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Chapter8

NursingCarePlan

NursingCarePlan
NursingDiagnosis
IneffectiveAirwayClearancer/ttracheobronchialobstruction

LongTermGoal:
Patientwillmaintainapatent
airway

ShortTermGoals/Outcomes:
Patientslungssoundswillbecleartoauscultate
Patientwillbefreeofdyspnea
Patientwilldemonstratecorrectcoughinganddeepbreathingtechniques

Intervention

Rationale

Evaluation

Assessairwayfor
patencybyasking
thepatienttostate
hisname.

Maintaininganairwayisalwaystoppriority
especiallyinpatientswhomayhave
experiencedtraumatotheairway.Ifapatient
canarticulateananswer,theirairwayis
patent.

Patientisabletostatetheirname
withoutdifficulty.

Inspectthemouth,
neckandposition
oftracheafor
potential
obstruction.

Foreignmaterialsorbloodinthemouth,
hematomaoftheneckortrachealdeviation
canallmeanairwayobstruction.

Noforeignobjects,bloodin
mouthnoted.Neckisfreeof
hematoma.Tracheaismidline.

Auscultatelungsfor
presenceofnormal
oradventitiouslung
sounds.

Decreasedorabsentsoundsmayindicatethe Patientslungssoundsareclearto
presenceofamucousplugorairway
auscultationthroughoutalllobes.
obstruction.Wheezingindicatesairway
resistance.Stridorindicatesemergentairway
obstruction.

Assessrespiratory
quality,rate,depth,
effortandpattern.

Flaringofthenostrils,dyspnea,useof
accessorymuscles,tachypneaand/orapnea
areallsignsofseveredistressthatrequire
immediateintervention.

Patientisfreeofsignsofdistress.

Assessformental
statuschanges.

Increasinglethargy,confusion,restlessness
and/orirritabilitycanbeearlysignsof
cerebralhypoxia.

Patientisawake,alertand
orientedX3.

Assesschangesin
vitalsigns.

Tachycardiaandhypertensionoccurwith
increasedworkofbreathing.

Patientisnormotensivewithheart
rate60100bpm.

Monitorarterial
bloodgases
(ABGs).

IncreasingPaCO2anddecreasingPaO2are
signsofrespiratoryfailure.

ABGsshowPaCO2between35
45andPaO2between80100.

Administer
supplemental
oxygen.

Earlysupplementaloxygenisessentialinall
traumapatientssinceearlymortalityis
associatedwithinadequatedeliveryof
oxygenatedbloodtothebrainandvital
organs.

Patientisreceivingoxygen.SaO2
viapulseoximetryis90100%.

PositionPatient
withheadofbed45
degrees(if
tolerated).

Promotesbetterlungexpansionandimproved
gasexchange.

Patientsrateandpatternareof
normaldepthandrateat45
degreeangle.

AssistPatientwith
coughinganddeep
breathing
techniques
(positioning,
incentive
spirometry,
frequentposition
changes).

Assistpatienttoimprovelungexpansion,the
productivityofthecoughandmobilize
secretions.

Patientisabletocoughanddeep
breatheeffectively.

Preparefor
placementof
endotrachealor
surgicalairway(i.e.
cricothyroidectomy,
tracheostomy).

Ifapatientisunabletomaintainanadequate
airway,anartificialairwaywillberequiredto
promoteoxygenationandventilation;and
preventaspiration.

Artificialairwayisplacedand
maintainedwithout
complications.

Confirmplacement
oftheartificial
airway.

Complicationssuchasesophagealandright
mainstemintubationscanoccurduring
insertion.Artificialairwayplacementshould
beconfirmedbyCO2detector,equalbilateral
breathsoundsandachestxray.

CO2detectorchangescolor,
bilateralbreathsoundsareaudible
equallyandartificialairwayisat
thetipofthecarinaonxray.

Ifmaxillofacial
traumaispresent:

Thepatientwithmaxillofacialtraumais
usuallymorecomfortablesittingup.Any
timethereistraumatothemaxillofacialarea
thereisthepossibilityofacompromised
airway.

Patientexhibitsnormal
respiratoryrateanddepthin
sittingposition.Patientisfreeof
wheezing,stridorandfacial
edema.

