Nursing Care Plan

Nursing Diagnosis Long Term Goal:

Ineffective Airway Clearance r/t tracheobronchial obstruction 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 Maintaining an airway is always top priority especially in Patient is able to state their name without
by asking the patient to state patients who may have experienced trauma to the airway. If a difficulty.
his name. patient can articulate an answer, their airway is patent.
Inspect the mouth, neck and Foreign materials or blood in the mouth, hematoma of the neck No foreign objects, blood in mouth
position of trachea for or tracheal deviation can all mean airway obstruction. noted. Neck is free of hematoma. Trachea is
potential obstruction. midline.
Auscultate lungs for Decreased or absent sounds may indicate the presence of a Patients lungs sounds are clear to auscultation
presence of normal or mucous plug or airway obstruction. Wheezing indicates throughout all lobes.
adventitious lung sounds. airway resistance. Stridor indicates emergent airway
obstruction.
Assess respiratory quality, Flaring of the nostrils, dyspnea, use of accessory muscles, Patient is free of signs of distress.
rate, depth, effort and tachypnea and /or apnea are all signs of severe distress that
pattern. require immediate intervention.
Assess for mental status Increasing lethargy, confusion, restlessness and / or irritability Patient is awake, alert and oriented X3.
changes. can be early signs of cerebral hypoxia.
Assess changes in vital Tachycardia and hypertension occur with increased work of Patient is normotensive with heart rate 60
signs. breathing. 100 bpm.
Monitor arterial blood gases Increasing PaCO2 and decreasing PaO2 are signs of respiratory ABGs show PaCO2 between 35-45 and
(ABGs). failure. PaO2 between 80 100.
Administer supplemental Early supplemental oxygen is essential in all trauma patients Patient is receiving oxygen. SaO2 via pulse
oxygen. since early mortality is associated with inadequate delivery of oximetry is 90 100%.
oxygenated blood to the brain and vital organs.
Position Patient with head Promotes better lung expansion and improved gas exchange. Patients rate and pattern are of normal depth
of bed 45 degrees (if and rate at 45 degree angle.
tolerated).
Assist Patient with coughing Assist patient to improve lung expansion, the productivity of Patient is able to cough and deep breathe
and deep breathing the cough and mobilize secretions. effectively.
techniques (positioning,
incentive spirometry,
frequent position changes).
Prepare for placement of If a patient is unable to maintain an adequate airway, an Artificial airway is placed and maintained
endotracheal or surgical artificial airway will be required to promote oxygenation and without complications.
airway (i.e. ventilation; and prevent aspiration.
cricothyroidectomy,
tracheostomy).
Confirm placement of the Complications such as esophageal and right main stem CO2 detector changes color, bilateral breath
artificial airway. intubations can occur during insertion. Artificial airway sounds are audible equally and artificial airway
placement should be confirmed by CO2 detector, equal is at the tip of the carina on x-ray.
bilateral breath sounds and a chest x-ray.
If maxillofacial trauma is The patient with maxillofacial trauma is usually more Patient exhibits normal respiratory rate and
present: comfortable sitting up. Any time there is trauma to the depth in sitting position. Patient is free of
maxillofacial area there is the possibility of a compromised wheezing, stridor and facial edema.
1. position the patient airway.
for optimal airway
clearance and
constant assessment Noting swelling is important as a baseline for comparison later.
of airway patency
2. note the degree of
swelling to the face
and amount of blood
loss
 3. prepare the patient
for definitive
treatment

If neck trauma is present: Hemorrhage or disruption of the larynx and trachea can be Patient is free of signs of hemorrhage or
seen as hoarseness in speech, palpable crepitus, pain with disruption. CT scan reveals no injury to the
1. assess for potential swallowing or coughing, or hemoptysis. The neck should be larynx.
hemorrhage and also assessed for ecchymosis, abrasions, or loss of thyroid
disruption of the
larynx or trachea prominence.
2. prepare the patient Laryngeal injuries are most definitely diagnosed by CT scans
for CT scan 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 Long Term Goal

