Ncm 106: Disaster and Emergency nursing

Ncm 106: Disaster and Emergency nursing
IAN VAN V. SUMAGAYSAY, RN, MAN

DISASTER and EMERGENCY NURSING
Learning Outcomes: At the end of the topic, the students will be able to: Define what is triage. Identify when and why to triage. Perform triage properly when the need arises.

WHAT is TRIAGE? Trier (French). To Sort out or choose.

TRIAGE – A method of quickly identifying victims of a mass casualty incident (MCI) who my have immediately life-threatening injuries and those who have the best chance of surviving.

Why TRIAGE? Goal is to identify the sickest patients on order to assess and provide treatment to them first, before providing treatment to others who are less ill.

TRIAGE is done by: Trained individuals Paramedical personnel (Medics, EMR’s, EMT’s) Medical personnel (Doctors, NURSES, etc.)

How to be an Effective Triage Nurse: Clinically experienced Good judgment and leadership skills Calm and cool Decisive Knowledgeable of available resources Anticipates casualties

DISASTER NURSING S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. It has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been field- proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by community emergency response teams (CERTs) and firefighters after earthquakes.

DISASTER NURSING S.T.A.R.T. (Simple Triage and Rapid Treatment) system: All patients who can walk are categorized as Delayed (Green) and are asked to move away from the incident area to a specific location. The next group is assessed quickly by evaluating RPM: Respiration, Perfusion and Mental Status and then tagged accordingly.

DISASTER NURSING CRTICAL (RED) R – >30 BPM
CATEGORY (COLOR) RPM INDICATORS CRTICAL (RED) R – >30 BPM P – CAPILLARY REFILL > 2 SEC. M – DOES NOT OBEY COMMANDS URGENT (YELLOW) R - < 30 BPM P - < 2 SEC. M – OBEYS COMMAND EXPECTANT, DEAD OR DYING (BLACK) R – NOT BREATHING

DISASTER NURSING (Red)Immediate: The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal. (Yellow)Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening, but can wait until the Immediate casualties are stabilized and evacuated. (Green)Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring. (Black)Expectant: The casualty is expected not to reach higher medical support alive without compromising the treatment of higher priority patients. Care should not be abandoned, spare any remaining time and resources after Immediate and Delayed patients have been treated.

START First Step Can the Patient Walk? YES NO Green (Minor)
Evaluate Ventilation (Step-2)

START Step-2 Open Airway > 30/Min < 30/min Red/ Immediate
Ventilation Present? NO YES Open Airway Ventilation Present? > 30/Min < 30/min NO YES Red/ Immediate Black Evaluate Circulation (Step-3) Red/ Immediate

START Step-3 Absent Radial Pulse Present Radial Pulse
Circulation Absent Radial Pulse Present Radial Pulse Control Hemorrhage Evaluate Level of Consciousness Red/ Immediate

START Step-4 Level of Consciousness Can Follow Simple
Commands Can’t Follow Simple Commands Yellow/ Delayed Red/ Immediate

Triage scheme as recommended by the Simple Triage and Rapid Treatment protocol. Not how the first question is “Is the Patient a Walking Wounded” if so categorize as green.

Tagging is an activity that should occur simultaneously to the primary triage process, one a patient is classified it should be tagged so that rescue technicians identify those that need to be transported and treated.

“TRIAGE is a process which places the right patient in the right place at the right time to receive the right level of care” (Rice and Abel, 1992)

Disaster and Emergency nursing
IAN VAN V. SUMAGAYSAY, RN, MAN

DISASTER NURSING Disaster – any destructive event that disrupts the normal functioning of a community Medical disaster Natural disaster Man-made disaster Complex emergencies Technologic disasters Synergistic emergencies Onset, impact and duration

DISASTER NURSING Effects of a disaster:
Premature death, illnesses and injuries Destroy local health care infrastructure Environmental imbalances, increase risk of communicable diseases and environmental hazards Affect the psychological, emotional and social well-being of a population Cause shortages of food and water Large population movement

DISASTER NURSING Disaster continuum or emergency management cycle:
Preimpact, impact, post impact Basic phases of disaster management: Preparedness, mitigation, response, recovery and evaluation

