NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 21

Materials: MS notebook, paper, pen, index card,

LESSON TITLE: Environmental Emergencies (Heat and bond paper (short & long size)
Stroke, Frostbite and Hypothermia)
References:

LEARNING TARGETS:
At the end of the lesson, the student nurses can:
1. Identify the environmental emergencies;
2. Describe the common causes of these environmental
emergencies;
3. Explain the clinical manifestation of heat stroke,
frostbite and hypothermia; and,
4. Discuss the nursing management process of client
with heat stroke, frostbite and hypothermia.
Smeltzer S.C., & Bare B.G. (2010) Brunner and
Suddarth’s Textbook of Medical- Surgical Nursing.
Lippincott William & Wilkins
Sommer S., Johnson J. (2013) RN Adult Medical
Surgical Nursing. Assessment Technology
Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: List down at least three conditions of patient who are at risk for multi organ dysfunction syndrome.

1._________________________

2._________________________

3._________________________

MAIN LESSON (60 minutes)

HEAT STROKE
Heat stroke is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body.
The most common cause of heat stroke is prolonged exposure to an environmental temperature of greater than 39.2C
(102.5F). It usually occurs during extended heat waves, especially when they are accompanied by high humidity.
People at risk for heat stroke are those
 not acclimatized to heat,
 those who are elderly or very young,
 those unable to care for themselves,
 those with chronic and debilitating diseases, and
 those taking certain medications (eg, major tranquilizers, anticholinergics, diuretics, beta-blockers).

Exertional heat stroke occurs in healthy individuals during sports or work activities (eg, exercising in extreme heat and
humidity).

Hyperthermia results because of inadequate heat loss. This type of heat stroke can also cause death. Str. Another form of
heat stroke is heat exhaustion in which the patient’s temperature may be normal to 40C (104F). The patient demonstrates
weakness, hypotension, increased heart rate, and increased thirst.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 1 of 8
Assessment and Diagnostic Findings
Heat stroke causes thermal injury at the cellular level, resulting in coagulopathies and widespread damage to the heart,
liver, and kidneys.
Recent patient history reveals exposure to elevated ambient temperature or excessive exercise during extreme heat.
When assessing the patient, the nurse notes the following symptoms:
 profound central nervous system (CNS) dysfunction (manifested by confusion, delirium, bizarre behavior, coma);
 elevated body temperature (40.6C [105F] or higher);
 hot, dry skin;
 and usually anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia.

Management
The primary goal is to reduce the high body temperature as quickly as possible, because mortality is directly related to the
duration of hyperthermia.
 Simultaneous treatment focuses on stabilizing oxygenation using the ABCs (airway, breathing, and circulation) of
basic life support.
 This includes establishing IV access for fluid administration.
 After the patient’s clothing is removed, the core (internal) temperature is reduced to 39C (102F) as rapidly as
possible, preferably within 1 hour.
 One or more of the following methods may be used as prescribed:
o Cool sheets and towels or continuous sponging with cool water
o Ice applied to the neck, groin, chest, and axillae while spraying with tepid water
o Cooling blankets
o Immersion of the patient in a cold-water bath (if possible)
 During cooling procedures, an electric fan is positioned so that it blows on the patient to augment heat dissipation
by convection and evaporation.
 The patient’s temperature is constantly monitored with a thermistor placed in the rectum, bladder, or esophagus
to evaluate core temperature.
 Caution is used to avoid hypothermia and to prevent hyperthermia, which may recur spontaneously within 3 to 4
hours.
 The cooling process should stop at 38.8C (102F) in order to avoid iatrogenic hypothermia.
 Throughout treatment, the patient’s status is monitored carefully, including vital signs, ECG findings (for possible
myocardial ischemia, myocardial infarction, and dysrhythmias), central venous pressure (CVP), and level of
responsiveness, all of which may change with rapid alterations in body temperature.
 A seizure may be followed by recurrence of hyperthermia.
 To meet tissue needs exaggerated by the hypermetabolic condition, 100% oxygen is administered.
 Endotracheal intubation and mechanical ventilation to support failing cardiopulmonary systems may be required.
IV infusion therapy of normal saline or lactated Ringer’s solution is initiated as directed to replace fluid losses and
maintain adequate circulation.
 Fluids are administered carefully because of the dangers of myocardial injury from high body temperature and
poor renal function.
 Cooling redistributes fluid volume from the periphery to the core. Urine output is also measured frequently,
because acute tubular necrosis may occur as a complication of heat stroke from rhabdomyolysis (myoglobin in
the urine).
 Blood specimens are obtained for serial testing to detect bleeding disorders, such as disseminated intravascular
coagulation (DIC), and for serial enzyme studies to estimate thermal hypoxic injury to the liver, heart, and muscle
tissue.
 Permanent liver, cardiac, and CNS damage may occur.