1.

position
thepatient
foroptimal
airway
clearance
and
constant
assessment
ofairway
patency

2.

notethe
degreeof
swellingto
theface
and
amountof
bloodloss

3.

preparethe
patientfor
definitive
treatment

Ifnecktraumais
present:
1.

assessfor

Notingswellingisimportantasabaselinefor
comparisonlater.

Hemorrhageordisruptionofthelarynxand
tracheacanbeseenashoarsenessinspeech,
palpablecrepitus,painwithswallowingor
coughing,orhemoptysis.Theneckshouldbe

Patientisfreeofsignsof
hemorrhageordisruption.CT
scanrevealsnoinjurytothe

potential
hemorrhag
eand
disruption
ofthe
larynxor
trachea
2.

alsoassessedforecchymosis,abrasions,or
lossofthyroidprominence.
Laryngealinjuriesaremostdefinitely
diagnosedbyCTscansassofttissueneck
filmsarenotsensitivetotheseinjuries.

larynx.

preparethe
patientfor
CTscan

TeachpatientcorrectcoughingandDeepbreathingtechniques.
Weak,shallowbreathingandcoughingisineffectiveinremovingsecretions.
Patientisabletodemonstratecorrectcoughingandbreathingtechniques.

NursingDiagnosis
ImpairedGasExchanger/talteredoxygensupply

LongTermGoal
Patientwillmaintainoptimalgas
exchange

ShortTermGoals/Outcomes:
Patientwillmaintainnormalarterialbloodgas(ABGs).
Patientwillbeawakeandalert.
Patientwilldemonstrateanormaldepth,rateandpatternofrespirations.

Interventions

Rationale

Evaluation

Assessrespirations:
quality,rate,
pattern,depthand
breathingeffort.

Rapid,shallowbreathingandhypoventilation
affectgasexchangebyaffectingCO2levels.
Flaringofthenostrils,dyspnea,useof
accessorymuscles,tachypneaand/orapnea
areallsignsofseveredistressthatrequire
immediateintervention.

Patientisfreeofsignsof
distress.
ABGsshowPaCO2between35
45
Ptsrespirationsareofanormal
rateanddepth.

Assessforlife
threatening

Absenceofventilation,asymmetricbreath
sounds,dyspneawithaccessorymuscleuse,

Patientexhibitsspontaneous
breathing,nodyspnea,useof

problems.(i.e.resp
arrest,flailchest,
suckingchest
wound).

dullnessonchestpercussionandgrosschest
wallinstability(i.e.flailchestorsuckingchest
wound)allrequireimmediateattention.

accessorymuscles,resonanceon
percussionandnochestwall
abnormalities.

Auscultatelung
Absenceoflungsounds,JVDand/ortracheal Patientslungssoundsareclear
sounds.Alsoassess deviationcouldsignifyaPneumothoraxor
toauscultatethroughoutall
forthepresenceof Hemothorax.
lobes.
jugularvein
distention(JVD)or
trachealdeviation.

Assessforsignsof
hypoxemia.

Tachycardia,restlessness,diaphoresis,
headache,lethargyandconfusionareallsigns
ofhypoxemia.

Patientisfreeofsignsof
hypoxia.

Monitorvitalsigns.

Initiallywithhypoxiaandhypercapniablood
Patientisnormotensivewith
pressure(BP),heartrateandrespiratoryrate
heartrate60100bpmand
allincrease.Astheconditionbecomesmore
respiratoryrate1020.
severeBPmaydrop,heartratecontinuestobe
rapidwitharrhythmiasandrespiratoryfailure
mayensue.

Assessforchanges
inorientationand
behavior.

Restlessnessisanearlysignofhypoxia.
Mentationgetsworseashypoxiaincreasesdue
tolackofbloodsupplytothebrain.

Patientisawake,alertand
orientedX3.

MonitorABGs.

IncreasingPaCO2anddecreasingPaO2are
signsofrespiratoryfailure.

ABGsshowPaCO2between35
45andPaO2between80100.

Placethepatienton Pulseoximetryisusefulindetectingchanges
continuouspulse
inoxygenation.Oxygensaturationshouldbe
oximetry.
maintainedat90%orgreater.

SaO2viapulseoximetryremains
at90100%.

Assessskincolor

Patientisfreeofcyanosis.

Lackofoxygendeliverytothetissueswill

fordevelopmentof
cyanosis,especially
circumoral
cyanosis.

resultincyanosis.Cyanosisneedstreated
immediatelyasitisalatedevelopmentin
hypoxia.

