ADDIS ABABA UNIVERSITY

HEALTH SCIENCE COLLEGE, SCHOOL OF MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE

Title

Assessment of knowledge and practice of nurses’ on initial management of acute

poisoning at adult emergency department of two Public hospitals in Hawassa town,
Hawassa, southern Ethiopia.

By Tamiru Beyene (BSc)

A Thesis to be submitted to school of graduate studies of Addis Ababa University,

department of emergency medicine and critical care in partial fulfillment of the
requirement for the degree of masters in emergency medicine and critical care
nursing.

Advisors: Dr. Sofia Kebede(MD,Assisstant prof.& Em physcian)

: Mr. Asmamaw Abebe(Bsc,MSc in EM&CCN)

June 2017

Addis Ababa, Ethiopia

 Declaration

I the under signed declared that this thesis is my original work ,has not been presented for
degree in this or any other university and that all sources of material used for the thesis have
been fully acknowledged.

Name of the student: Tamiru Beyene

Date.____________________ Signature _________________

This thesis has been submitted for examination with our approval as university Advisors.

Approval of primary Advisors.

Name of the primary advisors:

1. Dr.Sofia Kebede 2. Mr.Asmamaw Abebe

Date.__________ Signature _________ Date--------------- Signature------------------

Name of examiner

1. DR. Assefu W/Tsadik (MD,Anesthesiologist) Signature___________

I
Abstract
Background: Poisoning is a major health problem worldwide, and it causes significant
morbidity and mortality. It is estimated that 350,000 people died worldwide from unintentional
poisoning. As acute poisoning is common reason for visits to emergency departments and for
hospitalization worldwide, it is essential that all ED nurses should be familiar with the clinical priorities
in life-threatening situations in order to ensure that problems are identified and treated accordingly.
Objective: To determine the nurses’ knowledge and practice on the initial management of acute
poisoning among adult casualties seen at emergency department of Adare District Hospital(ADH)&
Hawassa University Referral Hospital(HURH),Hawassa.

Methodology: Institution based cross sectional descriptive study that employs both qualitative and
quantitative methods of data collection was employed on all nurses working at emergency
department of Adare District Hospital & Hawassa University Referral Hospital.

Result: There were 67 nurses working at ED of both hospitals from which 63(94%) participated
in the study. All ED nurses that participated in this study had unsatisfactory knowledge <75%
(mean knowledge 61.50%) and practice level(mean practice 65.50%). The majority 58(92.10%)
of ED nurses required training related to emergency and poisoning management.

Conclusion All ED nurses that participated in this study had unsatisfactory general knowledge

on poisoning, knowledge on initial management of acute poisoning and practice

.Recommendation: there Should be various type of emergency related training that focusing on

poisoning management, IEMM etc that help in assessment diagnosis and management of

casualties at ED by nurses.

II
 Acknowledgement

Above all, I would like to give thanks and glory to my LORD JESUS CHRIST who gave
me the courage to pursue my study and also who provide me everything through my study.

My special gratitude and appreciation goes to my advisors Dr. Sofia Kebede and Mr. Asmamaw
Abebe for their encouragement, provision of important and constructive guidance from the
beginning of my proposal development.

I would like to express my heartfelt gratitude to Addis Ababa University giving me this
educative and golden opportunity and provision of financial support for this study; and also
department of emergency medicine and critical care for the support and follow up throughout
the whole course.

I would like to express my great thank to both Hawassa University Comprehensive referral
hospital and Adare District hospital, both hospital staffs and all study participants who gave me
their time and valuable data for this study.

Lastly my great thanks goes to my beloved wife Salamawit Thomas for her support in all aspects
of my study and life

III
 Table of contents
Title Page
1. Abstract …………………………………………………………………………..…II
2. Acknowledgement………………………………………………………………...…III
3. Table of contents …………………………………...……………………….…….....IV
4. List of tables and figures……..……………………………………………………....VI
5. Abbreviations and Acronym…………..……………………………………………..VII
6. Chapter 1: Introduction…….…………………………….…….…………………....;1
1.1. Background………………………………………….………….…………..….....1
1.2. Statement of the problem…………………………….……..……...……………..2
1.3. Significance of the study……………………………………………………........4
7. Chapter 2: Literature Review…………………………….………….…...……......….6
2.1. Incidence ................................................................................................................6
2.2.1. Incidence of drug poisoning death………..….……………..……….….....…....6
2.2.2.Signs and symptoms of acute poisoning…………………………….…………..7
2.2.3 General management of poisoning………………………………………….…...8
2.2.4. Management of poisoning at ED by nurses………………….............................9
2.2.5. Literature on knowledge of nurses…………………..………..….…….……....10
2.2.6. Literature on practice of nurses……..…….…….……….….…….….………...12
7. Chapter 3: Objective of the study……………………..……….……….….….……...13
3.1 General objective ………………………………..….……….…….….……13
3.2 Specific objectives………………………………………….….…….….………...13
8. Chapter 4: Methods and Materials……….….…..………………….…….....………..14
4.1. 4.3 study area and period .……………………….………….………...…………14
4.2 Study design………………………………………..………………….….……...14
4.3. Source population…………………………………….……………….…………14
4.4. Study population ………………………………………………………………...10
4.5 Sample size determination and sampling technique…………..……….…..…......10
4.6. Subjects inclusion and exclusion criteria………….……………………...……...15
4.6.1 Subjects inclusion criteria……………………………..……………….…….....15
4.6.2.subjects exclusion criteria…………….……..……………………….…………15
4.7. Study variables……………………………….…………………………...……...15
4.8. Data collection ………………..………………………………………...….……16
4.8.1. Study tools ……………………………………………………………….........16
4.8.2. Data collector training …………………………………………………….…..16
4.8.3.pre-testing…………………………………………………….…………….......16
4.8.4. Data collection method…………………………………………..……..….…..16
4.8.5. Organisation of questionnaire………………………………………….......…..16

IV
 4.8.6.Organisation of checklists………….…………………….….…….….…………16
4.9. Data management..…………………………………………….…...………..…....16
4.9.1. Data Quality control..……………………………………..……..….……..........16
4.9.2. Data analysis………..……………………………………………….……….….17
4.9.3.Data presentation…….……………………………………………….……….....17
4.10. Operational Definition………………………………………………….…....….17
4.11. Ethical Consideration………………………………………………………...….18
4.12. Dissemination plan……………………………………………………......……..18
9. Chapter .5………….……………………………………………………...…..…..…...19
5.1. Results…………………………………………………………………………....19
5.1.1. Socio-demographic characteristics of ED nurses…………………………….....19
5.1.2. ED experience and post qualification training among nurses……...………...…20
5.1.3. General knowledge of ED nurses on poisoning….……………………..….......21
5.1.4. professional qualification versus general knowledge of ED nurses on poisoning22
5.1.5.Nurses’ length of experience versus general knowledge on poisoning…………. 23
5.1.6. ED nurses response on initial management of poisoning.…………………….....24
5.1.7. ED nurses’ professional qualification versus knowledge on initial
management of acute poisoning practice……………………………………......25
5.1.8. Self reported nursing practice…………………………..,……………………....25
5.1.9. Assessment of ED nurses on the management of acute poisoning practice….... 27
5.1.10. Drugs used in management of poisoned casualties………………..……….…..29
5.1.11. Gut decontamination practice………………………………………….........….29
5.2. Discussion……………………………………………………………….….......….30
5.2.8.Strength and limitations of the study……………………………………......…...35
5.3. Conclusion……………………………………………………………...…...…….36
5.4. Recommendation…………………………………………………….……...…….36
10. References………………………………………………………………………...…...37
11.Annexes
I. Consent form…………………………………………………………..41
II. Research questionnaire…………………………………………….…42

V
 List of tables and figures
1. 1 Socio-demographic characteristics of ED nurses…………………..19
2. 2 ED experience and post qualification training among ED nurses….20
3. 3 Nurses’ general knowledge on poisoning………………………. …21
4. 4 Professional qualification versus general knowledge on poisoning..22
5. 5 Nurses’ length of experience versus general knowledge on
poisoning…………………………………………………………..….23
6. 6 Ed nurses response on initial management of poisoning…….….…24
7. 7 ED nurses profession qualification versus knowledge on initial
management of acute poisoning practice………..…………….……..25
8. 8 Drugs used by ED nurses to manage acute poisoning……....……..29
9. 9 GI decontamination…………………………………….…….....….29

