Nursing Care Plan

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Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction		Long Term Goal: Patient will maintain a patent airway
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	Rationale	Evaluation
Assess airway for patency by asking the patient to state his name.	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.	Patient is able to state their name without difficulty.
Inspect the mouth, neck and position of trachea for potential obstruction.	Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction.	No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline.
Auscultate lungs for presence of normal or adventitious lung sounds.	Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction.	Patient’s lungs sounds are clear to auscultation throughout all lobes.
Assess respiratory quality, rate, depth, effort and pattern.	Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.	Patient is free of signs of distress.
Assess for mental status changes.	Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia.	Patient is awake, alert and oriented X3.
Assess changes in vital signs.	Tachycardia and hypertension occur with increased work of breathing.	Patient is normotensive with heart rate 60 – 100 bpm.
Monitor arterial blood gases (ABGs).	Increasing PaCO₂ and decreasing PaO₂ are signs of respiratory failure.	ABGs show PaCO₂ between 35-45 and PaO₂ between 80 – 100.
Administer supplemental oxygen.	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 receiving oxygen. SaO₂ via pulse oximetry is 90 – 100%.
Position Patient with head of bed 45 degrees (if tolerated).	Promotes better lung expansion and improved gas exchange.	Patient’s rate and pattern are of normal depth and rate at 45 degree angle.
Assist Patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes).	Assist patient to improve lung expansion, the productivity of the cough and mobilize secretions.	Patient is able to cough and deep breathe effectively.
Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy).	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 airway.	Complications such as esophageal and right main stem intubations can occur during insertion. Artificial airway placement should be confirmed by CO₂ detector, equal bilateral breath sounds and a chest x-ray.	CO₂ detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray.
If maxillofacial trauma is present: position the patient for optimal airway clearance and constant assessment of airway patency note the degree of swelling to the face and amount of blood loss prepare the patient for definitive treatment	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.	Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema.
If neck trauma is present: assess for potential hemorrhage and disruption of the larynx or trachea prepare the patient for CT scan	Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with swallowing or coughing, or 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.	Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the larynx.

