Nursing Care Plan

Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction Short Term Goals / Outcomes: Patients lungs sounds will be clear to auscultate Patient will be free of dyspnea Patient will demonstrate correct coughing and deep breathing techniques Intervention Assess airway for patency by asking the patient to state his name. Inspect the mouth, neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Assess respiratory quality, rate, depth, effort and pattern. Assess for mental status changes. Assess changes in vital signs. Monitor arterial blood gases (ABGs). Administer supplemental oxygen. Rationale Maintaining an airway is always top priority especially in patients who may have experienced trauma to the airway. If a patient can articulate an answer, their airway is patent. Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction. Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia. Tachycardia and hypertension occur with increased work of breathing. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Early supplemental oxygen is essential in all trauma patients since early Evaluation Patient is able to state their name without difficulty. Long Term Goal: Patient will maintain a patent airway

No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline. Patients lungs sounds are clear to auscultation throughout all lobes. Patient is free of signs of distress. Patient is awake, alert and oriented X3. Patient is normotensive with heart rate 60 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. Patient is receiving oxygen. SaO2 via pulse oximetry is

mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. Position Patient with head of bed 45 degrees (if tolerated). Assist Patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). Promotes better lung expansion and improved gas exchange. Assist patient to improve lung expansion, the productivity of the cough and mobilize secretions.

90 100%. Patients rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.

If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration.

Artificial airway is placed and maintained without complications.

Confirm placement of the artificial Complications such as esophageal and right main stem intubations can occur airway. during insertion. Artificial airway placement should be confirmed by CO2 detector, equal bilateral breath sounds and a chest x-ray. If maxillofacial trauma is present:
1. position the patient for optimal airway clearance and constant assessment of airway patency 2. note the degree of swelling to the face and amount of blood loss 3. prepare the patient for definitive treatment

CO2 detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray. Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema.

The patient with maxillofacial trauma is usually more comfortable sitting up. Any time there is trauma to the maxillofacial area there is the possibility of a compromised airway. Noting swelling is important as a baseline for comparison later.

If neck trauma is present:

Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness Patient is free of signs of hemorrhage or disruption. CT in speech, palpable crepitus, pain with swallowing or coughing, or scan reveals no injury to the larynx.

1. assess for potential hemorrhage and disruption of the larynx or trachea 2. prepare the patient for CT scan

hemoptysis. The neck should be also assessed for ecchymosis, abrasions, or loss of thyroid prominence. Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries.

Teach patient correct coughing and Deep breathing techniques. Weak, shallow breathing and coughing is ineffective in removing secretions. Patient is able to demonstrate correct coughing and breathing techniques.

Nursing Diagnosis Impaired Gas Exchange r/t altered oxygen supply Short Term Goals / Outcomes: Patient will maintain normal arterial blood gas (ABGs). Patient will be awake and alert. Patient will demonstrate a normal depth, rate and pattern of respirations. Interventions Rationale

Long Term Goal Patient will maintain optimal gas exchange

Evaluation Patient is free of signs of distress. ABGs show PaCO2 between 35-45 Pts respirations are of a normal rate and depth. Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities. Patients lungs sounds are clear to auscultate throughout all lobes.

Assess respirations: quality, rate, Rapid, shallow breathing and hypoventilation affect gas exchange by affecting pattern, depth and breathing effort. CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound). Auscultate lung sounds. Also assess for the presence of jugular Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention. Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.

vein distention (JVD) or tracheal deviation. Assess for signs of hypoxemia. Monitor vital signs. Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all Patient is free of signs of hypoxia. signs of hypoxemia. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue. Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. Patient is normotensive with heart rate 60 100 bpm and respiratory rate 10-20.

Assess for changes in orientation and behavior. Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2non-rebreather mask. Prepare the patient for intubation. Treat the underlying injuries with appropriate interventions.

Patient is awake, alert and oriented X3. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. SaO2 via pulse oximetry remains at 90 100%. Patient is free of cyanosis.

Patient is receiving 100% oxygen. SaO2 via pulse oximetry is 90 100%.

Early intubation and mechanical ventilation are necessary to maintain adequate Artificial airway is placed and maintained without oxygenation and ventilation, prior to full decompensation of the patient. complications. Treatment needs to focus on the underlying problem that leads to the respiratory failure. Appropriate injury specific treatment has been started.

If rib fractures exist:

1. Assess for paradoxical chest movements. 2. Provide adequate pain 3. relief.

Assess breath sounds. If Pneumothorax or Hemothorax exist:

1. obtain chest x-ray 2. prepare for insertion of a chest tube

Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care. Pain relief is essential to enhance coughing and deep breathing. Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax.