List of figures
1. 1.Conceptual framework………………………………………....…..5
2. 2.Nursing practice self repot……………...………………………….26
3. 3.Management of ABCD of poisoned casualty by ED nurses….........28

VI
List of abbreviations and acronyms
 ABC- Airway, Breathing and Circulation
 ADH- Adare district Hospital
 AVPU-Alert, Responsive to voice, Responsive to pain, Unconscious
 ED- Emergency Department
 BLS- Basic Life Support
 BSc- Bachelor of Science
 ERC- Ethics and Research Committee
 EM&CCN-Emergency medicine and critical care nursing
 FMOH-Federal Ministry of Health
 IEMM- Integrated Emergency Medical Management
 HURH- Hawassa University referral Hospital
 MOH-Ministry of Health
 MScN- Masters of Science in Nursing
 SPSS- Statistical Package of Social Science
 WHO- World Health Organization
 GCS- Glasgow Coma Scale
 GIT – Gastro-intestinal tract

VII
 Chapter one
Introduction
1.1Background
The word poison originates from the Latin word Potionem which means deadly draught. The
Herald of modern Toxicology, Paracelsus, states that everything is poison and only the dose
plays a pivotal role (1). Any substance when ingested in large quantities can be toxic (2).
Poison may be defined as any agent that can injure, kill or impair normal physiological function
in humans producing general or local damage or dysfunction in the body by its chemical activity
(3).
Poisoning occurs by the absorption of chemicals (poisonous) substances into the body through
the GI tract, skin, respiratory tract or parentally causing damage to the body cells (4).

According to Dorland’s Medical Dictionary, poisons are substances that can cause damage to
organisms, usually by chemical reaction on the molecular scale [5 ].
Poisoning is a major health problem worldwide, and it causes significant morbidity and
mortality.

Worldwide, poisonings account for 5-10% of all interventions ( 6). According to WHO more
than three million poisoning with 251,881 deaths occur worldwide annually of which, 99% of the
death occur in developing countries (3).
In developed countries, it has been shown that the leading cause for visit to the emergency
department among patient aged 2 to 30 years is acute poisoning, whereas in developing
countries, it is the second most common cause following infectious disease ( 7).

It is estimated that 350,000 people died worldwide from unintentional poisoning in 2002 [8,9 ].
It is believed that between 7,50,000-30,00,000 Organo-Phosphate poisoning cases occur globally
every year. Mortality is higher in the developing countries where Organo-Phosphate pesticides
are readily available and may be misused for suicide. They are estimated to cause 3,00,000
fatalities annually ( 10).
1
In Singapore, injuries(including poisoning) ranked as the fifth leading cause of death and the
leading cause of hospitalization from 2007 to 2009. The pattern of poisoning has changed as the
public is encountered with other new drugs and chemicals. New antidotes have also been
developed for the management of such poisoning, and are now available for management of
casualties [9 ].
WHO, of all case fatalities due to acute poisoning, Africa accounts 8% and Kenya 3.13% in
2015[11].
Few studies exist in Ethiopia that showed the greatest proportion of poisonings occurred in
adults(below 30 years of age) and the most frequent circumstance was intentional poisoning.
Organophosphate pesticide was the leading cause of poisoning. The case fatality rate was
reported from 2.4%-8.6%[12].

Acute poisoning can be defined as exposure to a poison on one occasion or in a short period of
time [13]. Acute poisoning is one of a life threatening conditions therefore, critical care and
emergency nurses play important roles in the care and management of patients with acute
poisoning that consists of four elements: initial life support, decontamination, in some cases
antidotal administration and enhanced elimination. The initial life support consists of airway
management and correction of circulatory status. Protecting the airway is essential in order to
prevent aspiration and respiratory depression due to lowered level of consciousness. Arrhythmias
and hemodynamic compromises are corrected and managed as similar to any patient in critical
condition [14].

1.2 Statement of problem

Acute poisoning is a common reason to come to emergency departments and for hospitalization
worldwide and a cause of both morbidity and mortality in many parts of the world. The toxic
agents associated with the morbidity and mortality varies from one area to other due to the
availability and use of various chemicals (13).
Globally it is estimated that poisoning events are responsible for more than one million illnesses
annually [11].
2
Acute drug poisonings account for nearly one half of all poisonings reported [15].
One half million people die each year as a result of various kinds of poisoning [16].

In Egypt statistical data in 2013, it showed that the percentages of patients who were admitted
for Acute Drug Poisoning was 51% , 53% and 54.9% in the year 2011,2012 and 2013
respectively.

WHO reported that acute poising accounts 0.5% of intentional and unintentional injuries in
Ethiopia, in 2012 (17).
The case fatality rate was reported from 2.4%-8.6%[12].

Majority of these patients present in ED for their initial treatment. Their treatment poses
numerous clinical challenges where severely poisoned patients can be medically unstable and
require resuscitation, specific treatment, close observation and monitoring.
ED is an important access point for these clients who might be in dire need for emergent life-
saving interventions. Further, they found out that without focused skills training and deeper
understanding of the complexity of self-harm and therapeutic responses of emergency clinicians;
nurses are likely to provide inadequate emergency care for this type of patients.

ED nurses are frequently the first health care professionals to come in contact with patients who
have ingested poisons. Proper initial assessment, evaluation and treatment are very essential for
patient survival. It is essential that all ED nurses are familiar with the clinical priorities in life -
threatening situations in order to ensure that problems are identified and treated accordingly.
Poisoning is a common cause of mortality and morbidity around the world, with several
million incidences reported annually.

Therefore, ED nurses should be equipped with professional knowledge and skills that enables
them to manage poisoned patient accordingly.

3
1.3 Significance of the study
In Ethiopia currently there is increasing incidences of acute poisoning which range from
ingestion of home cleansing bleach, illicit brews consumption and use of uncertified herbal
medicine for treatments and unsafe abortion. ED nurses are often at the forefront when it comes
to this initial and critical assessment of poisoned casualties.
Their knowledge and skills are fundamental to their practice and influence the overall patient
outcome.
There is no study of the same that has been done in ADARE district hospital as well as HURH;
specifically being the largest referral hospital in Southern region of Ethiopia. The findings of the
study therefore will be valuable in understanding the capabilities of ED nurses in management of
these patients.
Furthermore, the study will form a basis for improving the quality of service delivery in
management of poisoned casualties at ED by nurses as a whole in Ethiopia.

4
Conceptual Framework
Individual nurses and situational factors (Independent variables) such as nursing professional
qualification, ED experience and social demographic characteristics could enhance nurses’ skills
and practices on the initial management of acute poisoned casualties (dependent variables).
Attaining the desired goals is indirectly influenced by ED resources, staff motivation and
hospital policy (confounding variables). The relationships between the various variable are
summarized in Figure 1.1
Independent variable dependent variable

-Age

-Sex i-Knowledge

-Professional qualification ii-Practice

-Experience of nurses

-Training

Staffing

Institutional policy

Availability of materials

Work environment

Confounding variables
Fig.1. Conceptual frame work, partially adapted from Rutto’s study with important modifications
5
 Chapter two
Literature review

2.1. Incidence of hospitalizations

The global prevalence of acute poisoning especially in the developed nations reported as
decreased. Not all contacts with the health care system due to acute poisoning lead to hospital
admission. The proportion of patients treated by ambulance service or solely on emergency
departments varies, depending on the area, from 20% to 80%. [16,22].
Acute drug poisonings account for between 0.7 and 15% of all emergency department
admissions in different locations [16,24]. Intensive care is required in 3.7–40% of patients
hospitalized due to drug poisoning. The highest rates of intensive care are in the Nordic
countries, with the highest rate, 40%, in Oslo, Norway.
In Finland, approximately 10% of the patients admitted to hospital from the emergency
department due to acute poisoning required intensive care[24,25]. Approximately 5.2% of all
ICU admissions in Finland are due to acute drug poisoning [26]. The incidence of hospital
admissions due to drug poisonings in the Nordic countries is reported to be 2–2.5/1000
inhabitants per year.[22,24].
It has been reported that 50–60% of patients admitted to hospital due to acute drug poisonings are female
[23,26,28]. .
2.2. Incidence of drug poisoning deaths
The overall incidence of poisoning-related deaths in Finland in 2002 was16.6/100 000
inhabitants, which is approximately 50% higher than in the other Nordic Countries or the United
Kingdom [24,28]. In Finland, the incidence of non-alcohol poisoning deaths was 6.8 in males
and 3.2 in females per 100 000 inhabitants per year in 2005. None alcohol poisonings are the
sixth commonest cause of death and the rate has increased over the last 30 years [25,26]. Most of
the deaths from acute drug poisoning occur outside the hospital environment. [27].

