Reposting Tonsilectomy question...

EricJRN, MSN, RN · Sep 27, 2008

Thanks again! I only choose the cooling blanket b/c it was listed in my course outline under nursing interventions for ASA posioning and was also said in lecture but she did not give rationale why.

Hyperthermia is a potential complication of severe aspirin overdose, but from the question, there is no indication that the patient is hyperthermic. You do know that you're going to have to do something to address the ingestion - and usually that will involve activated charcoal.

Here's a good article that gives an overview of the signs and symptoms of salicylate toxicity: http://www.emedicine.com/ped/topic2031.htm

Noryn · Sep 28, 2008

(http://www.emedicinehealth.com/aspirin_poisoning/page3_em.htm):

severe deep and rapid breathing, prominent nervous system disturbances, such as marked lethargy or excitability, but no coma or convulsions
you don't need to go any further in problem solving this because the answer is already there. . .
-->administer activated charcoal
- this
is
a treatment for aspirin od and likely that the er doctor will order it

apply cooling blanket
- fever is
not
a symptom of aspirin od, it is not likely that a fever is occurring because of aspirin poisoning
that is how you critical think these answers out. i didn't know the answer to this. that's why i went to the emedicinehealth site for some help. you should do the same to verify things. i am a med/surg nurse.

fever along with seizures absolutely can be seen with aspirin toxicity. be careful with internet sites.

if that was the entire question (and those were the 2 best answers) then it was a very poor question. the correct answer? obtain more information. it depends on the patient condition--i realize they didnt specify how symptomatic the patient however this is critical information.

the answer they are looking for most likely is to give charcoal. but if the patient was significantly hyperthermic and having seizures then a cooling blanket may be indicated where charcoal may not. if they are having significant toxicity then treatment will most likely be dialysis not charcoal (charcoal may be a supplemental but not primary treatment in this scenario).

if that was a question your instructor made up, tell them that noryn on the internet said it was not a good question--ha! seriously, they need to be careful with overdose questions. treat the patient, not the overdose! charcoal is really controversial now. there is really no evidence that it improves patient outcomes but does pose several risks such as aspiration--especially if loc is decreased.

if the patient presents early, within 1 hour or so and is not having any effects then i think giving charcoal could be considered.

icunurse42066 · Sep 28, 2008

Thanks to all of your posts, they have been great help. I'd like to ask one more question........I know I know, but I need to know this for future questions. The question was something like; 15 year old comes to ER with Aspirin poisioning. The nurse would take which action?
A. administer activated charcoal
B. apply cooling blanket
Now, activated charcoal is the form of tx for this but it does not state anywhere that the MD ordered this. I chose cooling blanket b/c that is an intervention for this condition. When it comes to medication I thaught you would need to see something stateing it was ordered for the med to be the correct answer OR the question would have to ask what would the nurse EXPECT to do? So when taking exams am I supposed to assume all meds listed in answers were ordered? This question threw me to cauase a question further down the test actually stated in the question "MD ordered all of the following."

One of the first things you will notice if you go to work in the ER, is for the nurses that have been there a while, they tend to do things without the MD ordering it and usually the MD will go back and write the order. While it is not good nursing practice, it is a fact of life, especially on midnights when the doc is in his/her room asleep and something life threatening comes in. Like with chest pains, while the MD may not write the order for it, we automatically start IV's, draw labs, hang fluids, get an EKG, give ASA as appropriate, start O2, and give Morphine. But as I said, that because the nurses and the MD work so close together in the ER that they know what each other is going to do and it gets done for the sake of the pt.

Daytonite, BSN, RN · Sep 28, 2008

Fever along with seizures absolutely CAN be seen with aspirin toxicity. Be careful with internet sites.
If that was the entire question (and those were the 2 best answers) then it was a very poor question. The correct answer? Obtain more information. It depends on the patient condition--I realize they didnt specify how symptomatic the patient however this is critical information.
The answer they are looking for most likely is to give charcoal. But if the patient was significantly hyperthermic and having seizures then a cooling blanket may be indicated where charcoal may not. If they are having significant toxicity then treatment will most likely be dialysis not charcoal (charcoal MAY be a supplemental but not primary treatment in this scenario).
If that was a question your instructor made up, tell them that Noryn on the internet said it was not a good question--Ha! Seriously, they need to be careful with overdose questions. Treat the patient, not the overdose! Charcoal is really controversial now. There is really no evidence that it improves patient outcomes but does pose several risks such as aspiration--especially if loc is decreased.
If the patient presents early, within 1 hour or so and is not having any effects then I think giving charcoal could be considered.