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		Long Term Goal Patient will maintain optimal gas exchange
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	Evaluation
Assess respirations: quality, rate, pattern, depth and breathing effort.	Rapid, shallow breathing and hypoventilation affect gas exchange by affecting 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.	Patient is free of signs of distress. ABGs show PaCO₂ between 35-45 Pts respirations are of a normal rate and depth.
Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound).	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.	Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities.
Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation.	Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.	Patient’s lungs sounds are clear to auscultate throughout all lobes.
Assess for signs of hypoxemia.	Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.	Patient is free of signs of hypoxia.
Monitor vital signs.	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.	Patient is normotensive with heart rate 60 – 100 bpm and respiratory rate 10-20.
Assess for changes in orientation and behavior.	Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain.	Patient is awake, alert and oriented X3.
Monitor ABGs.	Increasing PaCO₂ and decreasing PaO₂ are signs of respiratory failure.	ABGs show PaCO₂ between 35-45 and PaO₂ between 80 – 100.
Place the patient on continuous pulse oximetry.	Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater.	SaO₂ via pulse oximetry remains at 90 – 100%.
Assess skin color for development of cyanosis, especially circumoral cyanosis.	Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.	Patient is free of cyanosis.
Provide supplemental oxygen, via 100% O₂ non-rebreather mask.	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 receiving 100% oxygen. SaO₂ via pulse oximetry is 90 – 100%.
Prepare the patient for intubation.	Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient.	Artificial airway is placed and maintained without complications.
Treat the underlying injuries with appropriate interventions.	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: Assess for paradoxical chest movements. Provide adequate pain relief. Assess breath sounds.	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.
If Pneumothorax or Hemothorax exist: obtain chest x-ray prepare for insertion of a chest tube If open Pneumothorax exists place a dressing that is taped on three sides for temporary management.	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.
Position patient with head of bed 45 degrees (if tolerated).	Promotes better lung expansion and improved gas exchange.	Patient’s rate and pattern are of normal depth and rate at 45 degree angle.
Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest).	Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts.	Patient is able to cough and deep breathe effectively.
Suction patient as needed.	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% before and after suctioning. Keep suctioning to 10-15 seconds.	Prevents alteration in oxygenation during suctioning.	Patient’s SaO₂ remained >90% during suctioning.
Pace activities and provide rest periods to prevent fatigue.	Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.	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		Long Term Goal Patient will maintain adequate fluid and electrolyte balance.
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	Evaluation
Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate.	If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 – 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular.	All pulses palpable, strong and regular.
Assess skin color and temperature.	Cool, pale, diaphoretic skin suggests ineffective circulation due to hypovolemia.	Skin pink, warm and dry.
Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.	Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids.	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.	Vital signs within normal limits.
Monitor blood pressure for orthostatic changes.	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%.	No orthostatic changes noted when patient placed from supine to Fowlers position.
Auscultate heart tones and inspect jugular veins.	Abnormally flattened jugular veins and distant heart tones are signs of ineffective circulation.	S1, S2 audible. No flattening or distention of jugular vein noted.
Assess mental status.	Loss of consciousness accompanies ineffective circulating blood volume to the brain.	Awake, alert and oriented X3.
Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes.	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.	Normal skin turgor. Mucous membranes pink and moist.
Assess color and amount of urine.	Concentrated urine and output <30cc for two consecutive hours indicate insufficient circulating volume.	Urine clear, yellow. Output at least 30cc/hr.
Monitor serum electrolytes and urine osmolality.	Elevated hemoglobin, Hematocrit and blood urea nitrogen (BUN) accompany a fluid deficit. Urine specific-gravity is also increased.	All lab values within normal ranges.
Monitor hemodynamic pressures: central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), if available.	All values decrease with inadequate circulating volume. Hemodynamic stability is the goal of fluid replacements. Monitoring of hemodynamic pressures can guide fluid replacements.	All pressures within normal ranges.
Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered.	14 -16 gauge catheters are preferred in case fluids need to be given rapidly. Parenteral fluids are necessary to restore volume. Lactated Ringers is usually the fluid of choice due to its isotonic properties and close resemblance to the electrolyte composition of plasma.	Two large bore IVs started, lactated ringers infusing as per physician orders without complications.
Obtain a serum specimen for type and cross matCh Administer blood and blood products as ordered.	Blood and blood products will be necessary for active blood loss. If there is no time to wait for cross matching, Type O blood may be transfused.	Type and cross sent. Type specific blood infusing as per physician orders.
During treatment monitor for signs of fluid overload.	Due to large amounts of fluids administered rapidly, circulatory 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.	No signs of overload noted with fluid replacements.
Assist the physician with insertion of a central venous line and arterial line if indicated.	Provides for more effective fluid replacements and accurate monitoring of hemodynamic picture.	Central venous line and arterial line inserted without difficulty.

Nursing Diagnosis Acute Pain r/t trauma		Long Term Goal Patient will be free of pain
Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patient’s vital signs will be within normal limits.
Interventions	Rationale	Evaluation
Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors.	A good assessment of pain will help in the treatment and ongoing management of pain.	Patient reports pain as 3 or less on 0-10 scale; intermittent and sharp in incision area.
Monitor vital signs.	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 to focus, frowning, grimacing and guarding of the area may be non-verbal signs of acute pain.	No non-verbal signs of pain noted.
Give analgesics as ordered and evaluate the effectiveness.	Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration.	Analgesics given as ordered. Patient reports satisfactory pain relief after administration.
Assess the patient’s expectations of pain relief.	Some patients are content with reduction in pain, others may expect complete elimination. This effects the patient’s perception of the effectiveness of treatment.	Patient states “I want some relief. I know some pain will still exist.”
Assess for complications to analgesics, especially respiratory depression.	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.	No complications of analgesia noted.
Anticipate the need for pain relief and respond immediately to complaints of pain.	The most effective way to deal with pain is to prevent it. Early intervention can decrease the total amount of analgesic required. Quick response decreases the patient’s anxiety regarding having their needs met and demonstrates caring.	Patient reports pain as soon as it starts.
Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation.	Outside sources of stress, anxiety and lack of sleep all may exaggerate the patient’s perception of pain.	Patient appears relaxed, is sleeping throughout the night.
Institute non-pharmacological approached to pain (detraction, relaxation exercises, music therapy, etc.).	Non-pharmacological approaches help distract the patient from the pain. The goal is to reduce tension and thereby reduce pain.	Patient is relaxing by use of non-pharmacological technique of choice.
If patient is on patient controlled analgesia (PCA): Dedicate an IV line for PCA only. Assess pain relief and the amount of pain the patient is requesting. Educate patient and significant others on correct use of PCA.	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 increased to cover the patient’s 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.	PCA infusing without complications. Patient and family understand purpose and use of PCA. Patient is getting adequate pain relief with current dose.
If the patient is receiving epidural analgesia: Assess for numbness, tingling in extremities; and a metallic taste in the mouth. 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 life-threatening complications.	All tubing labeled. No signs of allergic reaction or catheter migration noted.
For PCA and epidural analgesia: Keep Narcan readily available. Place “No additional analgesia” sign over head of bed.	In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing.	Narcan on unit if needed. Sign placed in room for safety.