The reported incidences of poisoning-related deaths are 15.6/100,000 inhabitants per year in the
United States [14], and there has been an increase in incidents over the years, especially due to
opioid toxicity [14,31,32].Most deaths are due to accidental poisonings and occur most often
among people aged 30 or over [14]. 6
WHO, of all case fatalities due to acute poisoning, Africa accounts 8% and Kenya 3.13% in
2015[11].
The case fatality rate in Ethiopia was reported from 2.4%-8.6%[12].

2.3. Signs and symptoms of acute poisoning

In most cases patients are able to tell what they have taken and symptoms have little diagnostic
value. Many poison affect multiple body systems and symptoms are frequently numerous and
non specific. Some of the signs and symptoms are listed in Table 2.1 below.

Alimentary signs Pain and ulceration of the oral cavity,

salivation, dry mouth, nausea and vomiting,
abdominal pain and diarrhea
Cerebral and neuromuscular signs Staggering and dizziness, coma, convulsions,
delirium and hallucination, restlessness
Respiratory signs Cyanosis, hypoventilation, coughing,
wheezing, breathlessness, distress, broncho-
spasm.
Cardiovascular features Loss of pulse, tachycardia and bradycardia,
and hypotension
Skin Purpura, sweating, sting or injection marks.

7
2.3.1 General management of poisoning.
Acutely poisoned patients are commonly encountered in Emergency department. Acute
poisoning (accidental or intentional) requires accurate assessment and prompt therapy. The
necessity to prevent cross contamination during the initial evaluation should be emphasized.
Early identification of the involved toxin/s is crucial and the majority will be identified by a
thorough history and physical examination.

An ABC-approach should be followed ensuring a protected airway, adequate ventilation and

hemodynamic stability. Supportive and symptomatic care remains the cornerstone of treatment.
A stepwise approach may be followed to decrease the bioavailability of toxins. Indications,
contra-indications, risks and dosage regimens for decontamination procedures including both
termination of topical exposures and decreasing exposure to ingested toxins.[33,34].

In the management of poisoned cases, a quick and correct decision is always necessary. The familiar
adage “TREAT THE PATIENT, NOT THE POISON” was appropriately stated. The first is the provision
of good supportive care and the second is decontamination or elimination measures. Management begins
with the evaluation, recognition that poisoning has occurred, identification of the agent, assessment of
severity and prediction of toxicity. Supportive care is aimed at preventing or limiting the complications of
a toxic exposure and is the main part of good management (34).

It is essential to ensure a patent airway, adequate ventilation and effective circulation. A

thorough history is essential in determining management and assessing the risk posed by a
particular poison.
Important historical factors include what exactly was taken, when it was taken, how it was taken,
how much was taken, why it was taken, and what else was taken. As with any patient attending
an emergency department, physical assessment of the poisoned patient starts with the airway,
breathing and circulation (ABC). The patient must be capable of maintaining and protecting a
patent airway. If there is any doubt, active airway management is required to protect against
further compromise or aspiration. Evaluation of breathing involves measuring the respiratory rate
and assessing the adequacy of ventilation (9,34).
8
Observation, auscultation of the chest, and oxygen saturation will confirm adequate ventilation in
most cases, though arterial blood gases should be checked if there is any doubt. Evidence of
inadequate ventilation requires immediate correction. Evaluation of the circulation includes a
baseline pulse rate and blood pressure (BP)(9,34).
Serious poisoning requires continuous electrocardiograph monitoring and regular BP checks.
After assessment of ABC, a complete physical examination should be undertaken to look for
other signs of poisoning, injection marks, trauma and other disease. The neurological assessment
is quite important. Altered level of consciousness is a complication of poisoning and ranges from
mild drowsiness to agitation, delirium, coma and seizures. A Glasgow Coma Scale (GCS) of 8 or
less strongly suggests that the patient may be unable to protect airway and intubation is required.
Pupil size and reaction are affected in many poisonings, and also muscle tone . Temperature
should be recorded as many agents cause hyperthermia (9, 34).

2.3.2. Management of poisoning at ED by nurses

According to study conducted at a Nut Shell UK, on first contact with the poisoned patient,
assessment of the level of consciousness is important. For an unconscious patient, careful
evaluation of the ABC should be followed by active measures to not only secure these, but also
to reverse the unconscious state, if possible(33).
The cornerstone on the management of poisoning is supportive that is, care of the airway and the
maintenance of breathing and the blood circulation. Symptoms such as convulsion and
arrhythmia should be monitored as their onset can be quite sudden. If the patient’s history and
physical examination support toxin ingestion, gut decontamination should be considered (9).

In the management of ingested poisons, after one hour, the amount of poison remained in gastro-
intestinal tract will be much decreased because of absorption to body system. The choice of a
decontamination procedure depends upon its relative efficacy, the associated complications, and
the presence of contraindications.

9
After arriving at the emergency department(ED), all poisoned patients are triaged as being in a
critical emergency condition, whether they are stable or not. This practice will ensure that the
patients can be seen almost immediately for stabilization and consideration of early gut
decontamination, a Nutshell, UK [33].

2.4. Literature on knowledge of nurses

ED nurses are frequently the first health care professionals to come in contacted with patients
who have ingested poisons. Knowledge of the proper initial evaluation and treatment of these
patients are very essential. ED nurses should be equipped with the professional knowledge and
skills to enable them to deal with a poisoned patient, and to assess the patients’ and family
structure professionally. It is essential that all ED nurses should be familiar with the clinical
priorities in life-threatening situations in order to ensure that problems are identified and treated
accordingly.

After arriving at the ED, all poisoned patients are triaged as being in a critical or emergency
condition, whether they are stable or not. This practice will ensure that the patients can be seen
almost immediately for stabilization and consideration for early gut decontamination [12, 33].
The process of assessment starts as soon as the patient arrives at the ED and incorporates the
gathering of information regarding the patient’s current physiological status along with a history
of the present and any previous episodes.

There are two main elements in the management of poisoned patients. The first is the provision
of good supportive care and the second is decontamination or elimination measures. It begins
with a thorough evaluation, recognition that poisoning has occurred, identification of the agent
involved, assessment of severity and prediction of toxicity. Supportive care is directed at
preventing or limiting the complications of a toxic exposure and the cornerstone of good
management [ 9,34].

10
Healthcare workers have an individual and collective responsibility to reflect on their own
performance and address any deficits in knowledge or skills as well as to evaluate the strengths
and weaknesses of their system as a whole [35].

“Chain of Response” should be in place, which shou1d be timely, effective, and different
professional groups with in ED should contribute to different parts of the chain according to the
local setting. The most important requirement is that the “overall team” is to posses’
competencies that cover assessment, recognition, intervention and communication to ensure help
is obtained when needed [34].

Study conducted in Kenya in 2011 the general knowledge of nurses on poisoning was assessed
using 14 items. The item for which nurses displayed the lowest knowledge level was the
relationship between gender and ingestion of poison in the general population. Only 35 (51.5%)
of the nurses were aware that women were more likely to take poison than men. Another
question that was poorly scored was the alimentary signs and symptoms of acute poisoning
during early stages, most nurses could not differentiate signs affecting gastrointestinal system
and those affecting other body system. 44 (64.7%) thought that there was a euthanasia
poisoning[35].

Study done in Kenya in 2012 there was very little variation in nurses’ knowledge on the initial
management of acute poisoning practices. The mean scores for acute poisoning knowledge
practices ranged from 7.2 among certificate nurses to 7.4 for higher diploma and degree nurses
[36].