DISASTER NURSING

DISASTER NURSING Preparedness Proactive planning
Risk assessment, warning Mitigation Measures taken to reduce the harmful effects of a disaster Response Implementation of a disaster plan Recovery Stabilization and returning to preimpact phase Evaluation

DISASTER NURSING Challenges to disaster planning: Communication
Distribution of all types of resources Advance warning systems Evacuation Mass media Comprehensive disaster plan Information system

DISASTER NURSING Common reactions of disaster survivors:
Emotional: depression, sadness, irritability, anger, resentment, anxiety, fear, despair, hopelessness, guilt, self-doubt Behavioral: sleep problems, cry easily, excessive activity level, hypervigilance Cognitive: confusion, disorientation, nightmares Physical: fatigue, exhaustion, GI distress, appetite changes

DISASTER NURSING Privacy issues Quarantine, isolation Vaccination
Reporting of diseases Disclosure of health information Quarantine, isolation Vaccination Screening and Testing Professional Licensing Resource allocation, provision of adequate care Professional liability

DISASTER NURSING Essential Elements for Hospital Disaster Management:
Infrastructure Competency of the staff Disaster plan Pre-existing relationships and partnerships Response

DISASTER NURSING Hospital Incident Command System (HICS) – an emergency management system that is comprised of specific disaster response functional role positions within an organizational chart

Hospital Incident Command System
Incident commander Operations section chief Planning section chief Logistics section chief Finance/ administration section chief Public information officer Liaison officer Safety officer Medical/technological specialist

DISASTER NURSING Triage; french (trier): to sort out or choose
A process of prioritizing which patients should be treated first and is the cornerstone of good disaster management in terms of judicious use of resources Airway, breathing, circulation Vital signs (TPR/BP) Visual inspection Level of Consciousness

DISASTER NURSING Priority Military Disaster 1 Immediate care
Shock, airway, chest injury, amputation, open fx Class I (emergent) red Critical; life threatening 2 Minimal care Little or no treatment needed Class II (urgent) yellow Major illness or injury; treatment within 20min to 2 hours 3 Delayed care Treatment may be postponed; simple fx, non-bleeding Class III (non-urgent) green Care maybe delayed more than 2 hours or more 4 Expectant care No treatment needed Class IV (expectant) black Dead or expected to die

DISASTER NURSING Managing emergencies outside the hospital:
Type of Event Duration of the event Characteristics of the crowd Weather and environmental influences Alcohol and drug use Crowd mood Site layout Medical and nursing aid stations Transportation and communication Staffing and documentation

DISASTER NURSING Weapons of Mass Destruction (WMD) or Weapons of Terror (WOT) Biological Warfare Chemical Warfare Nuclear Warfare Decontamination Mass Casualty Incident (MCI) Material Safety Data Sheet (MSDS)

DISASTER NURSING Natural Disasters Chemical Weapons
Tornadoes, hurricanes, floods, avalanches, tidal waves, earthquakes and volcanic eruptions Chemical Weapons Vesicants, Nerve agents, Blood agents, Pulmonary agents Biological Disasters Anthrax, Small pox, SARS Nuclear Radiation Exposure

DISASTER NURSING The National Disaster Risk Reduction & Management Council (NDRRMC) or formerly called National Disaster Coordinating Council (NDCC) is an agency of the Philippine government under the Department of National Defense, responsible for ensuring the protection and welfare of the people during disasters or emergencies.

DISASTER NURSING In February 2010, the National Disaster Coordinating Council (NDCC) was renamed, reorganized, and subsequently expanded. The following composes the NDRRMC: Chairperson - Secretary of Department of National Defense Vice Chairperson for Disaster Preparedness - Secretary of Interior and Local Government Vice Chairperson for Disaster Response - Secretary of Department of Social Welfare and Development Vice Chairperson for Disaster Prevention and Mitigation - Secretary of the Department of Science and Technology Vice Chairperson for Disaster Rehabilitation and Recovery - Director-General of the National Economic Development Authority