Provide
supplemental
oxygen,via100%
O2nonrebreather
mask.

Earlysupplementaloxygenisessentialinall
traumapatientssinceearlymortalityis
associatedwithinadequatedeliveryof
oxygenatedbloodtothebrainandvitalorgans.

Patientisreceiving100%
oxygen.SaO2viapulse
oximetryis90100%.

Preparethepatient
forintubation.

Earlyintubationandmechanicalventilation
arenecessarytomaintainadequate
oxygenationandventilation,priortofull
decompensationofthepatient.

Artificialairwayisplacedand
maintainedwithout
complications.

Treatthe
underlyinginjuries
withappropriate
interventions.

Treatmentneedstofocusontheunderlying
problemthatleadstotherespiratoryfailure.

Appropriateinjuryspecific
treatmenthasbeenstarted.

Ifribfractures
exist:

Paradoxicalmovementsaccompaniedby
dyspneaandpaininthechestwallindicate
flailchest.Flailchestisalifethreatening
complicationofribfracturesthatrequires
mechanicalventilationandaggressive
pulmonarycare.
Painreliefisessentialtoenhancecoughing
anddeepbreathing.
Absenceofbilateralbreathsoundsinthe
presenceofaflailchest,indicatesa
pneumo/hemothorax.

Noparadoxicalmovementsare
noted.
Patientreportspainas<3on0
10scale.
Bilateralbreathsoundspresent
inalllobes.

1.

Assessfor
paradoxica
lchest
movement
s.

2.

Provide
adequate
pain

3.

relief.

Assessbreath
sounds.

IfPneumothoraxor
Hemothoraxexist:
Achestxrayconfirmsthepresenceofa
1. obtain
Pneumothoraxand/orHemothorax.
chestxray Achesttubedecreasesthethoracicpressure
andreinflatesthelungtissue.
2. preparefor
insertion
Athreesideddressinggivestheaccumulated
ofachest airawaytoescape,therebydecreasing
tube
thoracicpressureandpreventingatension
Pneumothorax.Achesttubemustthenbe
inserted.
Ifopen
Pneumothorax
existsplacea
dressingthatis
tapedonthreesides
fortemporary
management.

Positionpatient
withheadofbed45
degrees(if
tolerated).

Promotesbetterlungexpansionandimproved
gasexchange.

Patientsrateandpatternareof
normaldepthandrateat45
degreeangle.

Assistpatientwith
coughinganddeep
breathing
techniques
(positioning,
incentive
spirometry,
frequentposition
changes,splinting
ofthechest).

Promotesalveolarexpansionandprevents
Patientisabletocoughanddeep
alveolarcollapse.
breatheeffectively.
Splintinghelpsreducepainandoptimizesdeep
breathingandcoughingefforts.

Suctionpatientas
needed.

Suctioningaidestoremovesecretionsfromthe
airwayandoptimizesgasexchange.

Patientsuctionedformoderate
amountofthinyellowsecretion.
Lungsoundsclearafter
suctioning.

Hyperoxygenate
patientwith100%

Preventsalterationinoxygenationduring
suctioning.

PatientsSaO2remained>90%

Chesttubeisplacedand
connectedto20cmwallsuction
withgoodtidalingandnoair
leakorSQemphysemanoted.
Threesideddressing
maintained.Nofurther
cardiopulmonary
decompensationnotedinpatient.

beforeandafter
suctioning.Keep
suctioningto1015
seconds.

Paceactivitiesand
providerestperiods
topreventfatigue.

duringsuctioning.

Evensimpleactivities,suchasbathing,can
increaseoxygenconsumptionandcause
fatigue.

Nochangestocardiopulmonary
statusnotedduringactivity.
PatientsSaO2remains>90%
duringactivities.

NursingDiagnosis
DeficientFluidVolumer/tactivefluidlossduetobleeding

LongTermGoal
Patientwillmaintainadequate
fluidandelectrolytebalance.

ShortTermGoals/Outcomes:
Patientwillmaintainurineoutput>30cc/hr.
Patientwillbenormotensivewithheartrate60100bpm.
Patientwilldemonstratenormalskinturgor.

Interventions

Rationale

Evaluation

Palpatepulses:carotid,
brachial,radial,femoral,
poplitealandpedal.Note
qualityandrate.