Study conducted in Egypt in 2015, all nurses in the studied sample (100 %) had unsatisfactory
knowledge level (<75%) regarding detection and management of acute drug poisoning and the
participant nurses gave the correct answers for questions raised on the types of poisoning,
nursing diagnosis, antidote, basic knowledge, signs & symptoms, causes of poisoning in
percentage of 90%, 77%, 70%, 66%,66% & 57% respectively. However, 60% provided incorrect
answers in relation to nursing intervention with a subtotal mean knowledge score of 8.76 and a
total mean knowledge score of 36.86 indicating unsatisfactory knowledge level[37].

11
2.5. Literature on the practice of nurses

In order to develop and maintain good management skills and practice, the nursing education
must continue to design and develop units of study for casualty nurses. The study should focus
on the therapeutic care of poisoned patients at pre- and post-Registration levels as well as in
continuing professional education programs.

Study conducted in Kenya in 2012 out of 68 nurses included in the study, 13 (19.2%) gave the correct
response to all the ten questions on initial management of acute poisoning practices. The area in which
nurses displayed the least knowledge was in management of patients who had ingested controlled release
preparations with 40 (58.8%) of nurses recognizing that these patients may benefit from decontamination
even after a longer delay. Conversely, 64 (94.1%) of nurses rightly identified that the priority in managing
severe acute poisoning is maintaining adequate airway, breathing and circulation [36].

Study conducted in Egypt in 2015 on ED nurses revealed that all of the studied subjects had
unsatisfactory practice level (less than 75%) regarding detection and management of acute drug
poisoning. Participant nurses responded that the most frequently done activities were assessment
of the type of poison, nursing interventions for ingested poison, injected poison and inhaled
poison in percentages of 83%, 80%, 67% & 63% respectively [37].

12
 Chapter three

Study objectives
3.1 General objective
To assess the nurses’ knowledge and practice on initial management of acute poisoning among adult
casualties seen at ED of ADH& HURH from Dec 2016-June 2017.
3.2 Specific objectives
1- Assess the nurses’ knowledge in prioritizing, rapid assessment and intervention in the
management of poisoned casualties at ED of ADH and HURH.
2. To assess the level of practice of ED nurses on initial management of acute poisoning, at ED of
ADH& HURH
3-To determine whether work experience and educational qualification of nurses’ have any impact on
general knowledge and the initial management of poisoning at ED of ADH and HURH.

13
 Chapter four
Method and materials
4.1 Study area and period
Both ADH and HURH are found in the Southern Nations Nationalities and People’s Region
State (SNNPRS), Ethiopia. Both hospitals are located in Hawassa town, the capital of SNNPR,
Ethiopia which is 273 km far from Addis Ababa. The HURH is established and started its
activities in 2005, serving a catchment population of 5 million. The hospital is selected
purposively since it is the largest referral hospital in the region which provides a range of
services in its outpatient and inpatient units and Adare district hospital is also found in Hawassa
town and it is sidama zone’s district hospital and serving catchment population of 359558.

The study was conducted at both hospitals from Dec 2016-June 2017. HURH is a referral
hospital with a bed capacity of approximately 400 patients and ADH is a district hospital with a
bed capacity of 141 . They provide services for patients with in southern Ethiopia.
For effective and efficient administration, Nursing services in both hospitals have been
categorized into Emergency, Obstetrics/Gynecology/Radiotherapy, Pediatrics, Surgery (Minor
and Specialized), Orthopedics, ENT, ophthalmology, Patient Health Education and Research
Unit, Counseling and Continuing Education departments. The department operates 24 hours and
handles an average of 309 and 285 patients in a day respectively. Out of these, 9.6% and25% are
emergency victims and the rest are treated as outpatients, directed to consultant clinics for senior
reviews or admitted to respective wards depending on their presenting condition. They operates
in collaboration with the Hawassa University (HU) College of Health Sciences and Medical
school in offering teaching, training and research to students in their respective medical field.

4.2 Study design

Institutional based cross sectional descriptive study that employs both qualitative and
quantitative methods of data collection was employed.
4.3 Source population
Source population for the study was all nurses that are employed and working at both hospitals.
14
4.4 Study population
The study population was all nurses working at ED during the time of study.

4.5 Sample size determination and sampling technique.

All nurses working at ED of both hospitals were my sample since their number is fewer. To
select the subjects, non- probability sampling was used and specifically purposive sampling. So;
all Nurses working at ED were eligible to participate in this study as long as they met the
subject’s inclusion criteria.
4.6 Subject’s inclusion and exclusion criteria.
4.6.1 Inclusion criteria.
- Nurses working at HURH and ADH.

-They should assigned in ED during the time of study.

-They should directly involved in patient care.

-Nurses who were voluntary to participate in the study.

4.6.2 Exclusion criteria

-Nursing students in ED placement doing basic trainings.

-Nurses who were on leave during time of study.

-All ED nurses who declined to participate in the study.

4.7. Study variables

Independent variables Dependent variables
Professional qualification -knowledge of initial management of poisoning
Training -practice on initial management of poisoning
Experience
Age
Sex 15
4.8. Data collection
4.8.1 Study tools
Structured questionnaire and interview check list were used to collect the data.
4.8.2 Data collectors
Four data collectors holding a Bachelor of Science in nursing (BSc) qualification were recruited
to assist in data collection. They were trained on how to collect the data using various data
collection instruments.
4.8.3 Pilot study
After obtaining approval to carry out the study from AAU- Ethics and Research Committee
(ERC). Pilot study was conducted at Kibru primary hospital on 10 nurses, which found in close
proximity to ADH and shares the same catchment area of poisoning cases. Poisoned casualties
attending both health institutions share the same characteristics in one way or another as they are
served by the same catchment area of Hawassa town and its nearby areas.
4.8.4 Data collection methods
4.8.4.1 Questionnaires
The questionnaire comprised four sections as indicated below
1. Socio-demographic data
2. General knowledge on poisoning
3. Initial management of acute poisoning
4. Nurses practice self- report
4.8.4.2 Interview and observational Checklist

The focus of the observational and interview checklists was assessment of actual practice of
nurses on how they apply and implement their knowledge and skills on the initial management of
acute-poisoning. Checklist was used to ascertain what the nurses were doing to the patient at that
given moment

4.9 Data management

4.9.1 Data quality control

Data was cleansed, checked for completeness and store carefully.

16
4.9.2 Data Analysis

Data was entered to Epi infoTM version7 then transferred to SPSS version 20 and analyzed by
using statistical program SPSS version 20. Statistical measures like correlation chique squre,
cross tables were employed to determining the association between some of independent and
dependent variables.

4.9.3 Data presentation

Data were presented by using frequency tables, bar graphs and figures. Inferential statistics was
presented in relation to their level of significance.

4.10 Operational definitions

Emergency nurse. Any qualified nurse deployed at accident and emergency department with or
without accident and emergency specialization during time of study.
Acute poisoning: When the body is exposed to a toxic substance in a high dose, on one occasion
and during a short period of time. Symptoms develop in close relation to the exposure.
Adults: Anyone who is above 18 years.
Deliberate self-harm: An act with fatal or non-fatal outcome in which an individual deliberately
initiates a non-habitual behavior that without intervention from others will cause self-harm, or
deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic
dosage.
Emergency department: This is where all casualties brought to the hospital are received.
Initial assessment: Management and care given by nurses to poisoned patient on arrival at
emergency department as part of patient stabilization. The care ends when the patient’s
physiological parameters are within normal and patient is out of life threatening situations.
Knowledge: Familiarity with acute poisoning management among emergency nurses. It
includes; information, facts and skills acquired through experience and education on poisoning.

Satisfactory knowledge: knowledge level from 75-100% score for the given general knowledge
and initial management of acute poisoning items.

17
Unsatisfactory knowledge:-knowledge level below 75%.

Nursing practice: Actual provision of nursing care using the nursing process to poisoned
casualties.

Satisfactory practice: practice level from 75-100% score for the given acutely poisoned
casualty management items of practice.

Unsatisfactory practice: practice score of level below 75%.

4.11 Ethical Consideration

Ethical clearance of the proposal will be granted by AAU-ERC. Permission to carry out the study
will be granted by the Ministry of Science and Technology and MOH administration. All ED
nurses will be informed in advance that participation in the study is voluntary and the identities
of those who participated will be withheld throughout the study. Purpose of the study will be
explained to them, and those who are willing to participate will be provided a written consent by
signing a consent form provided.

