen concentration is low at the bottom of the pot, so there is a risk of large breeding.)
・Campylobacter (common in chicken, cows and pigs, also found in feces of dogs and cats)
・Vibrio parahaemolyticus (seawater and seafood) Vibrio parahaemolyticus loves salt and breeds profusely in a salty environment.
・Bacillus cereus (Abundant in soil and rivers, attached to grains and vegetables such as rice and wheat)
・Norovirus (bivalves such as oysters, feces and vomit contaminated with norovirus)
・Rotavirus (oysters, clams, clams, and other bivalves)
・Plants and organisms grown in areas containing hazardous substances: Excessive amounts of radioactivity, mercury, cadmium, lead, etc.
(2) Metal
Mercury (mercury is also absorbed through the skin)
・Cadmium (cause of itai-itai disease)
・Arsenic
・lead
(3) household medicines
・ Organophosphorus formulation (insecticide)
· Glyphosate (herbicide), paraquat (herbicide)
・Boric acid dumplings (exterminate cockroaches)
・ Camphor (insect repellent), naphthalene (insect repellent)
(4) Excessive oral drug intake
・ digitalis, colchicine, indomethacin,
(5) Toxic substances used in special environments
・Potassium cyanide (plating, etc.)
・Thinner (painting, etc.)
(6) Food
・Vitamins
・Vitamin A (fetal teratogenicity)
・Vitamin D (hypercalcemia)
・Vitamin E (diarrhea)
·caffeine
·alcohol
(7) Nicotine
(8) Illegal drugs
·stimulant drug
・ Cannabis (marijuana)
・MDMA
・Thinner
(9) Gas
·Carbon monoxide
·nitrogen
・Oxygen (high partial pressure oxygen inhalation of 2 atmospheres)
(10) Poisoning caused by disease
・Water poisoning (hyponatremia)
· Excessive drinking due to diabetes
· Excessive drinking due to antipsychotic drugs (schizophrenia)

2. Indications for the Nursing Diagnosis “Risk for poisoning”


・You live in a polluted area (air pollution, soil pollution, water pollution)
• Inadequate work environment for exposure prevention (ready access to hazardous materials, availability of illicit drugs with toxic additives).
・Home environment (opportunity to obtain a large amount of drugs in the house)
・ Decreased cognitive function (HDR = 20 points or less, MMSE = 21 points or less), undeveloped cognitive function (infant)
・pica eating, accidental ingestion, repeated administration after forgetting to take medication,
Emotional disorders, mental illness, suicidal ideation
・Excessive stress
・Soliciting from friends, dating (illegal drugs), events, binge drinking (alcohol)
・Lack of knowledge about drugs, excessive intake of supplements
・Handling fire without adequate ventilation (carbon monoxide poisoning)
・morbid dry mouth

3. setting a goal


Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Personal health status (2006)
(Definition: General physical, psychological, social and spiritual health status of adults 18 years and older)
・Safe Home Environment (1910)
(Definition: Physical arrangements to minimize environmental factors that can cause physical injury in the home)
・Knowledge: physical safety of children (with dementia) (1801)
(level of understanding about safety in caring for children (and people with dementia))
・Cognition (0900)
(definition: ability to carry out complex mental processes)
・Knowledge: Medicine (1808)
(Definition: degree of understanding of safe drug handling)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・To be able to describe the effects of illegal drug addiction on the body.

・To be able to describe how to protect yourself from illegal drugs and how to get out of them. (Breaking bad relationships, seeking counseling or therapy, joining a self-help group)

• Caregivers and caregivers can provide an environment that prevents accidental ingestion of toxic substances.

*Nurse goals include:

・For addiction due to the use of illegal drugs, consider personal developmental problems that are the background of delinquency, formulate a plan for fundamental relief (bridge with professionals), and prevent recurrence. . Physical support, emotional support, social support.

・Provide assistance to make the recuperation environment appropriate (especially at home) so that poisoning due to accidental ingestion does not occur.

・Provide assistance to create a living environment that matches the cognitive functions of the elderly and children.

4. nursing plan


1) Observation Plan 《OP》

We will draft an observation plan (OP) for each outcome of the linkage.

★Personal health status 2006>
・Poisoning symptoms (abdominal symptoms): nausea and vomiting, diarrhea, abdominal pain, decreased level of consciousness

