Poisoning: Nursing process (ADPIE)

Gabriel Hernandez is an 18 month old male who was brought to the emergency department, or ED, by his father.

Mr. Hernandez stated that he put Gabriel down for a nap in his room, and about an hour later he found Gabriel sitting in the kitchen with an empty bottle of children’s acetaminophen in his hand.

The 120mL bottle was previously about three-fourths full.

Mr. Hernandez immediately called the poison control hotline and was instructed to bring Gabriel to the ED.

Poisoning occurs when a person eats, drinks, or breathes in a harmful substance that can cause illness or death.

Poisoning can be intentional or purposeful, which is most common in clients who are suffering from a terminal illness or mental health issues; and unintentional or accidental, which typically occurs when a client is accidentally exposed to a chemical spill or aerosolized toxin, or when they ingest a substance without knowing it is dangerous, or finally, when they accidentally overdose on their prescribed medications.

This may occur when a client forgets that they already took their daily dose, or they take two medication brands that contain the same active ingredient.

Most cases of accidental poisoning involve children who ingest over-the-counter medications for pain, fever, cough, and cold and flu.

The most common ones include acetaminophen, since it is found in many over-the-counter products, and its maximum daily adult dose is only 4 grams; as well as NSAIDs, like ibuprofen; and cough syrups.

Other important causes of accidental poisoning include ingestion of supplements, like multivitamins or iron; as well as cleaning and disinfectant chemicals, such as bleach, soap solution, and window cleaners.

Less commonly, children might ingest essential oils or plants, like mushrooms, tobacco, or marijuana.

Now, there are some risk factors that can increase the risk of poisoning.

The first one are extremes of age, since toddlers are more likely to put unknown objects in their mouth to learn and explore; while older clients are more likely to have memory conditions, such as dementia.

The next risk factor involves use of medications in a manner other than prescribed.

Another risk factor includes mental health conditions like depression or suicidal thoughts; as well as risky behavior, such as excessive alcohol use.

Finally, there’s increased risk with professional exposure to harmful substances; for example, agricultural workers are at increased risk of developing organophosphate poisoning, which is commonly used as a pesticide.

Now, clinical manifestations associated with acetaminophen poisoning, can be subdivided into four main stages.

The first stage may last up to 24 hours after the ingestion, and during this period clients can have no or mild symptoms, such as nausea and vomiting.

The second stage starts about 18 to 72 hours after the ingestion, and typically presents with right upper quadrant pain due to liver involvement, and hypotension.

The third stage occurs 72 to 96 hours post-ingestion and it’s characterized by liver dysfunction, which leads to clinical manifestations like jaundice or yellowing of the skin; coagulopathy or impaired clot formation; and hepatic encephalopathy, which refers to a brain dysfunction due to liver disease.

Additionally, clients can develop renal failure, which may lead to metabolic acidosis.

Finally, the fourth stage usually occurs after 5 days post-ingestion, where the client can either completely recover or progress to multi-organ failure or even death.

Clients who completely recover from acetaminophen poisoning must be very careful, since continued heavy use of this medication in the long run can eventually lead to acute or chronic liver failure.

Diagnosis of acetaminophen poisoning is based on the plasma acetaminophen levels, which should be measured 4 hours after the ingestion.

This is the time needed for all acetaminophen to enter the bloodstream and reach detectable peak plasma levels.

Besides plasma acetaminophen levels, additional lab tests can be ordered to measure levels of aspartate transaminase or AST, and alanine transaminase or ALT, which are liver enzymes that are almost always elevated in clients with liver damage.

In severe cases, bilirubin can also be elevated.

Finally, prothrombin time or PT, and international normalized ratio or INR levels may be increased if the liver is not being able to synthesize clotting factors.

Treatment of clients with acetaminophen toxicity includes intravenous or oral administration of an antidote called N-acetylcysteine.

Additionally, clients who present within 1 hour after the ingestion should receive activated charcoal, which binds to acetaminophen and prevents its absorption in the gastrointestinal tract.

After Gabriel and his father arrive at the ED, you begin your assessment.