No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.

A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and re-inflates the lung tissue. A three sided dressing gives the accumulated air a way to escape, thereby decreasing thoracic pressure and preventing a tension Pneumothorax. A chest tube must then be inserted. Chest tube is placed and connected to 20cm wall suction with good tidaling and no air leak or SQ emphysema noted. Three-sided dressing maintained. No further cardiopulmonary decompensation noted in patient. Promotes better lung expansion and improved gas exchange. Patients rate and pattern are of normal depth and rate at 45 degree angle.

If open Pneumothorax exists place a dressing that is taped on three sides for temporary management. Position patient with head of bed 45 degrees (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed.

Promotes alveolar expansion and prevents alveolar collapse. Patient is able to cough and deep breathe effectively. Splinting helps reduce pain and optimizes deep breathing and coughing efforts.

Suctioning aides to remove secretions from the airway and optimizes gas exchange.

Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning.

Hyperoxygenate patient with 100% Prevents alteration in oxygenation during suctioning. before and after suctioning. Keep suctioning to 10-15 seconds. Pace activities and provide rest periods to prevent fatigue. Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.

Patients SaO2 remained >90% during suctioning.

No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities.

Nursing Diagnosis Deficient Fluid Volume r/t active fluid loss due to bleeding Short Term Goals / Outcomes: Patient will maintain urine output >30cc/hr. Patient will be normotensive with heart rate 60 -100bpm. Patient will demonstrate normal skin turgor. Interventions Rationale

Long Term Goal Patient will maintain adequate fluid and electrolyte balance.

Evaluation All pulses palpable, strong and regular.

Palpate pulses: carotid, brachial, radial, If carotid and femoral pulses are palpable, then the blood pressure is femoral, popliteal and pedal. Note quality and usually at least 60 80 mmHg systolic. If peripheral pulses are rate. present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular. Assess skin color and temperature. Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding. Cool, pale, diaphoretic skin suggests ineffective circulation due to hypovolemia. Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids.

Skin pink, warm and dry. All external bleeding controlled.

Monitor vital signs. (T,P,R,B/P)

Sinus tachycardia may occur with hypovolemia to maintain cardiac output. Hypotension is a hallmark of hypovolemia. Febrile states decrease body fluids through perspiration and increase respiratory rate. Greater than 10 mmHg drop signifies that circulating volume is reduced by 20%. Greater that 20 30 mmHg drop signifies blood volume is decreased by 40%.

Vital signs within normal limits.

Monitor blood pressure for orthostatic changes. Auscultate heart tones and inspect jugular veins. Assess mental status. Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes. Assess color and amount of urine. Monitor serum electrolytes and urine osmolality. Monitor hemodynamic pressures: central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), if available.

No orthostatic changes noted when patient placed from supine to Fowlers position.

Abnormally flattened jugular veins and distant heart tones are signs of S1, S2 audible. No flattening or distention of jugular ineffective circulation. vein noted. Loss of consciousness accompanies ineffective circulating blood volume to the brain. Dry mucous membranes and tenting of the skin are signs of hypovolemia. The sternum and inner thigh should be used for skin turgor due to loss of elasticity with aging. Concentrated urine and output <30cc for two consecutive hours indicate insufficient circulating volume. Elevated hemoglobin, Hematocrit and blood urea nitrogen (BUN) accompany a fluid deficit. Urine specific-gravity is also increased. All values decrease with inadequate circulating volume. Hemodynamic stability is the goal of fluid replacements. Monitoring of hemodynamic pressures can guide fluid replacements. Awake, alert and oriented X3. Normal skin turgor. Mucous membranes pink and moist. Urine clear, yellow. Output at least 30cc/hr. All lab values within normal ranges. All pressures within normal ranges.

Initiate two large bore intravenous catheters 14 -16 gauge catheters are preferred in case fluids need to be given Two large bore IVs started, lactated ringers infusing as (IVs) and start intravenous fluid replacements rapidly. Parenteral fluids are necessary to restore volume. Lactated per physician orders without complications. as ordered. Ringers is usually the fluid of choice due to its isotonic properties and close resemblance to the electrolyte composition of plasma.

Obtain a serum specimen for type and cross Blood and blood products will be necessary for active blood loss. If matCh Administer blood and blood products there is no time to wait for cross matching, Type O blood may be as ordered. transfused. During treatment monitor for signs of fluid overload.

