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ADVANCED CONCEPTS OF NURSING

SEMINAR ON DISASTER NURSING


Submitted to: Mr. Swamy vell Asso. Professor GGSMH College of Nursing Submitted by: Mr. Bibin C Mathew 1st M.Sc (N) GGSMH College of Nursing

Submitted on : 22/03/10

DISATER NURSING INTRODUCTION Disaster is unexpected events that usually occur all of a sudden. Disasters have been integral parts of the human experience since the beginning of time. Causing premature death, impaired quality of life, and altered health status. The disasters unfolding in this century are frequently associated with global instability, economic decay, political upheaval and collapse of government structure, violence and civil conflicts, famine and mass population and displacements. The increased incidence of disasters and the growing complexity of the nature of disasters create considerable challenges to those responsible for disaster planning. DEFINITION DISASTER Disasters may be defined as any destructive event that disrupts the normal functioning of a community. WHO defines disaster as any occurrence that causes damage, ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to cause an extra ordinary response from outside the affected community or area. DISASTER NURSING Disaster nursing can be defined as the adaptation of professional nursing skills in recognizing and meeting the nursing, physical and emotional needs resulting from a disaster. The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster. CLASSIFICATION OF DISASTERS Disasters may be classified into two broad categories: Natural or Manmade. NATURAL DISASTERS WHO define natural disaster as the result of an ecological disruption or threat that exceeds the adjustment capacity of the affected community. Natural disasters include events such as Hurricanes Tornados

Hair storms Tsunami Cyclone Blizzards Drought Floods Mudslides Earthquakes Volcanic eruptions Communicable disease epidemics MANMADE DISASTERS Disasters or emergency situations caused by people are those in which the principal direct causes are identifiable human actions, deliberate or otherwise. Manmade disasters include Disasters generated by man can be further divided into 3 broad categories. Complex emergencies Technologic disasters Disasters that are not caused by natural hazards but occur in human settlements. Conventional warfare Non conventional warfare (eg. Nuclear, Chemical) Transportation accidents Structural collapse Explosions Fires Toxic materials Pollution Civil unrest Terrorist attack

Complex emergencies involve situations where population suffers significant casualties as a result of war, civil strife, or other political conflict. Technologic disasters are those in which large numbers or people, property, community infrastructure and economic welfare are directly and adversely affected by major industrial accidents, unplanned release of nuclear energy and fires, or explosions from hazards substance such as fuel, chemicals or such as materials. Disasters that are not caused by natural hazards but occur in human settlements is the result or weakness in the human environment. An example of this is a chemical plant explosion following an earth quake.

EPIDEMIOLOGY OF DISASTER
Epidemiology is the study of pattern of disease occurrence in human population and the factors that influence these patterns. Disaster may be studied and analyzed using the epidemiological frame work of agent, host, and environment in an attempt to predict, prevent or control the outcome of a disaster. DISASTER AGENT: Agent is the physical item that causes injury or destruction. Primary agents include falling buildings, heat, wind, rising water and smoke. Secondary agents include bacteria and viruses that produce contamination or infection after the primary agent has caused injury or destruction. Primary and secondary agents vary according to type of disaster. DISASTER HOST: In the epidemiological frame work, host is human kind. Host factors are those characteristics of humans that influence the severity of the disasters effect. Host factors include age, immunization status, pre disaster health status, degree of mobility and emotional stability. Individuals most severely affected by a disaster are elderly persons, young children, person with respiratory and cardiac problems etc., for eg a fire in a nursing home is potentially more lethal than a fire in a college dormitory.

