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Natividad, Michael John F.

BSN IV

Nursing Care Plan for Gunshot Wound to the Head

ASSESSMENT Subjective: >N/A: Patient is unconscious

DIAGNOSIS Deficient Fluid Volume related to active fluid loss (bleeding) secondary to gunshot wound to the head

PLANNING After 4 hours of nursing intervention, patient will be able to maintain adequate fluid volume and electrolyte balance as evidenced by urine output >30 ml per hr, normotensive blood pressure (BP), heart rate (HR) 100 beats per min, and normal skin turgor.

INTERVENTION Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate.

RATIONALE 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. 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.

EVALUATION After 8 hours of nursing intervention, patient was able to maintain adequate fluid volume and electrolyte balance as evidenced by urine output >30 ml per hr, normotensive blood pressure (BP), heart rate (HR) 100 beats per min, and normal skin turgor.

Objective: >Profuse bleeding of the wounded head >BP: 80/50 >HR: 117 >Decreased Urine output >unconscious >pallor >cool, clammy skin

Assess skin color and temperature.

Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head

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%. Abnormally flattened jugular veins and distant heart tones are signs of ineffective

Monitor blood pressure for orthostatic changes.

Auscultate heart tones and inspect jugular veins.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


circulation. Assess mental status. 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. 14 -16 gauge catheters are preferred in case fluids need to be given rapidly. Parenteral

Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes.

Assess color and amount of urine.

Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


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. 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. Due to large amounts of fluids administered rapidly, circulatory overload can occur. Headache, flushed skin, tachycardia, venous distention, elevated hemodynamic

During treatment monitor for signs of fluid overload.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


pressures (CVP, PCWP), increased blood pressure, dyspnea, crackles, tachypnea and cough are all signs of overload.

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.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


ASSESSMENT Subjective: >N/A: Patient is unconscious DIAGNOSIS Impaired Gas exchange related to altered oxygen supply PLANNING After 2 hours of nursing intervention, oximetry results within normal range INTERVENTION Assess respirations: quality, rate, pattern, depth and breathing effort. RATIONALE 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. to reduce oxygen demands during acute respiratory distress 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. Tachycardia, restlessness, EVALUATION After 2 hours of nursing intervention, oximetry results within normal range

Objective: >RR: 7 CPM >O2 Sat: 85% >BP: 80/50 >HR: 117 >Decreased Urine output >unconscious >pallor >cool, clammy skin >Profuse bleeding of the wounded head >gunshot wound to the occiput penetrating to the periorbital area

Maintain client on bed rest

Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound).

Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


Assess for signs of hypoxemia. Monitor vital signs. diaphoresis, headache, lethargy and confusion are all 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. 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.

Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


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. Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient. Treatment needs to focus on the underlying problem that leads to the respiratory failure.

Prepare the patient for intubation.

Treat the underlying injuries with appropriate interventions.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


ASSESSMENT Subjective: >N/A: Patient is unconscious DIAGNOSIS Ineffective cerebral tissue perfusion related to brain injury PLANNING After4 hour of nursing interventions, patient will maintain optimal cerebral tissue perfusion, as evidenced by ICP<10 mm Hg, CGS>13, and CPP from 60 mm Hg to 90 mm Hg INTERVENTION Assess neurologic status as follows: LOC per Glasgow Coma Scale-pupil size, symmetry, and reaction to light; extraocular movement (EOM); gaze preference; speech and thought processes; memory; motor-sensory signs and drift; increased tone; increased reflexes; Babinski reflex. Monitor vital signs. RATIONALE Deteriorating neurological signs indicate increased cerebral ischemia. EVALUATION After1 hour of nursing interventions, patient was able to establish method of communication in which needs can be understood.

Objective: >gunshot wound to the occiput penetrating to the periorbital area >Profuse bleeding of the wounded head >O2 Sat: 85% >BP: 80/50 >HR: 117 >Decreased Urine output >unconscious >pallor >cool, clammy skin

Continually increasing ICP results in life-threatening hemodynamic changes; early recognition is essential to survival.

Monitor arterial blood gases (ABGs) and/or pulse oximetry. Recommended parameters of PaO2>80 mm Hg and PaCO2<35

A PaCO2<20 mm Hg may decrease CBF because of profound vasoconstriction that produces hypoxia. PaCO2>45 mm Hg induces vasodilation with increase in CBF, which

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


mm Hg with normal ICP. may trigger increase in ICP. If patient's lungs are being hyperventilated to decrease ICP, PaCO2 should be between 25 and 30 mm Hg. Monitor input and output with urine-specific gravity. Report urinespecific gravity >1.025 or urine output <1.50 ml/kg/hr. May indicate decreased renal perfusion and possible associated decrease in CPP.

Monitor ICP if measurement device is in place. Report ICP>15 mm Hg for 5 minutes. Calculate cerebral perfusion pressure (CPP)

Should be approximately 90 mm Hg to 100 mm Hg and not <50 mm Hg to ensure blood flow to brain.

Elevate head of bed 30 degrees, and keep head in neutral alignment.

To prevent decrease in venous outflow with increase in ICP. Exceptions include shock and cervical spine injuries.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head

Avoid Valsalva's maneuver

increases intrathoracic pressure and CBF, thereby increasing ICP.

If ICP increases and fails to respond to repositioning of head in neutral alignment and head elevation, recheck equipment. If ICP is increased, one or more of the following may be prescribed by the physician: Hyperventilate the patient to decrease PaCO2 to between 25 mm Hg and 30 mm Hg; this induces vasoconstriction and a decrease in CBF. This is a hyperosmotic agent and needs to be given with caution. It is contraindicated with hypovolemic symptoms (e.g., hypotension, tachycardia, CHF, renal failure, hypernatremia). A

Administer mannitol 0.25 to 1.0 g per kg given over 30 to 60 minutes.

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


diuretic response can be anticipated within 30 to 60 minutes. A Foley catheter should be in place. An intravenous (IV) filter should be used when mannitol is infused. Electrolytes, osmolality, and serum glucose must be monitored during mannitol infusion. Administer barbiturates and additional diuretics such as furosemide (Lasix) if ICP is refractory to hyperventilation and mannitol regimen.

If patient is intubated, administer neuromuscular blocking agent.

To reduce shivering, coughing, bucking, Valsalva's maneuver. Remember, however, that neuromuscular blocking agents have no effect on cerebration; therefore, the patient should receive short-acting sedation

Natividad, Michael John F. BSN IV

Nursing Care Plan for Gunshot Wound to the Head


before noxious stimulation.

Administer a short-acting pain reliever (e.g., morphine [Demerol] or midazolam [Versed]), before painful stimulation or stress-related care such as suctioning or IV line changes. Administer corticosteroids.

Pain response includes increased blood pressure.

To reduce the inflammatory response seen in acute brain injury.