Ifcarotidandfemoralpulsesare
palpable,thenthebloodpressureis
usuallyatleast6080mmHgsystolic.
Ifperipheralpulsesarepresent,theblood
pressureisusuallyhigherthan80mmHg
systolic.Pulsesmaybeweakand
irregular.

Allpulsespalpable,strongand
regular.

Assessskincolorand
temperature.

Cool,pale,diaphoreticskinsuggests
ineffectivecirculationdueto
hypovolemia.

Skinpink,warmanddry.

Monitorpatientforactive
bloodlossfromwounds,
tubes,etc.Controlany
externalbleeding.

Activefluidand/orbloodlossaddsto
Hypovolemicstateandmustbe
accountedforwhenreplacingfluids.

Allexternalbleeding
controlled.

Monitorvitalsigns.
(T,P,R,B/P)

Sinustachycardiamayoccurwith
hypovolemiatomaintaincardiacoutput.
Hypotensionisahallmarkof
hypovolemia.Febrilestatesdecrease
bodyfluidsthroughperspirationand
increaserespiratoryrate.

Vitalsignswithinnormal
limits.

Monitorbloodpressure
fororthostaticchanges.

Greaterthan10mmHgdropsignifiesthat Noorthostaticchangesnoted
circulatingvolumeisreducedby20%.
whenpatientplacedfrom
Greaterthat2030mmHgdropsignifies supinetoFowlersposition.
bloodvolumeisdecreasedby40%.

Auscultatehearttonesand
inspectjugularveins.

Abnormallyflattenedjugularveinsand
distanthearttonesaresignsofineffective
circulation.

S1,S2audible.Noflatteningor
distentionofjugularveinnoted.

Assessmentalstatus.

Lossofconsciousnessaccompanies
ineffectivecirculatingbloodvolumeto
thebrain.

Awake,alertandorientedX3.

Assessskinturgorover
thesternumorinnerthigh;
andassessmoistureand
conditionofmucous
membranes.

Drymucousmembranesandtentingof
theskinaresignsofhypovolemia.The
sternumandinnerthighshouldbeused
forskinturgorduetolossofelasticity
withaging.

Normalskinturgor.Mucous
membranespinkandmoist.

Assesscolorandamount
ofurine.

Concentratedurineandoutput<30ccfor
twoconsecutivehoursindicate
insufficientcirculatingvolume.

Urineclear,yellow.Outputat
least30cc/hr.

Monitorserum
electrolytesandurine
osmolality.

Elevatedhemoglobin,Hematocritand
bloodureanitrogen(BUN)accompanya
fluiddeficit.Urinespecificgravityis
alsoincreased.

Alllabvalueswithinnormal
ranges.

Monitorhemodynamic
pressures:centralvenous
pressure(CVP),
pulmonaryarterypressure
(PAP),pulmonary
capillarywedgepressure
(PCWP),ifavailable.

Allvaluesdecreasewithinadequate
circulatingvolume.Hemodynamic
stabilityisthegoaloffluid
replacements.Monitoringof
hemodynamicpressurescanguidefluid
replacements.

Allpressureswithinnormal
ranges.

Initiatetwolargebore
intravenouscatheters
(IVs)andstartintravenous
fluidreplacementsas
ordered.

1416gaugecathetersarepreferredin
casefluidsneedtobegivenrapidly.
Parenteralfluidsarenecessarytorestore
volume.LactatedRingersisusuallythe
fluidofchoiceduetoitsisotonic
propertiesandcloseresemblancetothe
electrolytecompositionofplasma.

TwolargeboreIVsstarted,
lactatedringersinfusingasper
physicianorderswithout
complications.

Obtainaserumspecimen
fortypeandcrossmatCh
Administerbloodand
bloodproductsasordered.

Bloodandbloodproductswillbe
necessaryforactivebloodloss.Ifthere
isnotimetowaitforcrossmatching,
TypeObloodmaybetransfused.

Typeandcrosssent.Type
specificbloodinfusingasper
physicianorders.

Duringtreatmentmonitor Duetolargeamountsoffluids
forsignsoffluidoverload. administeredrapidly,circulatory
overloadcanoccur.Headache,flushed
skin,tachycardia,venousdistention,
elevatedhemodynamicpressures(CVP,
PCWP),increasedbloodpressure,
dyspnea,crackles,tachypneaandcough
areallsignsofoverload.

Nosignsofoverloadnotedwith
fluidreplacements.