DISASTER NURSING INCIDENT COMMAND SYSTEM (ICS)
Center of operations for organization, planning and transport of patients in the event of a specific MCI Headed by an INCIDENT COMMANDER HOSPITAL EMERGENCY PREPAREDNESS PLANS

DISASTER NURSING COMPONENTS OF THE EMERGENCY OPERATIONS PLANS:
Activation Response Internal/External Communication Plan Plan for coordinated patient care Security Plans Identification of External Resources Plan of people management and traffic flow Data management strategy

DISASTER NURSING COMPONENTS OF THE EMERGENCY OPERATIONS PLANS:
Deactivation Response A Post-Incidence Response A Plan for Practice Drills Anticipated Resources MCI Planning An Educational Plan for All of the Above

DISASTER NURSING Initiating the Emergency Operations Plan
Identifying patients and documenting patient information Triage Managing internal problems Communicating with the media and the family

DISASTER NURSING TRIAGE Simple Triage
Simple triage is usually used in a scene of an accident or "mass-casualty incident" (MCI), in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. This step can be started before transportation becomes available. The categorization of patients based on the severity of their injuries can be aided with the use of printed triage tags or colored flagging.

DISASTER NURSING S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel or techniques. It has been (2003) taught to California emergency workers for use in earthquakes. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services. It has been field- proven in mass casualty incidents such as train wrecks and bus accidents, though it was developed for use by community emergency response teams (CERTs) and firefighters after earthquakes.

DISASTER NURSING S.T.A.R.T. (Simple Triage and Rapid Treatment
Triage separates the injured into four groups: The expectant who are beyond help The injured who can be helped by immediate transportation The injured whose transport can be delayed Those with minor injuries, who need help less urgently

DISASTER NURSING United States military
Triage in a non-combat situation is conducted much the same as in civilian medicine. A battlefield situation, however, requires medics and corpsmen to rank casualties for precedence in MEDEVAC or CASEVAC. The casualties are then transported to a higher level of care, either a Forward Surgical Team or Combat Support Hospital and re-triaged by a nurse or doctor. In a combat situation, the triage system is based solely on resources and ability to save the maximum number of lives within the means of the hospital supplies and personnel. The triage categories (with corresponding color codes), in precedence, are:

DISASTER NURSING (1)Immediate: The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal. (2)Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening, but can wait until the Immediate casualties are stabilized and evacuated. (3)Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients have been evacuated, and may not require stabilization or monitoring. (4)Expectant: The casualty is expected not to reach higher medical support alive without compromising the treatment of higher priority patients. Care should not be abandoned, spare any remaining time and resources after Immediate and Delayed patients have been treated.

DISASTER NURSING Afterwards, casualties are given an evacuation priority based on need: Urgent: evacuation is required within two hours to save life or limb. Priority: evacuation is necessary within four hours or the casualty will deteriorate to "Urgent". Routine: evacuate within 24 hours to complete treatment. In a "naval combat situation", the triage officer must weigh the tactical situation with supplies on hand and the realistic capacity of the medical personnel. This process can be ever-changing, dependent upon the situation and must attempt to do the maximum good for the maximum number of casualties.

DISASTER NURSING Field assessments are made by two methods: primary survey (used to detect & treat life-threatening injuries) and secondary survey(used to treat non-life threatening injuries) with the following categories: Class I Patients who require minor treatment and can return to duty in a short period of time. Class II Patients whose injuries require immediate life sustaining measures. Class III Patients for whom definitive treatment can be delayed without loss of life or limb. Class IV Patients requiring such extensive care beyond medical personnel capability and time.

DISASTER NURSING Roles of Nurses in Disaster Response Plans:
Nurses may perform roles outside of his or her expertise and responsibilities Triage Officer Documentation Crisis intervention Shelter

DISASTER NURSING Cultural and Ethical Considerations:
Language Difficulties Religious Practices Specific Places/Times for Prayer Rituals in handling the dead and timing of funeral Rationing care Futile therapy Consent Duty Confidentiality, Resuscitation, Assisted Suicide

DISASTER NURSING Critical Stress Management
An approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their jobs and that can also occur to anyone involved in a disaster or MCI. Education before the incident Field support during the incident Defusing, debriefing, demobilization and follow-up after the incident