Additional supportive care may include dialysis for renal failure, antiseizure medications to control seizures,
potassium for hypokalemia, and sodium bicarbonate to correct metabolic acidosis. Benzodiazepines (eg, diazepam
[Valium]) or chlorpromazine (Thorazine) may be prescribed to suppress seizure activity.
Patient education regarding the prevention of heat stroke is also important to prevent a recurrence.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 2 of 8
Frostbite
 Frostbite is trauma from exposure to freezing temperatures and freezing of the intracellular fluid and fluids in the
intercellular spaces.
 It results in cellular and vascular damage. Frostbite can result in venous stasis and thrombosis. Body parts most
frequently affected by frostbite include the feet, hands, nose, and ears.
 Frostbite ranges from first degree (redness and erythema) to fourth degree (full-depth tissue destruction).

Assessment and Diagnostic Findings

 A frozen extremity may be hard, cold, and insensitive to touch and may appear white or mottled blue-white. The
extent of injury from exposure to cold is not always initially known.
 The patient history should include environmental temperature, duration of exposure, humidity, and the presence
of wet conditions.

Management
The goal of management is to restore normal body temperature.
 Constrictive clothing and jewelry that could impair circulation are removed.
 Wet clothing is removed as rapidly as possible. If the lower extremities are involved, the patient should not be
allowed to ambulate.
 Controlled yet rapid rewarming is instituted. Frozen extremities are usually placed in a 37C to 40C (98.6F to
104F) circulating bath for 30- to 40-minute spans.
 This treatment is repeated until circulation is effectively restored. Early rewarming appears to decrease the
amount of ultimate tissue loss.
 During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be
very painful.
 To avoid further mechanical injury, the body part is not handled.
 Massage is contraindicated. Once rewarmed, the part is protected from further injury and is elevated to help
control swelling.
 Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration, and a bulky dressing is
placed on the extremity.
 A foot cradle may be used to prevent contact with bedclothes if the feet are involved. Hemorrhagic blebs, which
may develop 1 hour to a few days after rewarming, are left intact and not ruptured.
 Nonhemorrhagic blisters are débrided to decrease the inflammatory mediators found in the blister fluid.
 A physical assessment is conducted with rewarming to observe for concomitant injury, such as soft tissue injury,
dehydration, alcohol coma, or fat embolism.
 Problems such as hyperkalemia (eg, from release of potassium in the damaged cells) and hypovolemia, which
occur frequently in people with frostbite, are corrected.
 Risk of infection is also great; therefore, strict aseptic technique is used during dressing changes, and tetanus
prophylaxis is administered as indicated.
 Nonsteroidal anti-inflammatory medication is prescribed for its anti-inflammatory effects and to control pain.

Additional measures that may be carried out when appropriate include the following:
 Whirlpool bath for the affected body parts to aid circulation and debridement of necrotic tissue to help prevent
infection
 Escharotomy (incision through the eschar) to prevent further tissue damage, to allow for normal circulation, and to
permit joint motion
 Fasciotomy to treat compartment syndrome

After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and
to prevent contractures.

Discharge instructions also include encouraging the patient to avoid tobacco, alcohol, and caffeine because of their
vasoconstrictive effects, which further reduce the already deficient blood supply to injured tissues

Hypothermia
 Hypothermia is a condition in which the core (internal) temperature is 35C (95F) or less as a result of exposure to
cold or an inability to maintain body temperature in the absence of low ambient temperatures.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 3 of 8
  Urban hypothermia (extreme exposure to cold in an urban setting) is associated with a high mortality rate; elderly
people, infants, people with concurrent illnesses, and the homeless are particularly susceptible.
 Alcohol ingestion increases susceptibility because it causes systemic vasodilation.
 Some medications (e.g., phenothiazines) or medical conditions (e.g., hypothyroidism, spinal cord injury) decrease
the ability to shiver, hampering the body’s innate ability to generate body heat.
 Trauma victims are also at risk for hypothermia resulting from treatment with cold fluids, un-warmed oxygen, and
exposure during examination. The patient may also have frostbite, but hypothermia takes precedence in
treatment.

Assessment and Diagnostic Findings

Hypothermia leads to physiologic changes in all organ systems.
There is progressive deterioration, with
 apathy,
 poor judgment,
 ataxia,
 dysarthria,
 drowsiness,
 pulmonary edema,
 –base abnormalities,
 coagulopathy, and
 eventual coma.

 Shivering may be suppressed at a temperature of less than 32.2C (90F), because the body’s self-warming
mechanisms become ineffective.
 The heartbeat and blood pressure may be so weak that peripheral pulses become undetectable. Cardiac
dysrhythmias may also occur. Other physiologic abnormalities include hypoxemia and acidosis.

Management
Management consists of removal of wet clothing, continuous monitoring, rewarming, and supportive care.
 Monitoring the ABCs of basic life support are a priority.
 The patient’s vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (blood urea
nitrogen, creatinine, glucose, electrolytes), and chest x-rays are evaluated frequently.
 Body temperature is monitored with an esophageal, bladder, or rectal thermistor.
 Continuous ECG monitoring is performed, because cold-induced myocardial irritability leads to conduction
disturbances, especially ventricular fibrillation.
 An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling.