Assistthephysicianwith
insertionofacentral
venouslineandarterial
lineifindicated.

Centralvenouslineandarterial
lineinsertedwithoutdifficulty.

Providesformoreeffectivefluid
replacementsandaccuratemonitoringof
hemodynamicpicture.

NursingDiagnosis
AcutePainr/ttrauma

LongTermGoal
Patientwillbefreeof
pain

ShortTermGoals/Outcomes:
Patientwillreportpainlessthan3on010scale.
Patientsvitalsignswillbewithinnormallimits.

Interventions

Rationale

Evaluation

Assesspain
characteristics:quality
(sharp,burning);
severity(010scale);
location;onset
(gradual,sudden);
duration(howlong);
precipitatingor
relievingfactors.

Agoodassessmentofpainwillhelpinthetreatment
andongoingmanagementofpain.

Patientreportspainas
3orlesson010scale;
intermittentandsharp
inincisionarea.

Monitorvitalsigns.

Tachycardia,elevatedbloodpressure,tachypneaand
fevermayaccompanypain.

Vitalsignswithin
normallimits.

Assessfornonverbal
signsofpain.

Somepatientsmayverballydenypainwhenitisstill
present.Restlessness,inabilitytofocus,frowning,
grimacingandguardingoftheareamaybenon
verbalsignsofacutepain.

Nononverbalsignsof
painnoted.

Giveanalgesicsas
orderedandevaluate
theeffectiveness.

Narcoticsareindicatedforseverepain.Pain
medicationsareabsorbedandmetabolizeddifferently
ineachpatient,sotheireffectivenessmustbe
assessedafteradministration.

Analgesicsgivenas
ordered.Patient
reportssatisfactory
painreliefafter
administration.

Assessthepatients
expectationsofpain
relief.

Somepatientsarecontentwithreductioninpain,
othersmayexpectcompleteelimination.Thiseffects
thepatientsperceptionoftheeffectivenessof
treatment.

PatientstatesIwant
somerelief.Iknow
somepainwillstill
exist.

Assessfor
complicationsto
analgesics,especially
respiratorydepression.

Excessivesedationandrespiratorydepressionare
severesideeffectsthatneedreportedimmediately
andmayrequirediscontinuationofmedication.
Urinaryretention,nausea/vomitingandconstipation
canalsooccurwithnarcoticuseandneedreported
andtreated.

Nocomplicationsof
analgesianoted.

Anticipatetheneedfor
painreliefandrespond
immediatelyto
complaintsofpain.

Themosteffectivewaytodealwithpainisto
preventit.Earlyinterventioncandecreasethetotal
amountofanalgesicrequired.Quickresponse
decreasesthepatientsanxietyregardinghavingtheir
needsmetanddemonstratescaring.

Patientreportspainas
soonasitstarts.

Eliminateadditional
stressorswhen
possible.Providerest
periods,sleepand
relaxation.

Outsidesourcesofstress,anxietyandlackofsleep
allmayexaggeratethepatientsperceptionofpain.

Patientappears
relaxed,issleeping
throughoutthenight.

Institutenon
pharmacological
approachedtopain
(detraction,relaxation
exercises,music
therapy,etc.).

Nonpharmacologicalapproacheshelpdistractthe
patientfromthepain.Thegoalistoreducetension
andtherebyreducepain.

Patientisrelaxingby
useofnon
pharmacological
techniqueofchoice.

Ifpatientisonpatient
controlledanalgesia
(PCA):

Druginteractionmayoccur,ifdedicatedlineisnot
possibleconsultpharmacistbeforemixingdrugs.

PCAinfusingwithout
complications.Patient
andfamilyunderstand
purposeanduseof
PCA.Patientisgetting
adequatepainrelief
withcurrentdose.

1.

Dedicatean
IVlinefor
PCAonly.

Ifdemandsforthedrugarefrequentthebasalor
lockoutdosemayneedtobeincreasedtocoverthe
patientspain.
Ifdemandsforthedrugareverylow,thepatientmay

2.

3.

Assesspain
reliefandthe
amountof
painthe
patientis
requesting.

2.

Assessfor
numbness,
tinglingin
extremities;
andametallic
tasteinthe
mouth.

2.

Thesesymptomsindicateanallergicresponse,or
impropercatheterplacement.
Labelingoftubingisnecessarytoprevent
inadvertentadministrationoffluidsordrugsinthe
epiduralspace.