DISASTER NURSING Preparedness and Response
Recognition and Awareness Principles: Unusual increase in the number of people seeking care for fever, respiratory or gastrointestinal symptoms Take note of any clusters of patients presenting the same unusual illness from a single location Be suspicious of a large number of rapidly fatal cases, especially within 72 hours post admission Any increase in disease incidence in a normally healthy population

DISASTER NURSING Patient assessment Exposure history Work history
Environmental history Admission history

DISASTER NURSING Personal Protective Equipment
Purpose: To shield health care workers from chemical, physical, biologic, and radiologic hazards Level A: Highest level of respiratory, skin, eye and mucous membrane protection (SCBA, Suit, Gloves, Boots) Level B: Highest level of respiratory protection but less of skin and eye protection (SCBA and Suit)

DISASTER NURSING Level C: Air-purified respirator and chemical resistant coverall with splash hood, gloves, boots Level D: Common working uniform

PERSONAL PROTECTIVE EQUIPMENTS:

DISASTER NURSING Decontamination
Process of removing accumulated contaminants, is critical to the health and safety of health care providers by preventing secondary contamination Two steps of decontamination: Stripping and Rinsing Soap and Water Wash

NATURAL DISASTER Fire, Water, Earth, Wind Emergencies

DISASTER NURSING Natural disasters – occur anytime and anywhere; results to a mass casualty incident Tornadoes, hurricanes, floods, avalanches, tidal waves, earthquakes and volcanic eruptions Loss of communication, electricity and potable water Electrocution is the major cause of injury Food and water; Shelter PPE’s

DISASTER NURSING Natural Disasters can be categorized as:
Acute onset – avalanche, blizzard, earthquake, fire, flood, heat wave, hurricane, typhoon, tsunami, volcanic eruptions, wildfire Slow or Gradual Onset – deforestation, desertification, drought, pest infestation

DISASTER NURSING Heat Wave
Heat stroke – body temperature reaches 40.4 degrees Celsius Rapid progression of lethargy, confusion and unconsciousness Heat exhaustion Heat syncope Heat cramps Prevention: Cool environment, cool beverages, loose and light cotton clothing

DISASTER NURSING Cyclones, hurricanes and typhoons
Cyclones are large scale storms with low pressure in the center; over tropical or sub-tropical waters Hurricanes – storms formed in the Atlantic ocean typhoons – storms formed in the Pacific ocean and the China seas Normal wind speeds reach up to 74 mph or more Storm surge – a distinctive characteristic of hurricanes

DISASTER NURSING Risk of Morbidity and Mortality:
Failure to evacuate Food and water safety Shelter Drowning, electrocution, lacerations Risk reduction: early detection

DISASTER NURSING Drought
Result of too little rain, desertification, deforestation and unskilled irrigation Causes disease because of stress, crowding and unsanitary conditions

DISASTER NURSING Earthquake Measured using a Richter scale
Injury and death occurs from being trapped in the rubble Injuries include cuts, broken bones, crush injuries, dehydration Prevention: seismic safety into construction of structures

DISASTER NURSING Flood Rain of one inch per hour
Causes 30% of the world’s disasters per year Caused by deforestation, urbanization and El Niño Deaths are commonly caused by flash floods Morbidity is caused by crowded living conditions, low personal hygiene, contamination of water sources Waterborne diseases, vector borne diseases, food shortages

DISASTER NURSING Tornado
Wind velocity of 200mph and travels as far as 20kms Severity of damage is measured by a Fujita scale; F0(no damage) – F5(total destruction) Morbidity: STI, head injuries Prevention: early warning and protective shelters

DISASTER NURSING Thunderstorms
Lightning strikes are the major cause of deaths A bolt of lightning could reach 50,000 degrees fahrenheit Prevention: avoid open spaces and high spots; natural lightning rods

DISASTER NURSING Tsunami Signs of an approaching tsunami:
Recent submarine earthquake Sea appears to be boiling Water is hot, smells of rotten egg or stings the skin Audible thunder or booming sound followed by a roaring or whistling sound Water recede a great distance from the coast Red light might be visible near the horizon