4.12 Dissemination plan

The result of this study was disseminated to Emergency Department of AAU, and FMOH,
SNNPR Health bureau, HURH, ADH, and Sidama zone health bureau.

18
 Chapter five

Result and discussion

5.1. Results

5.1.1. Socio-demographic characteristics of ED nurses

Out of 67 nurses working at ED of HURH and ADH, 63 participated in the study which was 94%
response rate and 4(6%) non response rate. Of these participants 48(76.2%) were from HURH and
15(23.8%) were from ADH. There were 33(52.4%) male and 30(47.6%) were female nurses.

Majority 44(69.8%) were aged between 20-29 years and only 1(1.6%) aged between 40-49.
24(38.1%) of participant nurses held Diploma, 38(60.3%) had BSc and 1(1.6%) had MSc. The
average number of years since first qualified was 14.25 years and the earliest qualified 28 years ago,
as shown on the table below.

Table 1 Social demographic characteristics of ED nurses, HURH &ADH

Variable Characteristics Frequency Percent

Sex Male 33 52.40
Female 30 47.60
Age 20-29 44 69.80
30-39 18 28.60
40-49 1 1.60
Level of education Diploma 24 38.10
BSc 38 60.30
MSc 1 1.60
Total 63 100

19
Table 2 Emergency experience and post qualification training among ED nurses, HURH&ADH
Frequency Percent
Emergency experience
1-5 58 92
6-10 5 8
Total 63 100
Training on management of
acute poisoning
Yes 2 3.20
No 61 96.80
Total 63 100
Current training related to ED

Yes 2 3.20
No 61 96.80
Total 63 100

BLS 22 34.90
EM&CCN 7 11.10
IEMM 1 1.60
No got any training 33 52.40
Total 63 100

5.1.2. ED experience and post qualification training of respondent nurses.

Out of 63 nurses participated in the study 58(92%) had ED work experience below five years and
only 5(8%) had above five years of ED experience.

Regarding to post qualification training; more than half 33(52.4%) of participant nurses had no
got any of training related to ED and the training that more nurses got was BLS 22(34.9%) and
the least was IEMM 1(1.6%). Only 2(3.2%) of participant nurses had formal training on acute
poisoning management, as shown in the table above. 20
Table 3 Responses of ED nurses on their general knowledge of poisoning, HURH&ADH.

Responses
Knowledge on poisoning
Correct Incorrect
n(%) n(%)
1 Poison is any substance capable of producing damage or 61(96.80%) 2(3.20%)
dysfunction in the body by its chemical activity. (T)

2 Dose ingested and time of ingestion are not very necessary 37(58.80%) 26(41.30%)
consideration when managing poisoning cases in ED.(F)
3 As an ED nurse it is always very important to treat the poison 35(55.6%) 28(44.4)
not the patient.(F)
4 The commonest cause of poisoning in developing countries is 44(69.80) 19(30.20%)
pesticide poisoning.(T)
5 Women are more likely to take deliberate poison in general 47(74.60%) 16(25.40%)
population to commit suicide than men.(T)
6 Cause of poisoning among casualties attending any ED,
according to motive and nature of use, can be classified as:

i. Deliberate poisoning(T) 16(25.40%) 47(74.60%)

ii. Accidental poisoning(T) 23(36.50%) 40(63.50%)
iii. Homicidal poisoning(T) 4(6.30%) 59(93.70)
iv. Euthanasia poisoning(F) 20(31.70%) 43(68.30%)
7 Alimentary signs and symptoms of acute poisoning during early
stages include :
i. Dry mouth, abdominal pain and salivation(T) 8(12.70%) 55(87.30%)
ii. Nausea, vomiting, hallucinations and convulsions(F) 20(31.70%) 43(68.30%)
iii. Coughing, cyanosis, hyperventilation and salivation(F) 20(31.70%) 43(68.30%)
iv. Tachycardia, hypotension, diarrhea and breathlessness(F) 15(23.80%) 48(76.20)

21
5.1.3. General knowledge of nurses on poisoning

The general knowledge of nurses on poisoning was assessed using 7 questions that has 13 items.
For the given 13 questions only 2(3.2%) answered all and the range being 9. The item for which
nurses displayed the highest knowledge level was on the definition of poison which was
62(96.8%) and the item with lowest knowledge level was both classification of poison based on
its motive and cause, and Alimentary signs and symptoms of acute poisoning at early stage;
which was homicidal poisoning 4(6.3%) and 8(12.7%) respectively. The mean knowledge score
was 8.0(SD-1.97) which was only 61.50% of the items given. As shown on the table above.

Table 4 professional qualification versus general knowledge on poisoning among ED nurses

Profession Number Mean(SD) P-value

Diploma 24 7.25(1.78) 0.01
BSc 38 8.37(1.89)
MSc 1 12 -
Total 63 8.00(1.97)

5.1.4. Professional qualification versus general knowledge on poisoning among ED nurses of

HURH &ADH.
Based on the given 13 items to assess the general knowledge of nurses on poisoning ,the score ranges
between 4 to 13 with the range of 9 and mean score of 8.00 ( SD-1.97) for the entire respondents.
Diploma nurses score a mean of 7.25(SD-1.78), BSc nurses score a mean of 8.37(1.89) and MSc
nurse score a mean of 12 being the highest score, with the mean score of 8.00(SD-1.97) and p-value
being 0.01.Which shows there was statistically significant association between professional
qualification and general knowledge of nurses on poisoning since p-value was <0.05.

22
Table 5 Nurses length of experience versus general knowledge on poisoning among ED nurse

Length of experience Number Mean(SD) p-value Range

0-4 years 29 8.03(1.64) 0.27 9(max-13,
5-9 years 26 7.46(1.90) Min-4)
10 and above years 8 9.63(2.56)
Total 63 8.00(1.97)

5.1.5. Nurses length of experience versus general knowledge on poisoning.

Nurses were assessed using 13 item on general knowledge of poisoning and the score of each nurse
and each group based on their experience was evaluated. The score range from 4(min) to 13(max) the
range being 9 and the entire mean score was 8.00(SD-1.97) that was 61.50% for the given items that
was less than 75% which was unsatisfactory level of knowledge.

On the bases of their length of experience , nurses with 0-4 years of work experience had a mean
score of 8.03(SD-1.64),nurses with 5-9 years of work experience has a mean score of 7.46(SD-1.90)
being the least score and nurses with 10 and above years of work experience had a mean score of
9.63(SD-2.56) being the highest score and p-value was 0.27 which was statistically insignificant
association, as shown on the table above.

23
Table 6 ED nurses responses on initial management of acute poisoning practices.

No Statement/question Response
Correct Incorrect
n(%) n(%)
1 In severe acute poisoning, maintaining adequate airway, respiration
and circulation are always a priority.(T) 52(82.50%) 11(17.50%)
2 In case of organophosphate poisoning atropine should not be
administered in any circumstance.(F) 45(71.50%) 18(28.60%)
3 Nearly all poisoning encountered in accident and emergency
department have their specific antidote.(F) 20(31.80%) 43(68.30%)
4 The decision to perform Gastrointestinal (GI) decontamination should
be based upon the specific poison(s) ingested, time from ingestion to 54(85.70%) 9(14.30)
presentation, and the predicted severity of the poison.(T)
5 Emesis is to be considered in an alert, conscious patient who has
ingested a substantial amount of a toxic substance within 60 45(71.40%) 18(28.60%)
minutes of presentation.(T)

6 Activated charcoal can increase absorption of a wide range of poisons

from the gastro-intestinal tract to the entire human system.(F) 31(49.20%) 32(50.80)
7 Gastric lavage is indicated for patients who have ingested kerosene
or corrosive substances within an hour of presentation.(F) 18(28.60%) 45(71.40%)
8 The effectiveness of gastric lavage increases as the time between
ingestion and treatment increases.(F) 26(41.20%) 37(58.70%)
9 The volume of lavage fluid aspirated should approximate to the
amount of fluid given.(T) 54(85.70%) 9(14.30%)
10 Patients presenting following ingestion of controlled/ slow released
substances may benefit from decontamination even after a longer 39(61.90%) 24(38.10%)
delay (e.g. more than 2-4 hours).(T)

24
5.1.6. ED nurses responses on initial management of acute poisoning.
Out of 63 nurses participated in the study none of them answered all the 10 questions correctly. The
area were majority of nurses answered correctly on the initial management of poisoning were on the
decision to perform gastro-intestinal decontamination and the volume of lavage fluid which is
54(85.7%); and maintaining adequate airway, respiration and circulation in severe acute poisoning.
The least answered was indication of gastric lavage which was 18(28.6%), mean 6.37(SD-1.57)
which is 63.70% from the give 10 items, as shown on the table above.

