Asuhan kegawatdaruratan snakebite

1. Assessment
a. Subjective data collection
1) History of present injury/chief complaint
a) Description of incident
b) Description and identification of the snake
1. Pit vipers have a triangular heat with a pit between eyes and nostril (heat-sensing device), catlike elliptical pupils, to fangs that fold back when the mouth is close, a single row of subcaudal scales on the underbelly, and interconnecting horny segments on the tail that fuction as a rattle on the rattlesnake
2. Coral snake have red, yellow, and black bands, a black head, slender body, small, fixed fangs, and round, black eyes
a. The saying “red on yellow, kill of fellow; red on black, fenom lack” differentiates coral  snakes from harmless snake, but applies only to Micrurus fulvius and micrurus fulvius tenere found in the shouthern and eastern united states
c) Location of bite
d) size and weight of victim
e) prehospital care provided
f) signs and symptoms before arrival
g) shortness, paresthesia, diplopia, muscle pain
h) nausea and vomiting, diarrhea
i) time of incident
2) past medical history
a) Current or preexisting disease/illness
1. Cardiovascular desease
2. Diabetes
3. Immunocompromised
b) Previous bite injury
c) Previous administration of antivenom
d) Medication
e) Allergies
f) Immunization status
b. Objective data collection
1) Physical examination
a. General appearance
1. Level of consciousness, behavior, affect: anxiety, euphoria, confusion, seizures
2. Flaccid paralys
3. Moderate to severe distress/discomfort
b. Inspection
1) Appearance of wound
a) Pit viper: fang mark, semicircular teeth marks
b) Coral snake: scratch marks or tiny puncture marks
c) Nonvenomous: scratch marks, teeth marks
2) Ecchymosis, edema of area
3) Vesicles, bullae at or around bite site
4) Diaphoresis
5) Bleeding
2) Diagnostic procedures
a.  CBC with differential
b.  Serum chemister
c.  Type and crossmatch
d.  Coagulation profile including platelets, fibrin split products
e.  ABGs: if systemic symptoms present
f.  Urinalysis: myoglobulin
g.  Wound culture and sensitivity
h.  Radiograph or injured area as indicated: retained fangs
i.  Chest radiograph: if history of pulmonary edema
 

2. Analysis : differential nursing diagnoses/collaborative problems 

a) Risk of inefective airway clearance

b) Deficient fluid volume

c) Impaired skin integrity

d) Risk of infection

e) Acute pain

f) Anxiety/fear

g) Deficient knowledge

3. planning and implemetation/interventions

a) Maintain airway,breathing,and circulation 

b) Provide supplemental oxygen

c) Establish IV acces for administration of crystalloid fluids/blood product/medications

d) Prepare for/assist with medical interventions

a. Immobilize affected part: do not apply turniquets

b. Institute cardiac and pulse oximetry monitoring 

c. Perform wound care

d. Determine the severityof envenomation and need for antivenom

e. Assist with hospital admission and possible fasciotomy for severe tissue injury 

e) Administer pharmocologic therapy as ordered

a. Antivenom: most therapeutic when given within 4 hours of the bite;limited value after 12 hours .

1. Perform skin or conjunctival testing for horse serum sensitivity if using antivenom(crotalinae)polyvalent;not necessary if using crotaline polyvalent immune fab.

b. Non-narcotic anagesics

c. Narcotics

d. Antibiotics

e. Tetanus immunization

f) Educate patient and significant others

1. Wound care

2. Sign and symptoms of infection

3. Medications administration

4. Follow up care

5. Prevention

a. Wear boots or high top shoes when hiking

b. Do not attempt to pick up or profoke a snake 

c. Be familiar with venemous species in areas where camping or hiking 

4. evaluation and ongoing monitoring 

a. airway patency

b. level of consciousness

c. hemodynamic status 

d. breath sounds and pulse oximetry 

e. cardiac rate and rhyim

f. extremity edema progression 

g. neurovascular status distal to bite

h. pain relief