Alltubinglabeled.No
signsofallergic
reactionorcatheter
migrationnoted.

Cathetermigrationorimproperadministration
throughthecathetercanresultinlifethreatening
complications.

Labelall
tubingclearly.

ForPCAandepidural
analgesia:
1.

Thepatientandsignificantothersmustunderstand
thatthepatientistheonlyonewhoshouldcontrolthe
PCA.

Educate
patientand
significant
otherson
correctuseof
PCA.

Ifthepatientis
receivingepidural
analgesia:
1.

needfurthereducationofuseofthePCA.

KeepNarcan
readily
available.

Ineventofrespiratorydepressionreversalagentmust
beavailable.

Narcanonunitif
needed.Signplacedin
roomforsafety.

Thispreventsinadvertentanalgesiaoverdosing.

PlaceNo
additional
analgesia
signover
headofbed.

NursingDiagnosis

LongTermGoal

RiskForInfectionr/tinadequateprimarydefenses

Patientwillbefreeof
infection

ShortTermGoals/Outcomes:
Patientwillmaintainnormalvitalsigns.
Patientwilldemonstrateabsenceofpurulentdrainagefromwounds,incisionsandtubes.

Interventions

Rationale

Evaluation

Assessforpresenceofrisk
factors:openwounds,
abrasions;indwellingcatheters;
drains;artificialairways;and
venousaccessdevices.

Representabreakinbodysfirstlineof
defense.

Patienthasmidline
thoracicincision,Foley,
chesttubeand
peripheralIVaccess.

Monitorwhitebloodcount
(WBC).

NormalWBCis411mm3.RisingWBC
indicatesthebodysattempttocombat
pathogens.

PatientsWBCare
withinthenormalrange.

Monitorincisions,injuredsites
andexitsitesoftubes,drains
andcathetersforsignsof
infection.

Redness,swelling,increasedpain,or
purulentdrainageissuspiciousofinfection
andshouldbecultured.

Allareasarewithout
signsofinfection.

Monitortemperatureandthe
presenceofsweatingandchills.

Inthefirst2448hoursfeverupto38
degreesC(100.4F)isrelatedtothestress
ofsurgery.After48hoursfeverabove
37.7C(99.8F)suggestsinfection.High
feverwithsweatingandchillssuggests
septicemia.

Temperatureislessthan
37.7C.Nosweatingor
chillspresent.

Monitorthecolorofrespiratory
secretions.

Yelloworyellowgreensputumindicatesa
respiratoryinfection.

Patientcoughsuponly
thinclearsecretions.

Monitortheappearanceof
urine.

Cloudy,foulsmellingurine,with
sedimentsindicatesaurinarytractor
bladderinfection.

Urineisclearyellow
withnosediments.

Maintainstrictaseptic
techniquewithalldressing
changes;tubes,drainsand
cathetercare;andvenous
accessdevices.

Strictasepsisisnecessarytopreventcross
contaminationandnosocomialinfections.

Nofurtherinfections
arenoted.

Washhandsandteachothersto
washhandsbeforeandafter
patientcare.

Handwashingreducestheriskof
transmittingpathogensfromoneareaofthe
bodytoanotheraswellasfromonepatient
toanother.

Nofurtherinfections
arenoted.

Encouragefluidintakeof
2000ml3000mlofwaterper
day(unlesscontraindicated).

Fluidspromotefrequentemptyingofthe
bladder,reducingstasisofurineandriskof
urinarytractandbladderinfections.

Patientdrinks2000
3000mloffluid.No
presenceofurinarytract
orbladderinfections.

Encourageintakeofproteinand Optimalnutritionalstatuspromoteswound
calorierichfoods.Provide
healing.
enteralfeedinginpatientswho
areNPO.

Woundsarewell
approximated.

Encouragecoughinganddeep
breathing.

Reducesstasisofpulmonarysecretions,
reducingtheriskofpneumonia.

Patientcoughsupthin
clearsecretions.

Administerandteachtheuseof
antimicrobialdrugsasordered.

Allagentsareeithertoxictothepathogens
orretardthepathogensgrowth.Ideally
medicationsshouldbeselectedbasedona
culturefromtheinfectedarea.Abroad
spectrumagentmaybestarteduntilculture
reportsareavailable.

WBCwithinnormal
limits.Nofurther
infectionsnoted.