Where's the references to back up what you are saying?

Noryn · Sep 28, 2008

Overall it is just a really unfair question that is one of the most controversial topics in toxicology at the moment. The question indicates that charcoal is routinely given when it should not be routinely given. Again it depends entirely on the patient's presentation. If they are significantly symptomatic then charcoal is not your primary treatment and may pose substantial risks.

Aspirin toxicity from one of the gold standards of reference in toxicology.

http://books.google.com/books?id=HVYyRsuUEc0C&pg=PA511&lpg=PA511&dq=aspirin+toxicity+goldfrank%27s&source=web&ots=AHojbujkQ4&sig=gij8S0KllypgCW_Gf1ntoHeSFZE&hl=en&sa=X&oi=book_result&resnum=1&ct=result

Again the charcoal issue is really controversial as you can read in above link. Right now per the American Academy of Clinical Toxicology

http://www.clintox.org/Pos_Statements/MultipleDoseActivatedCharcoal.pdf

"The use of multiple-dose charcoal in salicylate poisoning is controversial. One

animal study and 2 of 4 volunteer studies did not demonstrate increased salicylate

clearance with multiple-dose charcoal therapy. Data in poisoned patients

are insufficient presently to recommend the use of multiple-dose charcoal therapy

for salicylate poisoning."

As far as single dose charcoal

http://www.clintox.org/Pos_Statements/SingleDoseActivatedCharcoal.pdf

"Single-dose activated charcoal should not be administered

routinely in the management of poisoned patients. Based on

volunteer studies, the administration of activated charcoal may

be considered if a patient has ingested a potentially toxic amount

of a poison (which is known to be adsorbed to charcoal) up to one

hour previously. Although volunteer studies demonstrate that the

reduction of drug absorption decreases to values of questionable

clinical importance when charcoal is administered at times

greater than one hour, the potential for benefit after one hour

cannot be excluded. There is no evidence that the administration

of activated charcoal improves clinical outcome. Unless a patient

has an intact or protected airway, the administration of charcoal

is contraindicated."

Daytonite, BSN, RN · Sep 29, 2008

Overall it is just a really unfair question that is one of the most controversial topics in toxicology at the moment. The question indicates that charcoal is routinely given when it should not be routinely given. Again it depends entirely on the patient's presentation. If they are significantly symptomatic then charcoal is not your primary treatment and may pose substantial risks.
Aspirin toxicity from one of the gold standards of reference in toxicology.
http://books.google.com/books?id=HVYyRsuUEc0C&pg=PA511&lpg=PA511&dq=aspirin+toxicity+goldfrank%27s&source=web&ots=AHojbujkQ4&sig=gij8S0KllypgCW_Gf1ntoHeSFZE&hl=en&sa=X&oi=book_result&resnum=1&ct=result
Again the charcoal issue is really controversial as you can read in above link. Right now per the American Academy of Clinical Toxicology
http://www.clintox.org/Pos_Statements/MultipleDoseActivatedCharcoal.pdf
"The use of multiple-dose charcoal in salicylate poisoning is controversial. One
animal study and 2 of 4 volunteer studies did not demonstrate increased salicylate
clearance with multiple-dose charcoal therapy. Data in poisoned patients
are insufficient presently to recommend the use of multiple-dose charcoal therapy
for salicylate poisoning."
As far as single dose charcoal
http://www.clintox.org/Pos_Statements/SingleDoseActivatedCharcoal.pdf
"Single-dose activated charcoal should not be administered
routinely in the management of poisoned patients. Based on
volunteer studies, the administration of activated charcoal may
be considered if a patient has ingested a potentially toxic amount
of a poison (which is known to be adsorbed to charcoal) up to one
hour previously. Although volunteer studies demonstrate that the
reduction of drug absorption decreases to values of questionable
clinical importance when charcoal is administered at times
greater than one hour, the potential for benefit after one hour
cannot be excluded. There is no evidence that the administration
of activated charcoal improves clinical outcome. Unless a patient
has an intact or protected airway, the administration of charcoal
is contraindicated."