DISASTER NURSING Early warning devices and animals moving to higher grounds Flood gates and barriers Morbidity and mortality: same as of flooding

DISASTER NURSING Winter/Ice storm
Wind chill is a combination of extremely low temperature and wind speed Winter storm watch Winter storm warning Blizzard warning – wind speeds of 35mph Risk for injuries: winter driving, frostbite, hypothermia, carbon monoxide poisoning, STI

DISASTER NURSING Wildfires Types: Surface fire – forest floor
Ground fire – caused by lightning; forest floor to the mineral soil Crown fire – tree tops; affected by the wind speed Cause of injuries: Burn, inhalation injuries, respiratory complications, MI

DISASTER NURSING Prevention: Build fires away from trees and bushes
Be prepared to extinguish fire quickly and completely Never leave a fire unattended Develop a wildfire evacuation plan

WEAPONS OF MASS DESTRUCTION

BIOLOGIC WEAPONS

DISASTER NURSING Weapons of Mass destruction: biological, chemical and radioactive weapons Biologic weapons – weapons used to spread disease Biological warfare is a covert method of effecting objectives by inflicting significant morbidity and mortality Applied to food or drinks; or by inhalation/ direct contact

DISASTER NURSING Biologic Agents
Anthrax – Bacillus Anthracis; replicates if exposed to air and infective in their spore state only. Infects through direct contact or inhalation Odorless and invincible; can travel great distances before disseminating 8000 to 50,000 spores must be inhaled to be infected 1500 BC (Egypt); 1979 (Russia); 1995 (Japan); 2001 (US)

DISASTER NURSING S/Sx: Causes hemorrhage, edema and necrosis
Incubation time: 1-6 days Skin, Inhalation and Gastrointestinal Skin lesions are the primary infection; develops to a ulcer with 1-3mm vesicles and lastly a painless eschar falls off after 1-2weeks GI: fever, nausea, vomiting, abdominal pain, bloody diarrhea and ascites; attacks the terminal ileum and cecum

DISASTER NURSING URT: flulike symptoms and not treated by antibiotics
Incubation: 60 days Cough, headache, fever, vomiting, chills, weakness, mild chest discomfort, dyspnea, syncope Brief recovery followed by a second stage within 1-3 days Fever, severe respiratory distress, stridor, hypoxia, cyanosis, diaphoresis, hypotension and shock Mediastinitis on CXR (Hallmark sign) Mortality at 100% 24 to 36 hours after onset of the second stage

DISASTER NURSING Treatment: Penicillin sensitive
Penicillin, Erythromycin, Gentamicin, Doxycycline In MCI: Doxycycline; Ciprofloxacin for 60 days Death: cremation is recommended No vaccine available to the public except the military

DISASTER NURSING Small pox (Variola) A DNA virus
Approx. 12 days incubation period Extremely contagious; spread by direct contact, contact with vectors or by droplets Rashes will appear after the fever state; 30% case fatality rate Smallpox survives in a cool and low humidity environment up to 24H

DISASTER NURSING S/Sx:
Initial: high fever, malaise, headache, backache After 1-2 days: maculopapular rash appears from the face to the trunk Smallpox is contagious after the appearance of the rash Treatment: Isolation, antibiotics, decontamination Cremation; virus survives in scabs for 13 years

DISASTER NURSING Severe Acute Respiratory Syndrome (SARS) SARS-CoV
Incubation period: 2-10 days Started in China as an ‘atypical’ pneumonia (Feb. 2003) S/Sx: SOB, Dry Cough, Pneumonia or ARDS in CXR; Evident of 7-10 days Tx: Droplet precaution; support; antiviral drugs

CHEMICAL WEAPONS

DISASTER NURSING Chemical weapons – used in chemical warfare; overt agents Results in major mortality or morbidity, panic, social disturbance These chemicals are: Nerve Agents Blood Agents Vesicants Heavy metals Volatile Toxins Pulmonary Agents Corrosive Acids

DISASTER NURSING Characteristics of Chemicals:
Volatility – tendency of a chemical to be a vapor; most chemicals are heavier than air; most volatile are phosgene and cyanide Persistence – Less likely to vaporize and disperse; most industrial chemicals are not persistent Toxicity – potential of a chemical to cause injury to the body Latency – time from absorption to the appearance of s/sx; sulfur mustards and pulmonary agents

