Copyright 2002 Delmar Learning, a division of Thomson ...



Copyright ( 2002 Delmar Learning, a division of Thomson Learning(, Inc., ALL RIGHTS RESERVED

Angelica Vigil

Background scenario

A nurse arrives for work at 7:30 a.m. at a public health clinic located in rural Oregon. At the same time, a white rental car pulls into the parking lot. Angelica, a 42-year old Latino female from Santa Fe, New Mexico, is sitting in the front seat of the car, head back and eyes closed. She is moaning. The driver, Jelena, approaches the curious nurse. She is very anxious and stressed and asks for directions to the emergency room. She says her partner is having repeated vomiting, painful cramping, and repeated diarrhea, and she is getting very weak. The nurse directs them to the emergency department of the community hospital two blocks down the street. She follows in her car. In the triage room, the ER nurse takes vital signs and starts an IV.

The public health nurse listens while the ER nurse asks the couple what happened. Angelica and Jelena report that they arrived in the area yesterday to meet friends for a week of horseback riding, bon fires, camping, and “just to get away from it all.” Angelica says she started having abdominal pain and cramping at about 4 a.m. and the diarrhea started shortly thereafter. She kept trying to drink fluids from soda pop bottles filled from a nearby spring, but the more she drank, the worse she felt.

Interview

Angelica:

“Maybe I got some bad food. We ate on the plane, but Jelena seems to be OK and had the same meal. I try to stay on a good diet. I have been taking the same vitamin supplements for years and occasionally I add Chinese herbs.”

Angelica’s Friend, Jelena:

“She was really in pain this morning. She woke me up at about four and had to just crawl into the bushes to keep from messing up her tent. She complained of severe cramping and had terrible diarrhea.”

Examination

Vital signs:

Temperature: 99° F

Pulse: 110

Respiration: 28

Blood pressure: 113/70

Observation:

Skin is cool and dry.

Decreased skin turgor.

Client is restless and anxious.

Client is oriented to place and time.

Client is having “dry heaves.”

Palpation:

Tenderness, all quadrants, with palpation

Slight distention

Tympany to percussion, all quadrants

Auscultation:

Respirations are shallow and rapid

Lungs are clear

Hyperactive bowel tones are present

Heart rate is regular

Laboratory and Test Data

Stool Culture:

Stool sample for Giardia, ovum/parasites

Blood Work:

Occult blood negative

Urinalysis:

Urine dark yellow; specific gravity 1.030

Additional Information as time passes

The public health nurse knows the camp where Angelica and Jelena are staying. She looks up the U.S. Geological Survey report and calls the consulting hydrologist for the region. The hydrologist reports that the area near the clinic is known to have arsenic levels around 10 mg/L but that 8% of the samples taken from springs and wells in the larger region showed arsenic above 50 parts per billion (ppb). One source had an arsenic level of 2000 ppb. He says the unusually dry year has dropped the ground water to very low levels, increasing the concentrations of dissolved solids in the remaining water.

The nurse calls the local health department, which reports that there have been several cases of local and out-of-town hikers with similar stomach complaints. The community health nruse working in the area reports that a popular campground has had similar problems. The camp director reported that customers complained that their lips burned when they drank the camp water. The camp director said he uses bottled water and his own private store of collected rainwater and was not sick.

Reference Information and Assessment Review

Background

Arsenic is a naturally occurring element found in the earth’s crust. It is present in groundwater through dissolution of minerals, ores, and erosion of rock. It is recognized as a human health concern due to its contribution to skin, bladder, and other cancers. The acceptable maximum level for drinking water is thought to be 50 ppb.

While forms of arsenic are found in herbicides, pesticides, and defoliants and as additives to animal feed, arsenic is not easily absorbed through the skin. The greatest threat to public health comes from ingestion of contaminated groundwater. The most common cause of widespread arsenic contamination is through the release of arsenic from iron oxide as a response to geocheical conditions, which includes the release of arsenic to groundwater through reaction of iron oxide with organic carbon. These concentrations can exceed 10 mg/L in groundwater.

Detection

Detecting arsenic in drinking water can be a challenge. It requires advanced technology and trained personnel that may not be readily available in rural areas. Field test kits can detect high levels but can be unreliable at lower concentrations. Arsenic contamination is difficult and expensive to remove, so avoiding contamination where possible is the best option. Prevention can be obtained by safeguarding the integrity of raw water and its watershed through routine inspections, education of consumers, and proper maintenance of water delivery systems. The watershed should be protected from contaminating activities, such as mining, use of fertilizers and pesticides, and unregulated/unmonitored recreational activities. Springs and wells should be located where they will not be contaminated by surface drainage and flooding.

Low-arsenic water (less than 50 ppb) can be used safely for drinking and cooking. Water with higher levels of arsenic can be used safely for laundry and bathing. Alternative low-arsenic sources such as rain water and treated surface water may be one solution in rural areas.

Symptoms and Treatment

Acute exposure that occurs through ingestion of arsenic produces symptoms that include burning lips, throat constriction, nausea, vomiting, diarrhea, abdominal pain, and difficulty swallowing (dysphagia). Diarrhea has a classic “rice water” appearance. Inhalation can lead to respiratory tract, skin and eye irritation. Clients can have acute hemolytic anemia. Serious complications include convulsions, delirium, coma, and death. Chronic exposures can lead to cancers, dermatitis, microcytic, hypochromic anemia, or leukocytopenia.