Nursing Diagnosis Risk For Infection r/t inadequate primary defenses		Long Term Goal Patient will be free of infection
Short Term Goals / Outcomes: Patient will maintain normal vital signs. Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes.
Interventions	Rationale	Evaluation
Assess for presence of risk factors: open wounds, abrasions; indwelling catheters; drains; artificial airways; and venous access devices.	Represent a break in body’s first line of defense.	Patient has midline thoracic incision, Foley, chest tube and peripheral IV access.
Monitor white blood count (WBC).	Normal WBC is 4-11 mm³. Rising WBC indicates the body’s attempt to combat pathogens.	Patient’s WBC are within the normal range.
Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection.	Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured.	All areas are without signs of infection.
Monitor temperature and the presence of sweating and chills.	In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia.	Temperature is less than 37.7C. No sweating or chills present.
Monitor the color of respiratory secretions.	Yellow or yellow-green sputum indicates a respiratory infection.	Patient coughs up only thin clear secretions.
Monitor the appearance of urine.	Cloudy, foul-smelling urine, with sediments indicates a urinary tract or bladder infection.	Urine is clear yellow with no sediments.
Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices.	Strict asepsis is necessary to prevent cross-contamination and nosocomial infections.	No further infections are noted.
Wash hands and teach others to wash hands before and after patient care.	Hand washing reduces the risk of transmitting pathogens from one area of the body to another as well as from one patient to another.	No further infections are noted.
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.	Patient drinks 2000 -3000 ml of fluid. No presence of urinary tract or bladder infections.
Encourage intake of protein and calorie rich foods. Provide enteral feeding in patients who are NPO.	Optimal nutritional status promotes wound healing.	Wounds are well approximated.
Encourage coughing and deep breathing.	Reduces stasis of pulmonary secretions, reducing the risk of pneumonia.	Patient coughs up thin clear secretions.
Administer and teach the use of antimicrobial drugs as ordered.	All agents are either toxic to the pathogens or retard the pathogen’s 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 Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema		Long Term Goal Patient will maintain optimal tissue perfusion to vital organs
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	Rationale	Evaluation
Assess each area for signs of decreased tissue perfusion.	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 decrease reaction to light	No signs of decreased perfusion noted.
Monitor vital signs for optimal cardiac output.	Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion.	All vital signs within normal limits.
Administer fluids and blood products as ordered.	Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage.	Fluids infusing. Vital signs, urine output and mentation all within normal limits.
Anticipate the need for possible antithrombolytic therapy.	If an obstruction to the area has developed an embolectomy, heparinzation, or thrombolytic therapy may be necessary to restore flow and prevent ischemia	Heparin infusing. PTT within therapeutic range.
Assess for compartment syndrome if peripheral circulation is impaired (pain, palor, pulselessness, paralysis, parathesia).	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.	No signs of compartment syndrome noted.
Administer oxygen as prescribed. Titrate oxygen based on continuous pulse oximetry levels.	Oxygen saturates circulating hemoglobin and increases the effectiveness of blood that reached the ischemic tissues. Thus improving tissue perfusion.	Patient receiving oxygen. Pulse Oximetry 90 – 100%.
Monitor ABGs, especially for metabolic acidosis and hypoxia.	Metabolic acidosis and hypoxia indicate that tissues are not adequately being perfused.	ABGs within normal limits.
If Patient complains of angina; administer nitroglycerin (NTG) sublingually.	NTG causes vasodilation, decreases preload and afterload and thus improves perfusion to the myocardium.	NTG administer. Patient reports relief of angina.
If cerebral perfusion is compromised: Ensure proper functioning of intracranial pressure (ICP) catheter if present. Elevate head of bed 30 -45 degrees. Avoid measures that may trigger increased ICP Administer anticonvulsants as needed.	Promotes venous outflow from brain and helps reduce pressure. 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.	Patient awake and alert with no change in mentation. No seizures noted.

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

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