DISASTER NURSING Lethal dose (LD50) Effective dose (ED50)
Concentration time (CT): Concentration x time of exposure = mg/min

DISASTER NURSING Vesicants
Cause blisters and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression and death Lewisite, phosgene, nitrogen mustard and sulfur mustard Liquid sulfur is the most commonly used vesicant Highly incapacitating S/Sx: superficial to partial thickness burns in warm and moist areas, stinging and erythema, pruritus and vesicle formation at 2-18 hours

DISASTER NURSING Eye: photophobia, lacrimation and decreased vision
Respiratory: airway obstruction GI: nausea, vomiting, upper GI bleeding Tx: decontamination, avoid scrubbing, eye irrigation, intubation and bronchoscopy, Dimercaprol IV for Lewisite exposure

DISASTER NURSING Nerve agents Most toxic agents
Sarin, Soman, Tabun, VX and organophosphates(pesticides) Inexpensive, effective in small quantities and easily dispersed Usually evaporates to a colorless and odorless vapor Effects begin at 30min to 18 hours after exposure

DISASTER NURSING S/Sx: cholinergic crisis, visual disturbances, increased GI motility, nausea and vomiting, diarrhea, substernal spasm, indigestion, bradycardia Insomia, forgetfulness, impaired judgement, depression, LOC, seizures, copious secretions, flaccid muscles, apnea Tx: decontamination with soap and water or saline solution for 8-20min, blotted dry, maintain airway patency, suctioning, Atropine 2-4mg IV, Pralidoxine IV and Diazepam

DISASTER NURSING Blood agents Hydrogen cyanide, cyanogen chloride
Directly affects cellular metabolism and results to asphyxiation also emitted during house fires during combustion of plastic, rugs, furniture and other construction materials Ingested, inhaled or absorbed S/Sx: respiratory muscle failure, respiratory arrest, cardiac arrest, flushing, tachypnea, bradycardia, stupor and coma

DISASTER NURSING Pulmonary Agents Chlorine, Phosgene
Causes: pulmonary edema, SOB Mask is used for protection

DISASTER NURSING Tx: Administration of Amyl nitrate, sodium nitrate and sodium thiosulfate intubation Hydroxocobalamin (Vit. B12a) binds to cyanide to form cyanocobalamin (Vit. B12)

Nuclear Radiation Exposure

DISASTER NURSING Radiologic weapon or “dirty bomb”
Weapon grade plutonium or uranium Nuclear fuel or medical nuclear supplies Types of radiation: Alpha particles – cannot penetrate the skin; ingestion, inhalation and injection; local damage Beta particles – moderately penetrate the skin; skin damage Gamma radiation – short wavelength electromagnetic energy; penetrating; X-ray

DISASTER NURSING Measurement:
rad – 0.01 joule of energy/kg of tissue; basic unit of measurement rem (roentgen equivalent man) – reflects the type of radiation and the potential of damage; normal exposure per year is at 360mrem (1 rem = 1000mrem) Half-life – amount of time for a radioactive product to lose half of its radioactivity Detected by: a Geiger counter or Geiger-Mueller survey meter

DISASTER NURSING Exposure: External Irridation – physical exposure
Contamination – exposure to gases, liquids and solids Incorporation – uptake of cells, tissues and organs Decontamination: Done outside the ER Survival: Probable – no s/sx Possible – nausea and vomiting for 1-2 days Improbable – rad at 800; shock

DISASTER NURSING Phase Time of Occurrence Signs and Symptoms
Prodromal Phase (presenting s/sx) 48-72H after exposure Nausea, vomiting, loss of appetite, diarrhea, fatigue Latent Phase (no s/sx) After prodromal phase up to 3 weeks or shorter Decreased lymphocytes, leukocytes, thrombocytes and RBC’s Illness Phase After latent phase Infection, F/E imbalance, bleeding, diarrhea, shock Recovery Phase or After illness phase Weeks to months for full recovery Death Increased ICP

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