  • Symptoms of poisoning (neurological symptoms): numbness, lowered level of consciousness, slurred speech, mydriasis, sweating
    ・Carbon monoxide poisoning symptoms: impaired judgment, confusion, loss of consciousness, seizures, chest pain, shortness of breath, low blood pressure, coma
    ・Drug withdrawal symptoms: increased respiratory rate, anxiety, restlessness, yawning, mydriasis, restlessness, stomach cramps, anorexia, nausea and vomiting, diarrhea
    ・Alcohol withdrawal symptoms: finger tremor, insomnia, nausea and vomiting, hallucinations, illusions, anxiety, restlessness, tachycardia
    ・Physical strength
    ・ADL
    ・Immune function
    ・Autoimmune disease
    ・Presence or absence of allergens
    ・Allergy history
    ・History of anaphylactic shock
    ・Presence or absence of allergic reactions
    ·vital signs
    ・shock symptoms
    ・Consciousness
    ·blood pressure
    ・Possession of an epi-pen
    ★ Safe home environment 1910>
    ・Area with environmental pollution (atmosphere, soil, water quality)
    ・New house (sick house syndrome)
    ・Use of clean water
    ・Food safety
    ・Presence or absence of smoke detectors, operating status
    ・Safe management of drugs (whether children or people with dementia can easily reach them)
    ・Environments where crime is likely to occur (local characteristics such as downtown areas)
    ・Economic situation (risk of developing into crime, environment and human relations that are prone to crime)
    ・Is the room well ventilated? (Can carbon monoxide poisoning be avoided?)
    Do you wash your hands thoroughly before preparing meals?
    ・Whether the ingredients are rotten or edible (mushrooms, etc.)
    ・Is it sufficiently heated?
    ★Knowledge: physical safety of children (dementia patients) 1801>
    ・Are you underage and not drinking alcohol?
    ・Are you underage and not smoking?
    ・Are you not using illegal drugs?
    ・Friendships among school children and adolescents (factors that lead to delinquency)
    Abuse or being abused
    ・Developmental delays in children due to child abuse (weak cognition/judgment, inability to understand other people’s feelings, etc.)
    ・Whether drugs are within easy reach for children or people with dementia (there is a possibility that they may eat internal medicines or pesticides).
    ・Are there any allergens (substances that have already caused an allergic reaction) nearby?
    ・Do not touch the source of the fire (risk of carbon monoxide poisoning due to fire)
    ★ Cognition 0900>
    ·age
    ・Developmental stage (infants, school children, the elderly)
    ・ IQ (Do you have the ability to make decisions?)
    ・Presence or absence of intellectual disability or developmental disability
    ・A score of 20 or less on the Hasegawa simple intelligence scale (suspected of dementia) *Maximum score of 30
    ・MMSE score of 21 or less (suspected of dementia) *Maximum score of 30 points
    ・Are you careful?
    ・Concentration ・Orientation ・Previous memory, recent memory, past memory ・Appropriate decision making
    ★Drug 1808>
    ・Level of understanding of drug effects and drug dosage and administration
    ・Understanding of drug side effects
    ・Are you following the instructions for taking the medicine (do you take it too many times by mistake?)
    ・Are oral medications properly managed?
    ・Are injection drugs (insulin and osteoporosis drugs) properly managed?
    ・ Do you follow the dosage and usage of injection drugs (insulin, etc.)?
    Are you handling the syringe correctly?
  • Are you using illegal drugs?
    ・Are you addicted to illegal drugs?
    Abnormal thinking and behavior, hallucinations
    Are your vital signs stable?
    ・Consciousness is normal
    Acute alcohol intoxication from a single binge of alcohol
    ・Irresistible personality
    ・Water poisoning due to antipsychotic drugs (risk of vomiting and convulsions with hyponatremia of 120 mEq/L or less)

2) Action plan 《TP》

・Improve the environment, check if there are any risks, and eliminate them if any.
・In environments where there are elderly people with cognitive decline or children with poor judgment, keep out of reach anything that may cause poisoning due to ingestion of oral medicines and agricultural chemicals. Or do not put it in a visible place.
・Explanation will be given so that the injection drug skills such as insulin can be acquired. Have the patient do it step-by-step.
Eliminate allergens if known.
・If poisoning causes a temporary decrease in ADL, provide assistance for the deficient part.
If delirium is caused by intoxication, ensure safety and, if necessary, restrain.
・ Organize routes such as intravenous drips and gastric tubes, and manage them cleanly and safely.

3) Education plan 《EP》

・Instruct children under 1 year old not to eat honey (risk of botulism poisoning)
・Ingredients that contain bacteria that can cause food poisoning should be thoroughly heated before eating.
・To prevent food poisoning, wash your hands thoroughly when cooking.
・Explain to follow the dosage and administration of oral medicines.
• Suggest consulting with the primary care physician so that the medication can be taken at a time when the caregiver can supervise. (For example, if an elderly person leaves the house during the day and is left alone, ask if it is possible to change the oral medicine taken three times a day to the oral medicine taken twice a day.)
Encourage participation in self-help groups if substance abuse leads to mental instability and addiction.
https://www.ask.or.jp/article/6521
・If you know the allergen, explain what kind of things contain the allergen and explain how to eliminate it.
・Explain the characteristics of anaphylaxis symptoms and explain how to deal with them, such as asking for help from family members or calling an ambulance if there are any abnormalities.
・Provide guidance to family members on how to prevent elderly people and children with cognitive disabilities from touching fire, such as locking the stove. Instruct the patient to ensure adequate ventilation under supervision during use.
・Since drug addiction and alcohol addiction can lead to death, explain the pathology (prevention of recurrence).
・If you are mentally unstable due to mental illness or have physical symptoms due to water intoxication, explain to the person and family that they should seek medical attention and receive appropriate treatment. . Make sufficient preparations for living at home (including support from family members, etc.).
・Identify individual developmental problems behind the use of illegal drugs and take appropriate measures. Intermediate to each expert, such as abuse, abused, poverty, intellectual disability, developmental disability, and decline in understanding. Help prevent recurrence.
・If you have ever had anaphylaxis, have an EpiPen (a doctor’s prescription is required. Not just any doctor can prescribe it, but a “registered doctor” must prescribe it. It can be prescribed from Mylan HP.) This is a quote from a medical facility introduction.
Medical facility https://allergy72.jp/search/Search | What is anaphylaxis.jp | Mylan EPD LLC (allergy72.jp)).
Below is a picture of the EpiPen in action. A puncture is made at a right angle from the outside of the thigh. Intramuscular. You can inject through your clothes.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Toru Yamaguchi, Mitsuo Kitahara, Tsuguya Fukui. (2012). Today’s treatment guidelines. Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008).

Thank you for coming this far. If you have any comments, impressions or questions, we are waiting for you from the comment section below (゚▽゚)

投稿者

florence.no.tomoshibi@gmail.com

コメントを残す

メールアドレスが公開されることはありません。 が付いている欄は必須項目です