ENVIRONMENT:

Environment factors that affect the outcome of a disaster include physical, chemical biological and social factors. Physical factors are: - Time of disaster occurrence, weather conditions, availability of food, water, electricity, telephone service etc. Chemical factors: Leakage of stored chemicals into air, soil, ground water or food supplies. Biological factors are: Those that occur or increase as a result of contaminated water, improper waste disposal, insect or rodent proliferation, improper food storage or lack of refrigeration owing to interrupted electrical services. Social factors: Are those that contribute to the individuals social support systems. Loss of family members, changes in roles & questioning of religions belief. Environmental health legislation supports public health problems in their efforts to resolve environmental health problems. One of the earliest attempts at research during a disaster was done by Florence Nightingale during the Crimean war & she emphasized the importance of a healthy environment for maintaining optimum health.

HEALTH EFFECTS OF DISASTERS Disasters affect community and population in many different ways. The health effects of the disaster may be extensive and broad in their distribution across, population. In addition to causing illness and injury, disasters disrupt access to primary care & preventive services. Depending upon the nature and location of disaster, its effects on short and long term health of a population may be difficult to measure. Disasters may cause premature deaths, illnesses and injuries in the affected community, generally exceeding the capacity of the local health care system. Disasters may destroy the local health care infrastructure, which will therefore be unable to respond to the emergency. Disruption of routine health care service and prevention initiatives may lead to long term consequences in health outcomes in terms of increased morbidity & mortality.

Disasters may create environmental imbalances, increasing the risk of communicable diseases and environmental hazards. Disasters may affect the psychological, emotional and social well being of the population in the affected community. Disasters may cause shortages of food and cause severe nutritional deficiencies. Disasters may cause large population movements creating a burden on other health care systems & communities PHASES OF DISASTER There are 3 phases to any disaster Pre impact phase The Pre impact phase is the initial phase of the disaster, prior to the actual occurrence. A warning is given at the sign of the first possible danger to a community. Many times there is no warning, but with the aid of weather networks and satellites, many meteorological disasters can be predicted. The earliest possible warning is crucial in preventing loss of life and minimizing damage. The community must be educated to recognize the threat as serious when communities experience false alarms several times members may not take future warnings very seriously. The role of the nurse during this phase is to assist in preparing shelters and emergency aid stations and establishing contact with other emergency service groups.

Impact phase The impact phase occurs when the disaster actually happens. It is a time of enduring hardship or injury and of trying to service. The impact phase may last for several minutes. This phase must provide for preliminary assessment of nature, extend and geographical area of the disaster. The number of persons requiring shelter, the type and number of needed disaster health services anticipated and the general health status and needs of the community must be evaluated. The impact phase continues until the threat of further destruction has passed and the emergency plan is in effect.

Post impact phase Recovery begins during the emergency phase and ends with the return of normal community order and functioning. For persons in the impact area this phase may last a life time. (eg. Victims of the atomic bombing of Hiroshima). The 4 phases of a communitys relation to disaster are as follows: Heroic phase This phase appears at the time of the disaster and is characterized by people working together to save each other and their property. Honeymoon phase This is a relatively short (2 wk 2 month) post disaster period in which the victims feel buoyed and supported by the promises of governmental and communal help and see an opportunity to reconstitute quickly. Reconstruction phase This phase may last for several years. It is characterized by a co-ordinated individual community effort to rebuild and reestablish normal functioning. VICTIMS REACTION TO DISASTER 1. Denial During the first stage, the victim may deny the magnitude of the problem or, more likely, will understand the problem but may seem unaffected emotionally. 2. Strong emotional response In this stage, the person is aware of the problem that but regards it as over whelming and unbearable. Common reactions during this stage are trembling, tightening of the muscles, sweating, speaking with difficulty, weeping, heightened sensitivity, restlessness, sadness, anger and passivity. 3. Acceptance

During the 3rd stage, the victim begins to accept the problems caused by the disaster and makes a concentrated effort to solve them. 4. Recover 4th stage represents a recovery from the crisis reaction. Victim feels that they are back to normal. Routines are established. A sense of well-being is restored.