Inorganic arenis in urine peaks at about 10 hours and returns to normal 20-30 hours after ingestion. The half-life of arsenic in blood is only about 2 hours, so blood tests are unlikely to detect it if more than 4 hours have passed. Arsenic can be detected in hair samples as early as 30 hours after ingestion.

Treatment of acute arsenic toxicity is supportive. Hydration to prevent hypovolemic shock is the first concern. Pain control in acute abdominal cramping may be initiated. Chelation therapy is started immediately. Dimercaprol (2,3-dimercaptopropanol), also known as BAL (British anti-Lewisite), is one chelator commonly used for heavy-metal poisoning. It binds heavy metals in the plasma, renders them nontoxic, and aids in their excretion.

Additional Information

Acute arsenic poisoning from contaminated groundwater.

Nursing diagnosis:

00076 Readiness for enhanced community coping (community)

00045 Impaired oral mucous membrane

00126 Deficient knowledge (environmental contaminants)

00027 Deficient fluid volume

00134 Nausea

00013 Diarrhea

00132 Acute pain

Quiz

1. The community health nurse in a rural area is suspicious that arsenic in well water may be making people ill at a local campground. The nurse decides to use a field test kit to check the water. Which of the following is true about detecting arsenic in drinking water?

a. Test kits are very reliable and should be used more frequently to test public water.

b. Water testing technology is advanced and field test kits are easy to use.

c. Field test kits can detect high levels but can be unreliable at lower concentrations.

d. Field test kits are highly reliable at lower concentrations.

2. A 54-year old female comes into a rural public health clinic complaining of burning lips, throat constriction, and nausea. She is visiting from another state and has stayed overnight at a local campground. The client’s symptoms could be a sign of:

a. Chronic arsenic exposure

b. Exposure

c. Acute exposure to pesticides

d. Acute exposure to ingested arsenic

3. The community health nurse is informed that several wells supplying drinking water to area residents have tested positive for high levels of arsenic. The nurse knows that the most common cause of widespread arsenic contamination is the release of:

a. Arsenic from pesticides and fertilizers

b. Arsenic from silica-rich ground deposits

c. Arsenic from iron oxide as a response to geochemical conditions

d. Pesticide residue from the feces of cattle

4. A client complains of burning lips, throat constriction, and nausea. The nurse suspects arsenic poisoning. Laboratory tests are ordered. Which of the following are true about testing for arsenic?

a. Tests can detect arsenic in blood up to 30 hours after ingestion.

b. Tests can detect arsenic in urine up to 20 hours after ingestion.

c. Arsenic can be detected in hair samples as early as 3 hours after ingestion.

d. Blood samples must be sent to regional testing centers and results take 7 days to process.

5. The health department has reported that several campers at a campground have symptoms of arsenic poisoning. The public health nurse has seen a few of these people. Which of the following statements is an inaccurate conclusion that might be made by the nurse?

a. Since all of the campers exhibited similar symptoms, there might be a common source.

b. The common source may have been shared food or other ingested source, so you consider food, water, or other unknowns.

c. The symptoms could indicate gastroenteritis or Giardia.

d. Criminal activity must be involved.

6. Widespread arsenic poisoning is reported to the public health nurse. The nurse knows that the greatest threat of arsenic exposure to humans is:

a. Agricultural pesticides

b. Fertilizer

c. Drinking water

d. Contaminated produce

7. A public health nurse reads an alert about widespread arsenic poisoning in the community. Which of the following best describes the symptoms produced through acute exposure from the ingestion of arsenic?

a. Coughing, sneezing, nausea, and joint pain

b. Joint pain, headaches, and coughing

c. Difficulty swallowing, coughing, sneezing, and nausea

d. Throat constriction, nausea, diarrhea, and abdominal pain

8. A client is diagnosed with acute arsenic toxicity. Which of the following is the most important nursing action?

a. Treat fluid overload.

b. Do not allow the use of pain medication.

c. Start chelation therapy as prescribed.

d. Administer IV antibiotics.

9. Chelation therapy is ordered for a client who has been diagnosed with acute arsenic toxicity. What does chelation therapy accomplish for the client?

a. It binds heavy metals in urine and aids in their excretion.

b. It binds heavy metals in the plasma, renders them nontoxic, and aids in their excretion.

c. It gives the client immunity from heavy-metal poisons.

d. It gives the client immunity from arsenic poisoning and aids in its excretion.

10. Widespread acute arsenic poisoning has recently occurred in a small town. The town’s people and water sources have been tested and treated. The public health nurse attends a planning meeting for a proposed resort outside of town. The nurse knows that the county commissioner understands why prevention of arsenic groundwater contamination is preferred over treating the contamination when he says…

a. Testing is easy and cheap so we will have the resort test its well water every month.”

b. “We do not need to change anything. Arsenic poisoning is not a major risk in our area, and when it happens, it is simple to address.”

c. “Expensive testing will tell us the level of contamination. Once we find contamination, it is dificult and expensive to remove.”

d. “The arsenic poisoning risk is over. Everyone is doing fine. All arsenic has been removed from the water.”

Copyright ( 2002 Delmar Learning, a division of Thomson Learning(, Inc., ALL RIGHTS RESERVED

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