Impaired Gas Exchange r/t altered oxygen supply 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, Rapid, shallow breathing and hypoventilation affect gas Patient is free of signs of distress.
rate, pattern, depth and exchange by affecting CO2 levels. Flaring of the nostrils, ABGs show PaCO2 between 35-45
breathing effort. dyspnea, use of accessory muscles, tachypnea and /or apnea are Pts respirations are of a normal rate and
all signs of severe distress that require immediate intervention. depth.
Assess for life-threatening Absence of ventilation, asymmetric breath sounds, dyspnea with Patient exhibits spontaneous breathing, no
problems. (i.e. resp arrest,
flail chest, sucking chest
wound).
Auscultate lung Absence of lung sounds, JVD and / or tracheal deviation could
sounds. Also assess for the signify a Pneumothorax or Hemothorax.
presence of jugular vein
distention (JVD) or tracheal
deviation.
Assess for signs of
hypoxemia.
Monitor vital signs.
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.
accessory muscle use, dullness on chest percussion and gross dyspnea, use of accessory muscles, resonance
chest wall instability (i.e. flail chest or sucking chest wound) all on percussion and no chest wall
require immediate attention. abnormalities.
Patients lungs sounds are clear to auscultate
throughout all lobes.
Tachycardia, restlessness, diaphoresis, headache, lethargy and Patient is free of signs of hypoxia.
confusion are all signs of hypoxemia.
Initially with hypoxia and hypercapnia blood pressure (BP), Patient is normotensive with heart rate 60
heart rate and respiratory rate all increase. As the condition 100 bpm and respiratory rate 10-20.
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 Patient is awake, alert and oriented X3.
as hypoxia increases due to lack of blood supply to the brain.
Increasing PaCO2 and decreasing PaO2 are signs of respiratory ABGs show PaCO2 between 35-45 and
failure. PaO2 between 80 100.
Pulse oximetry is useful in detecting changes in SaO2 via pulse oximetry remains at 90
oxygenation. Oxygen saturation should be maintained at 90% or 100%.
greater.
Lack of oxygen delivery to the tissues will result in Patient is free of cyanosis.
cyanosis. Cyanosis needs treated immediately as it is a late
development in hypoxia.
Early supplemental oxygen is essential in all trauma patients Patient is receiving 100% oxygen. SaO2 via
since early mortality is associated with inadequate delivery of pulse oximetry is 90 100%.
oxygenated blood to the brain and vital organs.
Prepare the patient for Early intubation and mechanical ventilation are necessary to Artificial airway is placed and maintained
intubation. maintain adequate oxygenation and ventilation, prior to full without complications.
decompensation of the patient.
Treat the underlying injuries Treatment needs to focus on the underlying problem that leads Appropriate injury specific treatment has
with appropriate to the respiratory failure. been started.
interventions.
If rib fractures exist:

1. Assess for paradoxical Paradoxical movements accompanied by dyspnea and pain in No paradoxical movements are noted.
chest movements.
the chest wall indicate flail chest. Flail chest is a life-threatening Patient reports pain as <3 on 0-10 scale.
2. Provide adequate pain
3. relief. complication of rib fractures that requires mechanical ventilation Bilateral breath sounds present in all lobes.
and aggressive pulmonary care.
Assess breath sounds. 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.
If Pneumothorax or
Hemothorax exist:
A chest x-ray confirms the presence of a Pneumothorax and / or
1. obtain chest x-ray Hemothorax.
2. prepare for insertion
A chest tube decreases the thoracic pressure and re-inflates the Chest tube is placed and connected to 20cm
of a chest tube
lung tissue. wall suction with good tidaling and no air
If open Pneumothorax exists leak or SQ emphysema noted.
place a dressing that is taped A three sided dressing gives the accumulated air a way to
on three sides for temporary escape, thereby decreasing thoracic pressure and preventing a Three-sided dressing maintained. No further
management. tension Pneumothorax. A chest tube must then be inserted. cardiopulmonary decompensation noted in
patient.
Position patient with head of Promotes better lung expansion and improved gas exchange. Patients rate and pattern are of normal depth
bed 45 degrees (if tolerated). and rate at 45 degree angle.
Assist patient with coughing Promotes alveolar expansion and prevents alveolar collapse. Patient is able to cough and deep breathe
and deep breathing Splinting helps reduce pain and optimizes deep breathing and effectively.
techniques (positioning,
incentive spirometry,
frequent position changes,
splinting of the chest).
Suction patient as needed.
Hyperoxygenate patient Prevents alteration in oxygenation during suctioning.
with 100% before and after
suctioning. Keep suctioning
to 10-15 seconds.
Pace activities and provide
rest periods to prevent
fatigue.
coughing efforts.
Suctioning aides to remove secretions from the airway and Patient suctioned for moderate amount of thin
optimizes gas exchange. yellow secretion. Lung sounds clear after
suctioning.
Patients SaO2 remained >90% during
suctioning.
Even simple activities, such as bathing, can increase oxygen No changes to cardiopulmonary status noted
consumption and cause fatigue. during activity.
Patients SaO2 remains >90% during
activities.