DISASTER MANAGEMENT
The primary goals of Disaster management are to: Prevent or minimize death disability, suffering & loss on the part of disaster victims. PRINCIPLES OF DISASTER MANAGEMENT There are 8 fundamental principles that should be followed by all who have a responsibility for helping the victims of a disaster. 1. Prevent the occurrence of the disaster whenever possible. 2. Minimize the number of causalities if the disaster cannot be prevented. 3. Prevent further casualties from occurring after the initial impact of the disaster. 4. Rescue the victims 5. Provide first aid to the injured
6. Evacuate the injured to medical facilities

7. Provide definitive medical care 8. Promote reconstruction of lives The first two actions are designed to control or mitigate the results of the disaster and have already been addressed. Preventing further casualties after initial impact depends on evaluating and lessening any unsafe conditions present after the disaster. Rescue involves locating and freeing trapped victims and then evaluating them to a safe place. An effective rescue and evaluation term with good leadership skills is essential for saving life after a disaster. First aid must be provided to victims with life threatening injuries to prevent death. Evacuation or victims must be done in an orderly but timely fashion. Many factors will affect evacuation and they are availability of transport vehicles, condition of roads leading to advanced care facilities, time between disaster impact and arrival at hospital.

Provision of definitive medical care depends on an existing disaster plan and adequately trained disaster personnel. Hospitals must have well -honed disaster plans to meet the needs of large groups of victims in a short time. Reconstruction of the victims life begins with initial care and continues until the victim has recovered. This may take days, months or years. This is a slow and long term phase. It aims at getting the community/ Victim back in to the groove.

Disaster management can be divided into 3 phases.


Disaster response Disaster Preparedness Disaster Mitigations The 3 aspects of the disaster management correspond to different phases in the disaster cycle.
Risk reduction phase

Before a disaster

Preparedness

Disaster Impact

Response Mitigation Rehabilitation

Reconstruction

Recovery phase after a disaster DISASTER CYCLE 1) DISASTER IMPACT AND RESPONSE

It is the immediate response once the disaster strikes. A number of causalities may be seen immediately after an disaster Thus immediate care is needed at this phase. The management of mass causalities include following steps Search & rescue First aid Field care
Triage and hospitalization of victims

Tagging Identification of dead Relief phase Disease control Nutrition Rehabilitation

Search, Rescue and first aid

After a major disaster the need for search, rescue and first aid is likely to be so great that organized relief services will be able to meet only a small fraction of the demand. Most immediate help comes from the uninjured survivors

Field care

Most injured persons converge to health facilities using whatever transport is available, regardless of the facilities operating status. Proper care to casualties requires that the health services resources to be redirected to this new priority Bed availability and surgical services should be maximized. Provision for food & shelter should be provided.

Triage

Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelihood of their survival with prompt medical intervention. It is the most important step in planning for management of mass causalities.

Aim of triage is: (a) To identify priority cases (b) To organize, streamline case management (c) To minimize complication and save limbs and organ (d) To utilize resources effectively. Sorting is done on the site or disaster itself. The most common classification uses the internationally accepted four color code system. 1. Red (Priority I) : High priority This group consist or patients requiring immediate care. They need short procedures to save life. This group is likely to constitute 20% of total causalities. The following cases are given highest priority: (a) Rapidly correctable mechanical respiratory defects. (b) Serious crush injuries involving extremities (c) Incomplete amputations (d) Severe lacerations and compound feature
(e) Involvement of upper respiratory tract necessitating tracheotomy. (f) Hemorrhage from easily accessible site

2. Yellow( priority II) : Medium priority

This group also consists of 20% of total causalities. This group includes: (a) Moderate laceration with extensive bleeding (b) Simple closed fracture of major bones
(c) 2nd degree burns of 10-15% body surface

(d) Non critical C.N.S injuries

3. Green (priority III) : ambulatory patients This group include patients whose treatment could be delayed. They would require technically complicated & time consuming procedures. Treatment would basically consist of

resuscitation and emergent medical treatment. This group also consists of 20% of total injured. This include (a) Critical injures of CNS and respiratory tract. (b) Penetrating abdominal injuries
4. Black (Priority iv) : Patient requiring minimum treatment

This group would constitute up to 40% of total injured .these causalities require minor treatment and when first seen and dispatched to minimal treatment facility area. Tagging All patents should be identified with tags stating their name, age, place of origin, triage, category, diagnosis and initial treatment.