Table 7 ED nurses’ professional qualification versus knowledge on initial management of acute

poisoning practices

Professional qualification Number Mean(SD) p-value Range

Diploma 24 5.62(1.16) 0.002 7(Max-9,
BSc 38 6.79(1.38) Min-2)
MSc 1 8.00
T0tal 63 6.37(1.57)

5.1.7. Professional qualification versus knowledge on initial management of acute

poisoning.

The knowledge of each nurse on initial management of acute poisoning at ED was assessed
using 10 items. The response of the nurses range between 2(min) to 9(max) the range was 7 and
the entire mean score was 6.37(SD-1.57) which was 63.70% of the given items.

The mean score for each professional group was computed ; Diploma nurses score a mean score
of 5.62(SD-1.16) which was the least score, BSc nurses score a mean of 6.79(SD-1.38) and MSc
scoring a mean of 8.00 which was the highest score, the p-value was 0.002.

25
 6

5 5 4
9 7

22
4
36

3 53

56 58 59
54
2
41
27
1
10 No
0 Yes

Fig. 5.1. Nursing practice self report among HURH and ADH ED nurses.

26
 5.1.8. Self reported nursing practice.

Out of 63 nurses participated in the study, 10(15.9%) respond that guidelines or flow charts were
available at ED and 27(42.9%) indicated that guidelines were necessary to assist in the management
of poisoned casualty at ED. 41(65.1%) of participant nurses felt insecure in the management of
poisoned casualty because they lack the necessary skill and confidence and 56(88.9%) require trained
or experienced staff while responding to poison related cases; 58(92.1%) need more training on the
management of poisoning. 54(85.7%) respond that they have professional skills to handle poisoned
casualty; as show in the figure 5.2 above.

4.5 55(87.3%) 56(88.9%)

44(69.8%)
3.5

3 35(55.6%)

2.5
28(44.4%)

19(30.2%)
1.5

1
8(12.7%) 7(11.1%)
0.5

0
Airway management Breathing Circulation Neurological status
Done Not done

Fig .5.2. shows management of ABCD of acute poisoning by nurses at ED of HURH and
AD
27
Practice part
5.1.9. Assessment of ED nurses on the management of acute poisoning
practice.

Practical competence of participant nurses was assessed by using both actual practices on
poisoned casualties as its availability during data collection; simulation cases were given with
interview checklist and questions to evaluate the practical knowledge of each participant
following ABCD:-

Airway management

Airway management of poisoned casualty by ED nurses was assessed using lists like check the
patient level of consciousness, check airway patency, assist in oro-pharyngeal or naso-
pharyngeal airway, inspect and remove foreign bodies and assist in intubation. Out of participant
nurses 35(55.6%) correctly did all the airway managements activities, while 28(44.4%) didn’t
manage correctly.

Breathing

Management of breathing of poisoned patient by nurses was assessed using checklist like
regulation of rate and rhythm of respiration, recognition of normal and compromised breathing
and Oxygen therapy. Generally, majority 55(87.3%) of participants managed breathing correctly
and only 8(12.7%) fail to do.

Circulation

Generally majority of participant nurses, 56(88.8%) managed and responded all practical
questions given on the management of circulatory problems like shock, bleeding, etc and only
7(11.1%) fail to do.

28
Neurological status assessment and monitoring.

Nurses’ practical knowledge of neurological assessment and monitoring of poisoned casualty

was assessed using checklists recognition of normal and abnormal neurological status,

neurological assessment and monitoring and recognition of altered level of consciousness.

Generally neurological status assessment and monitoring was the least managed part of practice
by nurses. Only 19(30.2%) of nurses assesses and managed neurological status of the casualties
using AVPU and GCS correctly, while 44(69.8%) fail to manage correctly; as shown on the
figure 5.2 above.

Table 8.drugs given to manage acute poisoning casualty by ED nurses of HURH and ADH

No Treatment given Frequency Percent

1 Antidote and other drugs 30 47.60
2 Fluid 19 30.20
3 All 14 22.20
Total 63 100

5.1.10. Drugs

To manage acutely poisoned casualty at ED , nurses had awareness and give the ordered
therapies like antidote and other drugs like antibiotic to treat aspiration pneumonia ,fluid therapy
to manage and treat shock, circulatory insufficiency, fluid loss and all therapies accordingly.
30(47.6%) of participant nurses give antidote and other drugs as ordered and 14(22.2%) give
antidote, other drugs and fluid therapy as ordered based on type of poison ingested, duration of
time between ingestion and presentation as shows on the table 5.8 above.

29
Table 9. shows GI decontaminator used to manage acute poisoning casualty at ED by nurses

No Decontaminator used Frequency Percent

1 Activated charcoal 14 22.20
2 Activated charcoal & 10 15.90
Gastric lavage
3 Gastric lavage 34 54
4 Whole bowel irrigation 5 7.90
Total 63 100

5.1.11. Gut decontamination

The GI of acutely poisoned casualties were decontaminated by ED nurses using Gastric lavage
34(54%) in its correct time interval(with in 1hour of ingestion mostly) and indication ,Activated
charcoal 14(30.2%) , whole bowel irrigation5(7.9%) and 10(15.9%) used both activated charcoal
and Gastric lavage in their correct indication , but none of nurses use emesis, as shown on the
table 5.10 above.

30
 5.2. Discussion

5.2.1. Introduction

This is institution based cross sectional descriptive study that used both quantitative and

qualitative methods of data collection was aimed to assess the general and practical knowledge

of nurses on the management of poisoned casualties seen at Adult ED of HURH and ADH.

5.2.2. General knowledge versus professional qualification and work

experience

The general knowledge score of nurses was assessed according to their professional qualification

and work experience. Those nurses with higher professional qualification had high mean score

than those with lower professional qualification, 7.25(SD-1.78), 8.37(SD-1.89) and 12; for

Diploma, BSc and MSc nurses respectively and had a mean general knowledge score of

8.00(SD-1.97) which was 61.50% for the given general knowledge items, and the p-value was

0.01. The general knowledge of nurses on poisoning has positive correlation with their

professional qualification since p<0.05.

On the bases of work experience, ED nurses were assessed for their general knowledge on

poisoning and scored a mean value; 0-4 years of experience 8.03(SD-1.64), 5-9 years of

experience 7.46(SD-1.90) and 10 and above years of experience 9.63(2.56) respectively; with the

total mean of 8.00(SD-1.97) for the entire group and 61.50% for the given items; and the p-

value was 0.27.

31
The current study was in agreement with the study conducted at Kenya (2011 and 2012) on

assessment of nurses’ KAP on initial management of acute poisoning at adult ED on 68 nurses

and at Egypt (2015) on nurses’ knowledge and practice regarding detection and management of

acute drug poisoning on 30 nurses which revealed nurses had unsatisfactory knowledge level that

was less than (<75%) even if they had increasing mean knowledge score as their professional

qualification (35,36,37 ); and

This study also shows that nurses had unsatisfactory knowledge level less than 75% which was

61.50% of mean general knowledge with increasing mean score with increasing their

professional qualification as well as their experience.

But this study was in contrary with both studies(35,36,37 ) that revealed general knowledge and

professional qualification has no significant association and nurses with experience of 5-9 years

had mean score higher than below 5 and above 10 years of work experience.

The result of this study the showed that there was a significant association between professional

qualification and general knowledge of nurses since p-value was 0.01 which was p<0.05.

In my point of view this might be due to increasing professional qualification of nurses increase

the general knowledge of nurses on poisoning management as well as their general medical

knowledge and as the years of experience increases the mean general knowledge of nurses

become high due to increased exposure to different poisoning cases at ED and different medical

illnesses and their management as well as they might got different trainings.