OK. I read it, but you do agree that the way the question was presented suggests that the only answer the student can possibly give in this circumstance is to administer the charcoal. Even you said that. It's an issue of critical thinking not the correct medical treatment.

Noryn · Sep 29, 2008

OK. I read it, but you do agree that the way the question was presented suggests that the only answer the student can possibly give in this circumstance is to administer the charcoal. Even you said that. It's an issue of critical thinking not the correct medical treatment.

No I don't agree. But it depends on the exact way the question was written. Aspirin "poisoned" indicates to me that the patient has developed toxicity in which case charcoal may very well not be given.

Here is how I would critically think this situation. Ok my patient is "poisoned" from Aspirin. What is one major effect of Aspirin with therapeutic use or overdose? GI irritation. Do I really want to add charcoal (which per evidenced based practice has not been proven to help the patient) to my patients stomach when there is a risk of vomiting and decreased loc or seizures?

The question and scenario are unfair, in my opinion it doesn't test the student's critical thinking skills because it is too vague and lacks adequate information.

smstar1996 · Sep 29, 2008

Thankyou for responding! Your rational makes perfect sense and plan on arguing this point with my instructor. Thanks:bow:

Fever along with seizures absolutely CAN be seen with aspirin toxicity. Be careful with internet sites.
If that was the entire question (and those were the 2 best answers) then it was a very poor question. The correct answer? Obtain more information. It depends on the patient condition--I realize they didnt specify how symptomatic the patient however this is critical information.
The answer they are looking for most likely is to give charcoal. But if the patient was significantly hyperthermic and having seizures then a cooling blanket may be indicated where charcoal may not. If they are having significant toxicity then treatment will most likely be dialysis not charcoal (charcoal MAY be a supplemental but not primary treatment in this scenario).
If that was a question your instructor made up, tell them that Noryn on the internet said it was not a good question--Ha! Seriously, they need to be careful with overdose questions. Treat the patient, not the overdose! Charcoal is really controversial now. There is really no evidence that it improves patient outcomes but does pose several risks such as aspiration--especially if loc is decreased.
If the patient presents early, within 1 hour or so and is not having any effects then I think giving charcoal could be considered.

squirtle · Sep 29, 2008

Thankyou for responding! Your rational makes perfect sense and plan on arguing this point with my instructor. Thanks:bow:

This is just my personal opinion... but in in nursing school our exams were designed to begin to get us to critically think so we weren't going in to NCLEX blind, but they also covered content and information that was discussed in our book and power points. I think that we all could have consulted the internet or found special circumstances somewhere that would provide us with information to argue the point with our instructors or that would make the answer choice questionable. I think this question is going to be one where I would consider the old "choose your battles carefully" saying... They were looking for the charcoal answer. If using it were not discussed in class or stated any where in your text book then you might have a chance, but I am fairly certain they were looking for that answer and the cooling blanket is a bit of a long shot in the world of nursing school, at least I know it would have been in mine. :twocents:

Daytonite, BSN, RN · Sep 29, 2008

No I don't agree. But it depends on the exact way the question was written. Aspirin "poisoned" indicates to me that the patient has developed toxicity in which case charcoal may very well not be given.
Here is how I would critically think this situation. Ok my patient is "poisoned" from Aspirin. What is one major effect of Aspirin with therapeutic use or overdose? GI irritation. Do I really want to add charcoal (which per evidenced based practice has not been proven to help the patient) to my patients stomach when there is a risk of vomiting and decreased loc or seizures?
The question and scenario are unfair, in my opinion it doesn't test the student's critical thinking skills because it is too vague and lacks adequate information.

Then, as the instructor I would mark the question wrong for you and you lose the points for it. Sorry. Read the question closely next time.

Noryn · Sep 29, 2008

Then, as the instructor I would mark the question wrong for you and you lose the points for it. Sorry. Read the question closely next time.

I would find it sad any instructor would ignore current treatment recommendations. Even worse is not teaching the nurse to "think" about the risks/benefits of their treatments.

Daytonite, BSN, RN · Sep 29, 2008

I would find it sad any instructor would ignore current treatment recommendations. Even worse is not teaching the nurse to "think" about the risks/benefits of their treatments.

The question isn't as much about treatment as it is about critical thinking skill.