Identification of dead Taking care of dead is an essential part of disaster management. Care of dead include Removal of dead from the deserter scene Shifting to the mortuary. Identification Reception of bereaved relatives

The health hazards associated with cadavers are minimal if death results from trauma and if corps are contaminating streams, wells or other sources as in flood etc they may transmit gastroenteritis, food poisoning etc.

Relief phase This phase begin when assistance from outside starts to reach the disaster area. The type and quantity of humanitarian relief supplies are usually determined by The type of quantity of supplies Type and quantity of supplies available locally. Immediately following a disaster the most critical health supplies are those needed for treating causalities and preventing the spread of communicable disease. Following initial

emergency phase the needed supplies include food, blanket, clothings, shelters, sanitary engineering equipment and nonstructural material. Disaster managers must be prepared to receive large quantities of donations. There are 4 prenatal components in managing humanitarian supplies. (a) Acquisition of supplies (b) Transportation (c) Storage (d) Distribution Disease control Disaster can increase the transmission of communicable disease through

Overcrowding and poor sanitation in temporary resettlements. Population displacement may lead to introduction of communicable diseases. Disruption and contamination of water supply and damage to sewage system and

power system are common in natural disasters.


Disruption of routine control programmes Ecological changes may favour breeding of vectors and lead to vector borne

diseases.

Displacement of domestic and wild animals that carry with them zoonoses that

can be transmitted to humans as well as to other animals. Provision of emergency food, water and shelter in disaster situation from

different or new sources may itself so a source of infectious disease.

The principles of preventing and controlling communicable disease are (a) Implement as soon as possible all public health measures to reduce the risk of disease transmission. (b) Organize a reliable disease reporting system. (c) Investigate full reports of disease outbreak. Supply of safe drinking water and proper disposal of concreter continue to be the most practical method of disease prevention.

Nutrition A natural disaster may affect nutritional status of the population by affecting one or more components of food chain. Infants, children, pregnant women, nursing mothers and sick persons are more prone to nutritional problems. The immediate steps for ensuring food relief are:a) Assessing the food supplies after the disaster b) Gauging the nutritional needs of the affected population. c) Calculating daily food rations and need for large population groups. d) Monitoring the nutritional status of the affected population. Rehabilitation The final phase in a disaster should lead to restoration of predisaster conditions. Rehabilitation starts from the very first moment of a disaster. In first weeks after disaster the pattern of health needs will change rapidly, moving from causality treatment to more routine primary health care. Priorities also will shift from health care towards environmental health measures.

Water supply The first priority of ensuring water quality in emergency situation is chlorination. The existing and new water sources require protection measures like. 1) Restrict access to people and animals. 2) Ensure adequate excreta disposal at a safe distance from water source. 3) Prohibit bathing, washing and animal husbandry near water sources. 4) Upgrade wells 5) Estimate maximum yield of wells

Food safety Paw hygiene is the major cause of food borne diseases. Kitchen sanitation and personal hygiene should be monitored.
Basic sanitation and personal hygiene.

Many communicable diseases are spread through fecal contamination of drinking water and food. Hence ensure sanitary disposal of excreta. Emergency latrine should be made available. Washing, cleaning and bathing facilities should be provided.
Vector control

Control programme for vector borne disease should be intensified in the emergency and rehabilitation period.

2) DISASTER PREPAREDNESS It is a programme of long term development activities whose goals are to strengthen the overall capacity and capability of a country to manage effectively all types of emergency, bring about an orderly transition from relief through recovery and back to sustained development. The objective of disaster preparedness is to ensure that appropriate systems, procedures and resources are in place to provide prompt and effective assistance to disaster victims, thus facilitating relief measures and rehabilitation of services.

