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  1. GENERAL PRINCIPLES OF TREATMENT FOR INGESTIONS AND POISONINGS
    1. Prevention: refer to section on toddler safety, Health Promotion and Maintenance.
    2. How to induce vomiting:
      1. pillImageDrug of choice—syrup of ipecac (available over the counter; does not require a physician's order). If families with young children keep this medication on hand it should be administered only if directed by Poison Control Center. Note: Safety of ipecac has been questioned due to esophageal tears (when misused) and anorexia nervosa/bulimia (when abused).
      2. Dose:
        1. 30 mL for adolescents over 12 years; repeat dosage once if vomiting has not occurred within 20 minutes.
        2. 15 mL for children 1 to 12 years; repeat dosage once if vomiting has not occurred within 20 minutes. Note: Do not administer to infants less than 1 year of age without physician's order.
        3. 10 mL for infants 6 to 12 months; do not repeat dosage.
      3. Follow dose of ipecac with 4 to 8 oz of tap water or as much water as child will drink. In young children, give water first because child may refuse to drink anything else after tasting the ipecac.
      4. The child must vomit the syrup of ipecac to avoid its being absorbed and causing potentially fatal cardiotoxicity (cardiac arrhythmias, atrial fibrillation, severe heart block). If child does not vomit within 20 minutes of second dose, summon paramedics; gastric lavage may be indicated upon arrival in emergency department. Do not manually stimulate gagging because gagging may ↑ vagal response → significant bradycardia.
    3. When not to induce vomiting:
      1. Child is stuporous or comatose.
      2. Poison ingested is a corrosive substance or petroleum distillate.
      3. Child is having seizures.
      4. Child is in severe shock.
      5. Child has lost the gag reflex.
  2. SALICYLATE POISONING
    1. Assessment:
      1. Determine how much aspirin was ingested, when, which type.
      2. Evaluate salicylate levels: normal, 0; therapeutic range = 15 to 30 mg/dL; toxic, >30 mg/dL.
      3. Early identification of mild toxicity:
        1. Tinnitus (ringing in the ears).
        2. Changes in vision, dizziness.
        3. Sweating.
        4. Nausea, vomiting, abdominal pain.
      4. Immediate recognition of salicylate poisoning:
        1. Hyperventilation ( earliest sign).
        2. Fever—may be extremely high (105° to 106°F).
        3. Respiratory alkalosis or metabolic acidosis.
        4. Late signs: bleeding tendencies, severe electrolyte disturbances, liver or kidney failure.
    2. Analysis/nursing diagnosis:
      1. Ineffective breathing patterns related to hyperventilation/respiratory alkalosis.
      2. Fluid volume deficit (dehydration) related to increased insensible loss of fluids through hyperventilation, increased loss of fluids through vomiting, and increased need for fluids due to hyperpyrexia (fever).
      3. Risk for injury related to bleeding.
      4. Anxiety related to parental/child feelings of guilt, uncertainty as to outcome, invasive nature of treatments.
      5. Knowledge deficit regarding accident prevention.
    3. Nursing care plan/implementation:
      1. Goal: promote excretion of salicylates.
        1. pillImageIf possible, induce vomiting using syrup of ipecac (save, bring to emergency department).
        2. pillImageAssist with gastric lavage, if appropriate.
        3. Administer activated charcoal as early as possible.
        4. Administer IV fluids, as ordered.
        5. Assist with hemodialysis, as ordered, to promote excretion of salicylates and fluids.
      2. Goal: restore fluid and electrolyte balance.
        1. Monitor I&O, urinalysis, specific gravity.
        2. pillImagePrepare sodium bicarbonate, administer as ordered to correct metabolic acidosis.
        3. Monitor IV fluids and electrolytes.
        4. NPO initially (NG tube).
      3. Goal: reduce temperature.
        1. pillImageNo aspirin or acetaminophen, which might further complicate bleeding tendencies or lead to liver or kidney damage.
        2. Supportive measures: cool soaks, ice packs to armpits/groin, hypothermia blanket.
      4. Goal: prevent bleeding and possible hemorrhage.
        1. Monitor urine and stools for occult blood.
        2. Insert NG tube to detect gastric bleeding.
        3. Observe for petechiae, bruising; monitor laboratory values for Hct and Hgb.
        4. pillImageAdminister vitamin K as ordered to correct bleeding tendencies.
      5. Goal: health education to prevent another accidental poisoning.
        1. Teach principles of poison prevention.
        2. Stress need to avoid accidental overdose with over-the-counter medications or dosage mix-ups.
        3. Allow child/parents to verbalize guilt, but avoid blaming or scapegoating.
    4. Evaluation/outcome criteria:
      1. Aspirin is successfully removed from child's body without permanent damage.
      2. Fluid and electrolyte balance is restored and maintained.
      3. Child is afebrile.
      4. Bleeding is controlled, no hemorrhage occurs.
      5. No further episodes of poisoning occur.
  3. ACETAMINOPHEN POISONING
    1. Assessment:
      1. Determine how much acetaminophen was ingested, when, and which type.
      2. Evaluate acetaminophen levels: normal = 0; therapeutic range = 15 to 30 mcg/mL; toxic = 150 mcg/mL 4 hours after ingestion.
      3. Initial period (2–4 hours after ingestion): malaise, nausea, vomiting, anorexia, diaphoresis, pallor.
      4. Latent period (1–3 days after ingestion): clinical improvement with asymptomatic rise in liver enzymes.
      5. Hepatic involvement (may last 7 days or may be permanent): pain in RUQ, jaundice, confusion, hepatic encephalopathy, clotting abnormalities.
