A child ingested 15 Paracetamol tablets 45 minutes back and is attended by a nursing staff in emergency. Which of the following orders should nursing do first?

1. A

   Gastric lavage

2. B

   Monitor pulse and blood pressure

3. C

   Start IV line

4. D

   Use acetyl cysteine (Antidote)

Appeared in: NHM MP Staff Nurse - 2015

Explanation

• The child presented 45 minutes after ingestion, which is within the critical one-hour window for effective gastric decontamination.
• The immediate priority in a potentially toxic ingestion is to prevent or reduce the absorption of the poison from the gastrointestinal tract.
• Gastric lavage is a method of decontamination that physically removes the unabsorbed tablets from the stomach, thereby reducing the overall toxic load on the body.
• Performing decontamination first is more effective than immediately starting the antidote, as it minimizes the amount of poison the body has to metabolize.

Why Other Options Were Wrong

• Option B: This is a continuous nursing assessment, not a single, primary therapeutic intervention. While vital signs monitoring is essential throughout the patient's care, it does not take precedence over the time-sensitive action of decontamination.
• Option C: Starting an IV line is a preparatory step for administering fluids and the antidote (N-acetylcysteine). However, it should not delay the more urgent, time-critical intervention of gastric decontamination when the patient presents within the first hour.
• Option D: N-acetylcysteine (NAC) is the antidote that treats the absorbed paracetamol. The first priority is to prevent absorption. Decontamination (lavage) must be done first to be effective. NAC administration follows decontamination.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Priority of nursing interventions in acute paracetamol toxicity in acute care settings.
• A nurse's first action in any poisoning case is to assess Airway, Breathing, and Circulation (ABCs), followed by obtaining a precise history, including the substance, amount, and exact time of ingestion.
• The time of ingestion is the most critical piece of information that guides the entire management plan for paracetamol overdose, determining whether decontamination is viable or if immediate antidote therapy is needed.
• What if the child had ingested the tablets 4 hours ago? In that case, gastric lavage would be ineffective and contraindicated. The first priority would be to start an IV line, draw blood for a paracetamol level, and prepare to administer N-acetylcysteine based on the results.

How to Approach the Question

• First, identify the question type: it's a priority question, asking what the nurse should do 'first'.
• Next, analyze the clinical scenario for key information: the substance (Paracetamol), the amount (15 tablets - a potentially toxic dose for a child), and the time since ingestion (45 minutes).
• The time '45 minutes' is the most critical clue. Recall the principles of toxicology management. Interventions performed within the first hour are aimed at preventing absorption (decontamination).
• Evaluate the options in this context: Gastric lavage is a decontamination method. Starting an IV and giving an antidote are treatments for an absorbed poison. Monitoring is an assessment.
• Conclude that since the patient is within the 1-hour window, preventing further absorption is the highest priority. Therefore, gastric lavage is the correct first action.

Concept Tested & Keywords

• Concept Tested: Priority of nursing interventions in acute paracetamol toxicity.
• Stem keywords: child, ingested, Paracetamol, 45 minutes, emergency
• Lead-in keywords: do first
• Clinical cues: Time of ingestion: 45 minutes ago (within the critical 1-hour window for gastric decontamination)

Question ID

QObTfENXo7jUuRG0uw9j-s

Copy ID

Reference Book

E6 Medicine Davidson Principles Practice 24e p. 158-160

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 752-754