Nursing Diagnosis Long Term Goal

Deficient Fluid Volume r/t active fluid loss due to bleeding 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, If carotid and femoral pulses are palpable, then the blood All pulses palpable, strong and regular.
radial, femoral, popliteal and pedal. pressure is usually at least 60 80 mmHg systolic. If
Note quality and rate. peripheral pulses are present, the blood pressure is

Assess skin color and temperature.
Monitor patient for active blood loss
from wounds, tubes, etc. Control
any external bleeding.
Monitor vital signs. (T,P,R,B/P)
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 Elevated hemoglobin, Hematocrit and blood urea
osmolality.
usually higher than 80 mmHg systolic. Pulses may be
weak and irregular.
Cool, pale, diaphoretic skin suggests ineffective Skin pink, warm and dry.
circulation due to hypovolemia.
Active fluid and/or blood loss adds to Hypovolemic state All external bleeding controlled.
and must be accounted for when replacing fluids.
Sinus tachycardia may occur with hypovolemia to Vital signs within normal limits.
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 No orthostatic changes noted when patient
volume is reduced by 20%. Greater that 20 30 mmHg placed from supine to Fowlers position.
drop signifies blood volume is decreased by 40%.
Abnormally flattened jugular veins and distant heart S1, S2 audible. No flattening or distention
tones are signs of ineffective circulation. of jugular vein noted.
Loss of consciousness accompanies ineffective Awake, alert and oriented X3.
circulating blood volume to the brain.
Dry mucous membranes and tenting of the skin are signs Normal skin turgor. Mucous membranes
of hypovolemia. The sternum and inner thigh should be pink and moist.
used for skin turgor due to loss of elasticity with aging.
Concentrated urine and output <30cc for two consecutive Urine clear, yellow. Output at least 30cc/hr.
hours indicate insufficient circulating volume.
All lab values within normal ranges.
nitrogen (BUN) accompany a fluid deficit. Urine
specific-gravity is also increased.
Monitor hemodynamic pressures:
central venous pressure (CVP),
pulmonary artery pressure (PAP),
pulmonary capillary wedge pressure
(PCWP), if available.
Initiate two large bore intravenous
catheters (IVs) and start intravenous
fluid replacements as ordered.
Obtain a serum specimen for type
and cross matCh Administer blood
and blood products as ordered.
During treatment monitor for signs
of fluid overload.
Assist the physician with insertion of Provides for more effective fluid replacements and
a central venous line and arterial line accurate monitoring of hemodynamic picture.
if indicated.
All values decrease with inadequate circulating All pressures within normal ranges.
volume. Hemodynamic stability is the goal of fluid
replacements. Monitoring of hemodynamic pressures
can guide fluid replacements.
14 -16 gauge catheters are preferred in case fluids need to Two large bore IVs started, lactated ringers
be given rapidly. Parenteral fluids are necessary to infusing as per physician orders without
restore volume. Lactated Ringers is usually the fluid of complications.
choice due to its isotonic properties and close
resemblance to the electrolyte composition of plasma.
Blood and blood products will be necessary for active Type and cross sent. Type specific blood
blood loss. If there is no time to wait for cross matching, infusing as per physician orders.
Type O blood may be transfused.
Due to large amounts of fluids administered rapidly, No signs of overload noted with fluid
circulatory overload can occur. Headache, flushed skin, replacements.
tachycardia, venous distention, elevated hemodynamic
pressures (CVP, PCWP), increased blood pressure,
dyspnea, crackles, tachypnea and cough are all signs of
overload.
Central venous line and arterial line inserted
without difficulty.