The reason for community preparedness is: Members of community have the most to lose from being vulnerable to disasters

and the most to gain from effective and appropriate disaster management programmes. Resources are most easily pooled at community level and every community

possesses capabilities. Those who first respond to disaster come from the same community and so they

can manage situation effectively.


Sustained development is best achieved by allowing emergency affected communities to

design manage and implement internal & external assistance programs.

3) DISASTER MITIGATION Disaster mitigation involves measures designed either to prevent hazards or to lessen the likely effects of disaster. These measures include flood mitigation works, appropriate land using techniques and protection of vulnerable population and structures. E.g.: improving the structural quality of houses, schools and other public and private buildings.

ROLE OF VOLUNTARY AGENCY IN DISASTER MANAGEMENT


The role of voluntary agencies can be divided as (a) Community Awareness Through community awareness programmes community becomes more informed, alert, self reliant and capable of participating in all activities of disaster management. Some important means of creating community awareness are:i.
ii.

Short films and folk songs Posters, cartoons, charts and photographs Training camps Street plays Educating children of schools of colleges Special known persons of the area.

iii. iv. v. vi.

vii. Group discussions viii. Media and press (b) Ensuring community participation The voluntary agencies can ensure community participation by helping the community in:a. Systematic identification of problems b. Soliciting innovative ideas c. Creating a sense of belonging d. Better utilization of local resources. e. Providing faster communication f. Effective & speedy monitoring g. Being cost effectives h. By involvement of all classes in the local community.

(c) Co-ordination with community The disaster preparedness programme would require the government agencies, volunteer groups or NGOs from outside and local NGOs to co-ordinate among themselves as well

as the community. There is a greater need for co-ordination, regarding mitigation actions, research, resource mobilization and utilization and networking among various factors involved in disaster management at local and outside levels. NGOs and CBOs are for more acceptable and effective at the grass root level than government. In times of disaster, they can exercise first aid; search and rescue operations promptly and efficiently compared to the government agencies. On the other hand, the Government has more resources, equipment and transport required to implement these activities. Thus there is a felt need & or an affective co-ordination between manpower and organizing capability of NGOs, and resources and initiatives of the Government.

(d) Identifying needs of the community The needs of the community in respect to disaster management are divided into three phases viz. pre-disaster, during disaster and post disaster. Community needs: Pre disaster (1) (2) (3) (4) (5) (6) (7) (8)
(9)

Hazard analysis Risk analysis Vulnerability analysis Resource analysis Communication Storage of essential items Health facilities Construction of shelter for victims Evacuation plans Emergency operation centre Disaster task force Education in schools Enforcement of rules and regulations Strengthening of building

(10) (11) (12)


(13)

(14)

Community needs: During disaster Search, Rescue, Evaluation, Treating & taking care of victims, shelter, food, communication, water and power supplies, health & sanitation, public information, security.

Community needs: Post disaster


- Quick damage assessment, need assessment, repair of houses, reconstruction, economic

rehabilitation, social rehabilitation, compensation including insurance, immediate rehabilitation measures for agriculture, strengthening of all disaster resources, public awareness. (e) Advocacy Along with relief the victims needs advocacy for better preparedness, increasing self help capacity and developing own coping mechanism by the community. Thus there is an urgent need for generating and sustaining community awareness on disaster.

ROLE OF A NURSE IN DISASTER MANAGEMENT Disaster nursing refers to nursing services offered to victims of disaster who experience trauma caused by disaster. The overall goal of disaster nursing is to achieve the best possible level of health for the people and community involved in disaster. The community health nurse has a pivot role in (i) Preventing disaster (ii) Preparing people to accept and to respond positively to any kind of disaster. (iii)Support people to recover from disaster situation The nurse in the disaster team has an important role in dealing with psychosocial problems of victims and there by prevents stress and promotes mental health. Initially she has to assess any physical problems and to treat them appropriately. Assessment Nurses need assess the victims who are at high risk for developing mental disturbances and their need for crisis intervention as follows. Those victims who have lost their home or possession, who have lost one or more family members, who have suffered serious injuries Victims with history of psychiatric disorder. Those who do not have adequate support systems.
Elderly people.