Type and cross sent. Type specific blood infusing as per physician orders.

Due to large amounts of fluids administered rapidly, circulatory No signs of overload noted with fluid replacements. overload can occur. Headache, flushed skin, tachycardia, venous distention, elevated hemodynamic pressures (CVP, PCWP), increased blood pressure, dyspnea, crackles, tachypnea and cough are all signs of overload. Provides for more effective fluid replacements and accurate monitoring of hemodynamic picture. Central venous line and arterial line inserted without difficulty.

Assist the physician with insertion of a central venous line and arterial line if indicated.

Nursing Diagnosis Acute Pain r/t trauma Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patients vital signs will be within normal limits. Interventions Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors. Monitor vital signs. Rationale A good assessment of pain will help in the treatment and ongoing management of pain.

Long Term Goal Patient will be free of pain

Evaluation Patient reports pain as 3 or less on 010 scale; intermittent and sharp in incision area.

Tachycardia, elevated blood pressure, tachypnea and fever may accompany pain.

Vital signs within normal limits.

Assess for non-verbal signs of pain.

Some patients may verbally deny pain when it is still present. Restlessness, inability No non-verbal signs of pain noted. to focus, frowning, grimacing and guarding of the area may be non-verbal signs of acute pain. Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration. Some patients are content with reduction in pain, others may expect complete elimination. This effects the patients perception of the effectiveness of treatment. Excessive sedation and respiratory depression are severe side effects that need reported immediately and may require discontinuation of medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated. Analgesics given as ordered. Patient reports satisfactory pain relief after administration. Patient states I want some relief. I know some pain will still exist. No complications of analgesia noted.

Give analgesics as ordered and evaluate the effectiveness. Assess the patients expectations of pain relief. Assess for complications to analgesics, especially respiratory depression.

Anticipate the need for pain relief and The most effective way to deal with pain is to prevent it. Early intervention can respond immediately to complaints of decrease the total amount of analgesic required. Quick response decreases the pain. patients anxiety regarding having their needs met and demonstrates caring. Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation. Institute non-pharmacological approached to pain (detraction, relaxation exercises, music therapy, etc.). If patient is on patient controlled analgesia (PCA):
1. Dedicate an IV line for PCA only. 2. Assess pain relief and the

Patient reports pain as soon as it starts. Patient appears relaxed, is sleeping throughout the night.

Outside sources of stress, anxiety and lack of sleep all may exaggerate the patients perception of pain.

Non-pharmacological approaches help distract the patient from the pain. The goal is Patient is relaxing by use of nonto reduce tension and thereby reduce pain. pharmacological technique of choice.

Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs. If demands for the drug are frequent the basal or lock-out dose may need to be

PCA infusing without complications. Patient and family understand purpose and use of PCA. Patient is getting adequate pain relief with

amount of pain the patient is requesting. 3. Educate patient and significant others on correct use of PCA.

increased to cover the patients pain. If demands for the drug are very low, the patient may need further education of use of the PCA. The patient and significant others must understand that the patient is the only one who should control the PCA.

current dose.

If the patient is receiving epidural analgesia:

1. Assess for numbness, tingling in extremities; and a metallic taste in the mouth. 2. Label all tubing clearly.

These symptoms indicate an allergic response, or improper catheter placement. Labeling of tubing is necessary to prevent inadvertent administration of fluids or drugs in the epidural space. Catheter migration or improper administration through the catheter can result in lifethreatening complications.

All tubing labeled. No signs of allergic reaction or catheter migration noted.

For PCA and epidural analgesia:

1. Keep Narcan readily available. 2. Place No additional analgesia sign over head of bed.

Narcan on unit if needed. Sign placed in room for safety. In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing. Long Term Goal Patient will be free of infection

Nursing Diagnosis Risk For Infection r/t inadequate primary defenses Short Term Goals / Outcomes: Patient will maintain normal vital signs. Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes. Interventions Assess for presence of risk factors: open wounds, abrasions; indwelling catheters; drains; artificial Rationale Represent a break in bodys first line of defense.

Evaluation Patient has midline thoracic incision, Foley, chest tube and peripheral IV

airways; and venous access devices. Monitor white blood count (WBC). Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection. Monitor temperature and the presence of sweating and chills. Normal WBC is 4-11 mm3. Rising WBC indicates the bodys attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.

access. Patients WBC are within the normal range. All areas are without signs of infection.