Rewarming
 Rewarming methods include active internal (core) rewarming and passive or active external (spontaneous)
rewarming.
 Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28C to 32.2C
[82.5F to 90F]) and include cardiopulmonary bypass, warm fluid administration, warm humidified oxygen by
ventilator, and warmed peritoneal lavage.
 Monitoring for ventricular fibrillation as the patient’s temperature increases from 31C to 32C (88F to 90F) is
essential.
 Passive or active external rewarming is used for mild hypothermia (32.2C to 35C [90F to 95F]).
 Passive active rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic,
anaerobic extremities.
 The cold blood from peripheral tissues has high lactic acid levels. As this blood returns to the core, it causes a
significant drop in the core temperature (i.e. core temperature after drop) and can potentially cause cardiac
dysrhythmias and electrolyte disturbances.
 Active external rewarming uses forced air warm blankets. Care must be taken to prevent extremity burn from
these devices, because the patient may not have effective sensation to feel the burn.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 4 of 8
Supportive Care
Supportive care during rewarming includes the following as directed:
 External cardiac compression (typically performed only as directed in patients with temperatures higher than 31C
[88F]).
 Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32C [90F] experiences
spontaneous ventricular fibrillation if moved or touched. Defibrillation is ineffective in patients with temperatures
lower than 31C (88F); therefore, the patient must be rewarmed first.
 Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain
tissue oxygenation.
 Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as
described previously.
 Administration of sodium bicarbonate to correct metabolic acidosis if necessary.
 Administration of antiarrhythmic medications.
 Insertion of an indwelling urinary catheter to monitor urinary output and renal function.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be
attended first?
A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest
fatigue, hypotension, tachypnea, and profuse sweating.
B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen
skin; and whose duration of heat exposure is unknown.
D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and
tachycardia.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

2. You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order.
1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C).
2. Remove the victim from the cold environment.
3. Monitor for signs of compartment syndrome.
4. Apply a loose, sterile, bulky dressing.
5. Administer a pain medication.
A. 5, 2, 1, 3, 4
B. 2, 5, 1, 4, 3
C. 2, 1, 5, 3, 4
D. 3, 2, 1, 4, 5
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

3. You are caring for a patient who was brought into the emergency department unresponsive, hypotensive and
tachypneic. Upon further assessment, you realize that the patient’s temperature is 106 degrees Fahrenheit. You suspect
heat stroke. What would your priority nursing intervention be?
A. Obtain a history from the patient.
B. Take oral temperature to monitor effectiveness of treatment.
C. Call the family for consent to treat.
D. Take off the patient’s clothing, wrap him or her in wet towels and place a fan on the patient.
ANSWER: ________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 8
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

4. An elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student
statement demonstrates that the teaching has been effective?
A. "Dressing in layers is important."
B. "I will drink lots of water when I exercise."
C. "Taking frequent breaks will help me rest."
D. "Wearing three pairs of cotton socks is very important.''
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5. Which client is at greatest risk for heat exhaustion?

A. 24-year-old construction worker
B. 34-year-old policeman
C. 42-year-old swimming instructor
D. 78-year-old gardener
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

6. A 16-year-old high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how
to prevent a recurrence of this situation. Which student statement demonstrates that the teaching is effective?
A. "I should try to exercise between noon and 3 PM."
B. "I will limit my fluids to drinking 'sports' drinks after I exercise."
C. "Taking frequent rests is important when working in a hot environment."
D. "Wearing dark-colored clothing to deflect the sun away from me will help me stay cooler."
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

7. On a hot summer day, an older adult is found by a neighbor lying on the apartment floor, agitated and confused. After
calling 911, the neighbor places ice bags to the client's groin area and armpits. Upon arrival at the hospital, which action
does the emergency department (ED) nurse perform first?
A. Administers 2 acetylsalicylic acid tablets (aspirin) orally
B. Checks the client's airway, continuing oxygen by mask
C. Monitors the client's vital signs
D. Places a cooling blanket on the client
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

8. While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness
(LOC). What does the team nurse do first?
A. Gives salt tablets
B. Moves the player to the shade
C. Places ice packs under the arms
D. Provides a cool electrolyte fluid drink
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 6 of 8
9. Which of the following nursing interventions is appropriate for a client who is suffering from a fever?
A. Avoid giving the client food
B. Increase the client's fluid volume
C. Provide oxygen
D. All of the above
E. Both B and C
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. A client has started sweating profusely due to intense heat. His overall fluid volume is low and he has developed
electrolyte imbalance. This client is most likely suffering from:
A. Malignant hyperthermia
B. Heat exhaustion
C. Heat stroke
D. Heat cramps
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 7 of 8
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. ANSWER: ________

RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

Al Strategy: Buzz Group

Instruction: You will form into groups (compose of 4-6 students) in order to discuss answer to question prompt by the
instructor. You will be given 3 minutes to discuss among yourselves prior to sharing it with the class.

Activity 2:
NCP Making. Using the same groupings, each group will be instructed to prepare one nursing care plan for clients with
either heat stroke, frostbite or hypothermia.

(For Related Learning Experience, please refer to your clinical instructor.)

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 8 of 8