Planning It includes Personal preparation Rescue and recovery of victim triage. Immediate treatment and support of victims and families Identifying dead bodies.

INTERVENTIONS General interventions Keep families together, especially children & families
Provide adequate shelter, food & rest Promote awareness of what has happened.

Assist the person to establish contact with relatives or friends. Encourage individuals to share their feelings and support each other Give information about social financial health and other resources. Establish and maintain a communication network.

Specific intervention. Vitamin A supplement Immunization & preventive health Safe drinking water supply Sanitation and waste disposal In addition to these mental health services to disaster victims include Education about coping strategies Crisis intervention Problem solving counseling

EMERGENCY SUPPORT SERVICES


# # # # # # # # # Transportation Communications Fire fighting Mass care Resource support Health and medical services Hazardous materials Food Energy Among these most important emergency support service unit is health and medical services, which provides co-ordinated federal assistance to communities following a major disease or emergency the purpose of this unit is Health assessment and surveillance Medical supplies Victim evacuation Mental health care Vector control Victim identification Mortuary services Medical care personnel Food / drug personnel In hospital care

Health Assessment and Surveillance Assist in establishing surveillance systems to monitor the general population and special high risk population segments; carry out field studies and investigations, monitor injury and disease patterns and potential disease out breaks and provide technical assistance and consultation on disease and injury prevention and precautions.

Disaster Medical Assistance Team They assist in providing care for ill or injured victims at the location of a disaster or emergency.

Medical Equipment and Supplies Provide health and medical equipment and supplies, including pharmaceuticals, biologic products and blood & blood products in an area affected by a major disaster or emergency.

Victim Evacuation Provide for movement of seriously ill or injured patients from the area affected by a major disaster or emergency to locations, where definitive medical care is available. Hazards Consultation Assist in assessing health and medical effects of radiological chemical and biological exposure on the general population and on high risk population groups; conduct field investigation, including collection and analysis of relevant samples

Mental Health Care Assist in assessing mental health needs; provide disaster mental health training materials for disaster workers and provide liaison with assessment, training and program development activities.

Victor Control Assist in assessing the threat of vector borne diseases following a major disaster or emergency. Provide victor control equipments and supplies technical assistance and consultation on protective actions regarding vector borne diseases. Victim Identification / Mortuary Services Assist in providing victim identification and mortuary services, including temporary morgue facilities, victim identification by fingerprint, forensic dental & or forensic pathology / anthropology methods & processing, preparation, disposition of remains. Food/Drug Safety

Ensure safety and efficacy of regulated foods, drugs, biologic products and medical devices following a major disaster or emergency.

Public Health Information Assist by providing public health and disease and injury prevention information that can be transmitted to members of the general public who are located in or near areas affected by a major disaster.

In Hospital Care Provide definitive medical care to victims who become seriously ill or injured as a result of a major disaster or emergency.

CONCLUSION
Disaster may be sudden as slow onset in disaster, damage to community is on large scale. It may be loss of lives economic loss that disrupt the existing infrastructure of that community or it may threaten the future existence and survival of the community. Disasters can occur anywhere at any time, not related to development of the community. REFERENCE
1. B.T Basavanthappa, Text book of community health nursing. (2008) Jaypee brothers

New Delhi.
2. T. Bhaskara Rao Text book of community medicine. (2006) paras. New Delhi. 3. K. Park Textbook of preventive & social medicine (2005) Bhanot.

4. Tener Goodwin veenema, Disaster nursing (2006). Springs New York.


5. Indian journal of holistic nursing. vol (4) no June 2008. 6. http://www.stonybrookmedicalcentre.orgl.

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