In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to Temperature is less than 37.7C. No the stress of surgery. After 48 hours fever above 37.7C (99.8F) sweating or chills present. suggests infection. High fever with sweating and chills suggests septicemia. Yellow or yellow-green sputum indicates a respiratory infection. Cloudy, foul-smelling urine, with sediments indicates a urinary tract or bladder infection. Strict asepsis is necessary to prevent cross-contamination and nosocomial infections. Patient coughs up only thin clear secretions. Urine is clear yellow with no sediments. No further infections are noted.

Monitor the color of respiratory secretions. Monitor the appearance of urine. Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices.

Wash hands and teach others to wash hands before Hand washing reduces the risk of transmitting pathogens from one and after patient care. area of the body to another as well as from one patient to another. Encourage fluid intake of 2000ml 3000ml of water per day (unless contraindicated). Fluids promote frequent emptying of the bladder, reducing stasis of urine and risk of urinary tract and bladder infections.

No further infections are noted. Patient drinks 2000 -3000 ml of fluid. No presence of urinary tract or bladder infections. Wounds are well approximated. Patient coughs up thin clear secretions.

Encourage intake of protein and calorie rich foods. Optimal nutritional status promotes wound healing. Provide enteral feeding in patients who are NPO. Encourage coughing and deep breathing. Reduces stasis of pulmonary secretions, reducing the risk of pneumonia.

Administer and teach the use of antimicrobial drugs as ordered.

All agents are either toxic to the pathogens or retard the pathogens growth. Ideally medications should be selected based on a culture from the infected area. A broad-spectrum agent may be started until culture reports are available.

WBC within normal limits. No further infections noted.

Nursing Diagnosis Long Term Goal Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased Patient will maintain optimal tissue perfusion to vital organs arterial flow & cerebral edema Short Term Goals / Outcomes: Patient will maintain strong peripheral pulses. Patient will report absence of chest pain. Patient will be awake, alert and oriented. Patient will maintain normal arterial blood gases (ABGs). Patient will maintain normal urine output. Patient will maintain normal bowel sounds. Interventions Assess each area for signs of decreased tissue perfusion. Rationale Early detection facilitates prompt, effective treatment. Signs may be: Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina Renal: decreased output, hematuria, elevated BUN/creatinine ratio GI: decreased or absent bowel sounds; nausea; abdominal pain / distention Cerebral: restless, change in mentation seizure activity, papillary changes and Evaluation

No signs of decreased perfusion noted.

decrease reaction to light Monitor vital signs for optimal cardiac output. Administer fluids and blood products as ordered. Anticipate the need for possible antithrombolytic therapy. Assess for compartment syndrome if peripheral circulation is impaired (pain, palor, pulselessness, paralysis, parathesia). Administer oxygen as prescribed. Titrate oxygen based on continuous pulse oximetry levels. Monitor ABGs, especially for metabolic acidosis and hypoxia. If Patient complains of angina;
1. administer nitroglycerin (NTG) sublingually.

Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion. Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage. If an obstruction to the area has developed an embolectomy, heparinzation, or thrombolytic therapy may be necessary to restore flow and prevent ischemia Compartment syndrome develops as the tissue swells and the fascial covering over the muscles can not yield to the pressure. Blood flow to the extremity is drastically reduced. An emergent fasciotomy may need to be performed to restore flow. Oxygen saturates circulating hemoglobin and increases the effectiveness of blood that reached the ischemic tissues. Thus improving tissue perfusion. Metabolic acidosis and hypoxia indicate that tissues are not adequately being perfused. NTG causes vasodilation, decreases preload and afterload and thus improves perfusion to the myocardium.

All vital signs within normal limits. Fluids infusing. Vital signs, urine output and mentation all within normal limits. Heparin infusing. PTT within therapeutic range. No signs of compartment syndrome noted.

Patient receiving oxygen. Pulse Oximetry 90 100%. ABGs within normal limits. NTG administer. Patient reports relief of angina.

If cerebral perfusion is compromised:

1. Ensure proper functioning of intracranial pressure (ICP) catheter if present.

Patient awake and alert with no

2. Elevate head of bed 30 -45 degrees. 3. Avoid measures that may trigger increased ICP 4. Administer anticonvulsants as needed.

Promotes venous outflow from brain and helps reduce pressure.

change in mentation. No seizures noted.

Straining, coughing, neck or hip flexion and lying supine may increase ICP and further reduce blood flow. Reduces the risk of seizures, which may result from cerebral edema or ischemia.

References: Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St. Louis Taylor, K. Chapter 8. Care of the Patient Following a Traumatic Injury