32
5.2.3. Professional qualification versus initial management of acute poisoning practice.

The mean knowledge score of nurses on initial management of acute poisoning practice were

evaluated using 10 items.

Nurses who had higher professional qualification score high mean score than those with low

qualification. 5.62(SD-1.16), 6.79(SD-1.38) and 8.00; for Diploma, BSc and MSc respectively

with entire knowledge mean of 6.37(SD-1.57) which is only 63.70% for the given items on

initial management of poisoning with the p-value of 0.002. Which show nurses had

unsatisfactory knowledge and practice level on initial management of acute poisoning.

This study was also in agreement with the study done in Kenya 2011 and 2012 on KAP of

nurses’ on initial management of acute poisoning at adult ED and in Egypt 2015 on knowledge

and practice of nurses on detection and management of acute drug poisoning which revealed that

nurses had unsatisfactory knowledge and practice level on initial management of acute poisoning

even though their mean knowledge level increase with increasing professional

qualification(35,36,37 ).

But there was contrary result with both of studies in that; their study concluded that there was no

significant statistical association between professional qualification of nurses and initial

management of acute poisoning; in the current study the result shows that there was statistically

significant association since p-value =0.002 which shows positive association p<0.05.

This was from the fact that as the professional qualification of the nurses’ increases there should

be increase both the general knowledge of nurses medically as well as results in increase in

confidence in the care and management of casualties. This was why there was a positive

correlation. 33
5.2.4. Emergency related training among ED nurses.

The current study findings showed less than half of all ED nurses 30(47.62%) trained emergency

related training;

of which 22(34.9%) trained BLS, 7(11.10%) trained Em&Ccn, 2(3.2%) and 1(1.6%) trained

poison management and IEMM respectively; and 33(52.38%) did not trained none of the

courses.

The result of this study was in agreement with the study done in Egypt 2015 on nurses’

knowledge and practice in detection and management of acute drug poisoning which revealed

that all nurses got any of emergency related training that result in unsatisfactory knowledge and

practice level(37 ).

5.2.5. Nurses’ self response on poisoning management related to ED practice.

From participants of this study ED nurses, 56(88.9%) requires the presence of staff member

trained or experienced in poison management, 58(92.10%) need more training or education

pertaining to the management of poison management, and 59(93.70%) of participant nurses

indicated that it was necessary to develop procedures that improve in the identification and

management of acutely poisoned casualties seen at ED.

This study was in agreement with the study done in Kenya 2011 and 2012 by Rutto which

revealed that 60(88.2%) of ED nurses need training that would help them in improvement in

identification, diagnosis, intervention and management of poisoned cases(35,36).

34
5.2.6. Actual practice of nurses’ on the management of acutely poisoned casualties at ED.

The results of current study showed that the mean practical knowledge was unsatisfactory which

was 65.50%; Out of participant nurses, 28(44.4%) didn’t manage airway correctly, breathing

including O2 therapy 8(12.7%) fail to manage and 7(11.1%) fail to manage circulation correctly,

and In the assessment and monitoring of neurological status by using AVPU and GCS

44(69.8%) fail to manage correctly as per (9&34 guidelines).

The result of current study was in agreement with the findings of both study done in Kenya 2011

and 2012 by Rutto and in Egypt 2015 by El.sayed which revealed that nurses managing poisoned

casualties sometimes fail to recognize problems in respirations, circulation, neurological status;

and differentiate early signs of poisoning in different body systems. Nurses’ lack of practice was

attributed to lack of attending emergency related trainings, lack of continuous education and

nursing shortage (35, 36, 37 ).

5.2.7. Gut decontamination.

To decontaminate poisoned casualties at ED nurses were aware the benefits, the duration of

presentation and used procedures like:- 5(7.9%) whole bowel irrigation, 14(22.2%) activated

charcoal, the majority 44(69.9%) used gastric lavage.

This study was in agreement with the study done in Kenya 2012 and as Dr. Ali D Abas guideline

for nurses on poison management and MOH guideline which revealed that majority of ED

nurses were aware and used gastric lavage to decontaminate poisoned casualties in the time

range between 1 hour from time of ingestion for common poisons to 4 hours for controlled or

slow released substances to time of presentation to ED (9, 34, 36).

35
 5.2.8. Strength and limitation of the study.

5.2.8.1. Strength of the study.

This study tried to assess both the general knowledge, knowledge of initial management of acute

poisoning and practice knowledge level of nurses working at ED of both hospitals.

The study also included all nurses working at ED of both hospitals and both public hospitals that

located at Hawassa town; thus the sample was representative and can be generalized for the

study population.

The questionnaire was adapted from previous studies done in similar settings in other countries

and pretest was done to check for completeness, and to avoid any difficulty during data

collection and necessary modification was made.

5.2.8.2. Limitations of the study.

 As the study was based on only two institutions located in one town and professionals

involved in the study were from those institutions; so, generalization as whole was not

considered.

 The study period was very short and data collection and analysis was very difficult.

 As ED nurses were very busy it was very difficult to assess all participants in actual

practical observation

36
5.3. Conclusion

The findings of this study revealed that:-

 All ED nurses that participated in this study had unsatisfactory general knowledge on

poisoning, knowledge on initial management of acute poisoning and practice .

 Socio-demographic characteristics such as professional qualification had impact on

general knowledge and initial management of poisoning.

 The majority of ED nurses required training related to emergency and poisoning

management.

5.4. Recommendations

As the result of current study revealed that all participated ED nurses had unsatisfactory

knowledge and practice level ; so, there:-

 Should be various type of emergency related training focusing on poisoning management,

IEMM(Integrated emergency medical management), etc that help in assessment diagnosis

and management of casualties at ED by nurses.

 Flow chart or guidelines that will enhance easy identification and management of

poisoning casualties should be set and utilized at ED by nurses and other professionals.

 Stakeholders like FOH,SNNPR health bureau and Sidama Zone health bureau should

facilitate and give training related to poisoning management and emergency care for ED

nurses.

37
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severity of self-harms a predictor of subsequent suicide. British J of Psychiatry, 2005;
18(6):253-257.

8. Janne Liisanantti Acute drug poisoning, out come and factors affecting outcome

9. MOH Clinical Practice Guidelines Dec/2011-Management of Poisoning.

10. Kiran N, Rani S, Jaiprakash V, VanajaK. Pattern of poisoning reported at south Indian
tertiary care hospital.Ind J of Forensic Med and Toxicol,2012; 2(2):72-76.

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11. World Health Organization (2014). Poisons information, prevention and management.
Geneva: WHO, 2014.

12. Esayas Tadesse G/Mariam* and Belayneh Kefale Gelaw,2016-Global epidemiology of

acute Poisoning with an Emphasis to Ethiopia: Systematic Review.

13. Malangu, N., Ogunbanjo G.A., (2009). A profile of acute poisoning at selected hospitals
in South Africa: South Africa Journal of Epidemiology. 24(2),14-16.

14 Frithsen, I. L. & Simpson, W. M. (2010). Recognition And Management Of Acute

Medication Poisoning. American Family Physician , 81(3); 316-323.

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United States, 1999–2006. Public Health Rep 125(4): 542–547.

16. Hovda KE, Bjornaas MA, Skog K, Opdahl A, Drottning P, Ekeberg O, et al.Acute
poisonings treated in hospitals in Oslo: a one-year prospective study (I): pattern of
poisoning. Clin Toxicol. 2008;46:35–41.

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19. Hutton J, Dent A, Buykx P, Burgess S, Flander L & Dietze P (2010) The characteristics
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poisoning episodes presenting to a large regional teaching hospital in the UK. Br JClin
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hospital treatment of acute poisonings in Oslo. BMC Emerg Med.2008;8:15.

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E(2009) A prospective study of acute poisonings in a sample of Greek patients. CentEur J
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33. S L Greene, P I Dargan, A L Jones,2016-Acute poisoning: understanding 90% of cases in
anutshell.

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University of Baghdad, [email protected], 2011-Emergency Nursing: Poisoning.

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and practice on the initial management of acute poisoning among adult casualties: study
at accident and emergency department, Kenyatta national hospital, Kenya.