      6. Gradual recuperation.
    2. Analysis/nursing diagnosis:
      1. Altered tissue perfusion (liver) related to hepatic necrosis.
      2. Fluid volume deficit related to increased loss of fluids secondary to vomiting and diaphoresis.
      3. Risk for injury related to bleeding and clotting disorders.
      4. Anxiety related to parental/child feelings of guilt, uncertainty as to outcome, and invasive nature of treatments.
      5. Knowledge deficit regarding accident prevention.
    3. Nursing care plan/implementation:
      1. Goal: promote excretion of acetaminophen.
        1. pillImageIf possible, induce vomiting; save, bring to emergency department.
        2. Assist with gastric lavage, if appropriate.
        3. Administer activated charcoal.
        4. Assist with obtaining acetaminophen level 4 hours after ingestion.
      2. Goal: prevent permanent liver damage.
        1. Treatment must begin as soon as possible; therapy begun later than 10 hours after ingestion has no value.
        2. pillImageAdminister the antidote (acetylcysteine [Mucomyst]) per physician's order. Usually administered in cola or through NG tube because of offensive odor. Given as one loading dose and 17 maintenance doses.
        3. Monitor hepatic functioning—assist with obtaining specimens and check results frequently; be aware that liver enzymes will rise and peak within 3 days and then should rapidly return to normal.
      3. Goal: restore fluid and electrolyte balance.
        1. Monitor vital signs and perform neurological checks every 2 to 4 hours and prn.
        2. Monitor I&O; urine analysis, including specific gravity; and weight.
        3. Monitor IV fluids as ordered.
      4. Goal: prevent bleeding.
        1. Assist in monitoring child's PT; notify physician of significant changes.
        2. Monitor urine and stool for occult blood.
        3. Observe for and report any petechiae or unusual bruising.
      5. Goal: health education to prevent another accidental poisoning. (See Goal 5, Nursing care plan/implementation, Salicylate poisoning.)
    4. Evaluation/outcome criteria:
      1. Acetaminophen is successfully removed from child's body.
      2. Normal liver function is reestablished.
      3. Fluid and electrolyte balance is restored and maintained.
      4. No further episodes of poisoning occur.
  4. LEAD POISONING (PLUMBISM)
    1. Introduction: Lead poisoning is a heavy-metal poisoning that occurs from ingestion or inhalation of lead. In children, this is most common in the toddler age group (1–3 years) and is usually a chronic type of poisoning that occurs as the result of repeated ingestions of lead. Older plumbing is one source of lead. Children who engage in the practice of pica, the ingestion of nonnutritive substances, often ingest lead in flecks of lead-based paint from plumbing, walls, furniture, or toys. In addition, research demonstrates that the parent-child relationship is a significant variable in lead poisoning; typically, there is a lack of adequate parental supervision that enables the child to engage in pica repeatedly over a fairly long time, until symptoms of lead poisoning become evident. (Figure 5-14. Pathophysiological Effects of Lead Poisoningshows the pathophysiological effects of lead poisoning.)
    2. Assessment:
      1. Investigate history of pica.
      2. Evaluate parent-child relationship.
      3. Chronic lead poisoning: vague, crampy abdominal pain; constipation; anorexia and vomiting; listlessness.
      4. Neurological, renal, hematological effects: see Figure 5-14. Pathophysiological Effects of Lead Poisoning.
      5. "Blood lead line"—bluish-black line seen in gums.
      6. X-rays: lead lines in long bones and flecks of lead in GI tract.
      7. Elevated serum blood lead levels: ≥20 mcg/dL requires clinical management; ≥45 mcg/dL requires parenteral chelating therapy.
    3. Analysis/nursing diagnosis:
      1. Altered thought processes related to neurotoxicity.
      2. Activity intolerance (and risk for infection) related to anemia.
      3. Altered urinary elimination related to excretion of lead by kidneys.
      4. Pain related to lead poisoning and its treatment.
      5. Knowledge deficit related to etiology of lead poisoning.
    4. Nursing care plan/implementation:
      1. Goal: promote excretion of lead.
        1. pillImageAdminister chelating agents (EDTA [IM or IV], BAL [IM only]) as ordered. Chelation therapy typically continues over several days, with multiple treatments daily.
        2. Monitor kidney function carefully: the treatment itself is potentially nephrotoxic. Maintain adequate oral intake of fluids.
        3. Institute seizure precautions.
      2. Goal: prevent reingestion of lead.
        1. Determine primary source of poisoning.
        2. Eliminate source from child's environment before discharge.
        3. Follow up with home care referral.
          1. Screen other siblings prn.
          2. Monitor blood lead level of all children in the home.
      3. pillImageGoal: assist child to cope with multiple painful injections when treated with IM chelation therapy.
        1. Prepare child for treatment regimen.
        2. Stress that this is not a punishment.
        3. Rotate sites as much as possible.
        4. May use a local anesthetic (e.g., procaine, injected simultaneously with chelating agent to decrease pain of injections).
        5. Apply warm soaks to injection sites: may help lessen pain.
        6. Encourage child to self-limit gross muscle activity (which increases pain).
        7. Offer child safe outlets for anger, fear, frustration—punching bag, pounding board, clay.
        8. Offer opportunity for medical play with empty syringes, etc.
      4. Goal: health teaching.
        1. Stress (to child and parents) that removing the lead is the only way to prevent permanent, irreversible neurological damage (irreversible damage may have already occurred).
        2. Teach that the chelating agent binds with the lead and promotes its excretion through the kidneys.
    5. Evaluation/outcome criteria:
      1. Lead is successfully removed from child's body without permanent damage.
      2. No further episodes of lead poisoning.
      3. Child copes successfully with the disease and its treatment.