NursingDiagnosis
RiskForIneffectiveTissuePerfusion:peripheral,renal,GI,
cardiopulmonary,orcentralr/thypovolemia,decreasedarterialflow&
cerebraledema

LongTermGoal
Patientwillmaintain
optimaltissue
perfusiontovital
organs

ShortTermGoals/Outcomes:
Patientwillmaintainstrongperipheralpulses.
Patientwillreportabsenceofchestpain.
Patientwillbeawake,alertandoriented.
Patientwillmaintainnormalarterialbloodgases(ABGs).
Patientwillmaintainnormalurineoutput.
Patientwillmaintainnormalbowelsounds.

Interventions

Rationale

Evaluation

Assesseachareafor
signsofdecreased
tissueperfusion.

Earlydetectionfacilitatesprompt,effective
treatment.

Signsmaybe:
Peripheral:weak,absentpulses;edema;numbness,
pain,aches;cooltotouch;mottling;prolonged
capillaryrefill
Cardiopulmonary:tachycardia,arrhythmias,
hypotension,tachypnea,abnormalABGs,angina
Renal:decreasedoutput,hematuria,elevated
BUN/creatinineratio
GI:decreasedorabsentbowelsounds;nausea;
abdominalpain/distention
Cerebral:restless,changeinmentationseizure
activity,papillarychangesanddecreasereactionto
light

Nosignsofdecreased
perfusionnoted.

Monitorvitalsignsfor
optimalcardiacoutput.

Adequateperfusiontovitalorgansisessential.A
meanarterialbloodpressureofatleast60mmHgis
essentialtomaintainperfusion.

Allvitalsignswithin
normallimits.

Administerfluidsand
bloodproductsas

Aidsinmaintainingadequatecirculatingvolumeto
preventirreversibleischemicdamage.

Fluidsinfusing.Vital
signs,urineoutputand

ordered.

mentationallwithin
normallimits.

Anticipatetheneedfor
possible
antithrombolytic
therapy.

Ifanobstructiontotheareahasdevelopedan
embolectomy,heparinzation,orthrombolytic
therapymaybenecessarytorestoreflowandprevent
ischemia

Heparininfusing.PTT
withintherapeutic
range.

Assessfor
compartmentsyndrome
ifperipheralcirculation
isimpaired(pain,palor,
pulselessness,paralysis,
parathesia).

Compartmentsyndromedevelopsasthetissueswells
andthefascialcoveringoverthemusclescannot
yieldtothepressure.Bloodflowtotheextremityis
drasticallyreduced.Anemergentfasciotomymay
needtobeperformedtorestoreflow.

Nosignsof
compartment
syndromenoted.

Administeroxygenas
prescribed.Titrate
oxygenbasedon
continuouspulse
oximetrylevels.

Oxygensaturatescirculatinghemoglobinand
increasestheeffectivenessofbloodthatreachedthe
ischemictissues.Thusimprovingtissueperfusion.

Patientreceiving
oxygen.Pulse
Oximetry90100%.

MonitorABGs,
especiallyformetabolic
acidosisandhypoxia.

Metabolicacidosisandhypoxiaindicatethattissues
arenotadequatelybeingperfused.

ABGswithinnormal
limits.

IfPatientcomplainsof
angina;

NTGcausesvasodilation,decreasespreloadand
afterloadandthusimprovesperfusiontothe
myocardium.

NTGadminister.
Patientreportsreliefof
angina.

Patientawakeand
alertwithnochangein

1.

administer
nitroglycerin
(NTG)
sublingually.

Ifcerebralperfusionis
compromised:
1.

Ensureproper

functioningof Promotesvenousoutflowfrombrainandhelps
intracranial
reducepressure.
pressure(ICP)
catheterif

present.
2.

Elevatehead
ofbed3045
degrees.

3.

Avoid
measuresthat
maytrigger
increasedICP

4.

Administer
anticonvulsant
sasneeded.

mentation.
Noseizuresnoted.

Straining,coughing,neckorhipflexionandlying
supinemayincreaseICPandfurtherreduceblood
flow.
Reducestheriskofseizures,whichmayresultfrom
cerebraledemaorischemia.

References:Gulianick,M.andMyers,J.(2003).NursingCarePlans:NursingDiagnosisandInterventions.
Mosby:St.LouisTaylor,K.Chapter8.CareofthePatientFollowingaTraumaticInjury

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