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 Annex I
Consent Explanation
I am Tamiru Beyene a second year postgraduate student at the AAU, College of Health Sciences
Department of Emergency medicine &critical care pursuing a Masters degree in Emergency
Medicine and Critical Care Nursing.
Dear participant
I intend to carry out a study on “The initial nursing management of acute poisoning among
adult casualties seen at emergency department of Adare District Hospital (ADH) and Hawassa
University Referral Hospital (HURH)” as part of my course requirement. The study seeks to
evaluate nurses’ skills and knowledge on the initial management of acute poisoning among adult
casualties seen at emergency department, ADH&HURH. The study has no any material or
monetary benefits.
Your participation is on voluntary basis and will not result in any physical or psychological
harm. You will have the right to withdraw at any time without any penalty. We will require you
to fill a questionnaire which will take about 30 minutes and you will be guided through. You are
free to ask any question about the study any time. Study findings will be used to develop
strategies on how to improve poisoning management and service quality.
The information you provide will be kept confidential and anonymous, and on that note, you will
not write any of your personal particulars. Your participation will be highly appreciated
In case of any questions or clarifications feel free to contact the principal investigator on mobile
number 0910119799.
Thank you
Tamiru Beyene (Principal investigator)

Informed Consent
I have read consent explanation and understood it’s content.I have been given opportunity to
discuss all my concerns.So,I agree voluntarily to participate in the study on “the assessment of
knowledge and practice of nurses on tne initial management of acute poisoning at adult ED of
ADH&HURH at Hawassa town.
Signiture of participant…………………………….Date…………………………………….
Signiture of data collector………………………….Date…………………………………….
Signiture of investigater……………………………Date…………………………………….

Questionnaire code____________________________

42
Research Questionnaires
Date__________________________
Directions: You are requested to fill this form about some of your demographic data. Please
answer every question if possible.
SECTION A: Social and Demographic Data
1. 1. Gender: Female 1. Male 2.

2. What is your age?

1. 20-29 yrs.

2. 30-39yrs

3. 40-49yrs

4.> 50 Yrs

3. Highest nursing education earned:

1. Diploma

2. BSC

3. Masters

4. PhD 5. Others

4. Number of years since you first qualified as a nurse: ____________

5. How many years of experience do you have in emergency environment(department).

1. < 2 years 4. 6-7 years

2. 2-3 years 5. 8-9 years

3. 4-5 years 6. >10 years

6. Have you train(gote) any of the following courses since you first qualified as a nurse:

1. BLS(Basic life support) which year_____________

43
2. IEMM(Integrated Emergency Medical Management) which year ____________

3. emergency and Critical care nursing(CCN) which year______________

4. Any other course relevant to your field? 1. Yes 2. No

If yes which course? _____________________

7. Is there any course you are currently pursuing related to your nursing field?
1. Yes
2. No

If yes which course? _____________________

8. Have you had any formal training on the management of acute poisoning since you first
qualified as a nurse?
1. Yes
2. No

SECTION B: General Knowledge on Poisoning

Direction: Indicate whether the following statements are True, False or you are Not Sure
regarding poisoning. Tick the correct response in the space provided.
No Question/statement True False Not
sure
1 Poison is any substance capable of producing damage or
dysfunction in the body by its chemical activity.

2 Dose ingested and time of ingestion are not very necessary

consideration when managing poisoning cases in ED.
3 As an ED nurse it is always very important to treat the
poison not the patient.
4 The commonest cause of poisoning in developing countries
is pesticide poisoning.
5 Women are more likely to take deliberate poison in general
population to commit suicide than men.
6 Cause of poisoning among casualties attending any ED,
according to motive and nature of use, can be classified as:

i. Deliberate poisoning

ii. Accidental poisoning

44
 iii. Homicidal poisoning

iv. Euthanasia poisoning

7 Alimentary signs and symptoms of acute poisoning during
early stages include ;

i. Dry mouth, abdominal pain and salivation

ii. Nausea, vomiting, hallucinations and convulsions

iii. Coughing, cyanosis, hyperventilation and salivation

iv. Tachycardia, hypotension, diarrhea and breathlessness

SECTION C: Initial Management of Acute Poisoning Practices

When managing acute poisoned patient, indicate your management view if the following
statements are True, False or you are Unsure. Indicate the correct answer at the beginning of
each statement, T for true, F for False and US for Unsure
1. ______In severe acute poisoning, maintaining adequate airway, respiration and circulation are
always a priority.

2. ______ In case of organophosphate poisoning atropine should not be administered in any

circumstance.
3. ______ Nearly all poisoning encountered in accident and emergency department have their
specific antidote.

4. _____The decision to perform Gastrointestinal (GI) decontamination should be based upon the
specific poison(s) ingested, time from ingestion to presentation, and the predicted severity of the
poison.

5. _____Emesis is to be considered in an alert, conscious patient who has ingested a substantial

amount of a toxic substance within 60 minutes of presentation.

6. ______Activated charcoal can increase absorption of a wide range of poisons from the gastro-
intestinal tract to the entire human system.

7. ______Gastric lavage is indicated for patients who have ingested kerosene or corrosive
substances within an hour of presentation.

8. ______ The effectiveness of gastric lavage increases as the time between ingestion and
treatment increases.

45
9. ______ The volume of lavage fluid aspirated should approximate to the amount of fluid given.

10. _____ Patients presenting following ingestion of controlled/ slow released substances may
benefit from decontamination even after a longer delay (e.g. more than 2-4 hours).

SECTION D: Nursing Practice Self Report

Instruction: Indicate by ticking the correct box either Yes or No

No Nurses Practice Yes No

1 I have professional skills to handle patients with acute
poisoning.
2 I feel insecure dealing with poison patient as I lack necessary
skills and confidence.
3 I need more training/education pertaining to the management of
acute poisoned casualties.
4 While responding to poison related attendances in ED, I require
the presence of a staff member trained or experience in poison
management
5 It is necessary to developing procedures for improving the
identification and management of acute poisoning on casualties
seen at ED department
6 Are there any guidelines or flowcharts in place at ED to assist you
in management of poisoned casualties?
7 Are guidelines to ED staff on the management of poisoning
really necessary?

Interview and Observational Checklist

CHECKLIST ON THE MANAGEMENT OF POISONED PATIENT.
Indicate whether the following activities were done, not done or not necessary by ticking the
appropriate box. Provide comment on the performance if any,

Date______________________ Done Not Not Comment(s)/

Check list Done Applicable Remarks

A Emergency Management

1.Airway

i. Check the patient level of

consciousness
46
ii. Check airway patency

iv. Assist in insertion of oro-pharyngeal

or naso- pharyngeal tube

vi. Oral cavity inspected and any

obvious foreign bodies such as food or
broken dentures removed.
2. Breathing

i. Rate and rhythm of respiration

ii. Recognition of normal breathing

patterns

iii. Recognition of
compromised/Distressed Breathing

iv. Oxygen therapy, given

3. Circulation

i. Checked pulse rate and rhythm

ii. Checked blood pressure

iii. Recognition of normal and abnormal

cardiovascular status

iv. Cardiovascular monitoring of any

changes

v. Resuscitation fluids given

vi. Stop obvious bleeding

4. Neurological status ( use of AVPU
and GCS)

i. Recognition of normal and abnormal

neurological status
47
 ii. Neurological assessment and
monitoring

iii. Recognition of altered LOC

5. Drugs

i. Given specific antidote ( Specify)

ii. Given any other drug ( Specify)

iii. Fluid therapy ( Specify)

B Medical History: ascertain whether the
following where noted during history
taking; ( Specify where necessary)

i. Type of drug or poison ingested

ii. Dosage and amount if available

iii. Time of ingestion

iv. Reason for taking the drug or poison

v. Any presence of suicide intent (

yes/no)

vi. Current symptoms noted (yes/ no)

vii. Any treatment received prior

(yes/none)

viii. Past suicide attempts ( yes/ no)

48
C Gut decontamination: Decontaminator Comment(s)
Indicate the gut decontamination used by ticking at the used
appropriate box and give comment if appropriately
used.

i. Gastric lavage

ii. Emesis

iii. Activated charcoal

iv. Whole bowel irrigation

49