Nursing Diagnosis Long Term Goal

Acute Pain r/t trauma Patient will be free of pain
Short Term Goals / Outcomes:
Patient will report pain less than 3 on 0-10 scale.
Patients vital signs will be within normal limits.
Interventions Rationale Evaluation
Assess pain characteristics: A good assessment of pain will help in the treatment and ongoing Patient reports pain as 3 or less
quality (sharp, burning); management of pain. on 0-10 scale; intermittent and
severity (0 -10 scale); location; sharp in incision area.
onset (gradual, sudden);
duration (how long);
precipitating or relieving
factors.
Monitor vital signs. Tachycardia, elevated blood pressure, tachypnea and fever may Vital signs within normal
accompany pain. limits.
Assess for non-verbal signs of Some patients may verbally deny pain when it is still No non-verbal signs of pain
pain. present. Restlessness, inability to focus, frowning, grimacing and noted.
guarding of the area may be non-verbal signs of acute pain.
Give analgesics as ordered and Narcotics are indicated for severe pain. Pain medications are Analgesics given as
evaluate the effectiveness. absorbed and metabolized differently in each patient, so their ordered. Patient reports
effectiveness must be assessed after administration. satisfactory pain relief after
administration.
Assess the patients Some patients are content with reduction in pain, others may expect Patient states I want some
expectations of pain relief. complete elimination. This effects the patients perception of the relief. I know some pain will
effectiveness of treatment. still exist.
Assess for complications to Excessive sedation and respiratory depression are severe side effects No complications of analgesia
analgesics, especially that need reported immediately and may require discontinuation of noted.
respiratory depression. medication. Urinary retention, nausea/vomiting and constipation can
also occur with narcotic use and need reported and treated.
Anticipate the need for pain The most effective way to deal with pain is to prevent it. Early Patient reports pain as soon as
relief and respond immediately intervention can decrease the total amount of analgesic it starts.
to complaints of pain. required. Quick response decreases the patients anxiety regarding
having their needs met and demonstrates caring.
Eliminate additional stressors
when possible. Provide rest
periods, sleep and relaxation.
Institute non-pharmacological Non-pharmacological approaches help distract the patient from the
approached to pain (detraction, pain. The goal is to reduce tension and thereby reduce pain.
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 amount of pain the
patient is requesting.
3. Educate patient and
significant others on
correct use of PCA.
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.
For PCA and epidural
analgesia:
1. Keep Narcan readily
available.
2. Place No additional
Outside sources of stress, anxiety and lack of sleep all may Patient appears relaxed, is
exaggerate the patients perception of pain. sleeping throughout the night.
Patient is relaxing by use of
non-pharmacological
technique of choice.
Drug interaction may occur, if dedicated line is not possible consult PCA infusing without
pharmacist before mixing drugs. complications. Patient and
family understand purpose and
If demands for the drug are frequent the basal or lock-out dose may use of PCA. Patient is getting
need to be increased to cover the patients pain. adequate pain relief with
If demands for the drug are very low, the patient may need further current dose.
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.
These symptoms indicate an allergic response, or improper catheter All tubing labeled. No signs
placement. of allergic reaction or catheter
migration noted.
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.
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.
 analgesia sign over
head of bed.
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 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.
Monitor the color of respiratory
secretions.
Monitor the appearance of urine.
Maintain strict aseptic technique with all
dressing changes; tubes, drains and
Long Term Goal
Patient will be free of infection
Rationale Evaluation
Represent a break in bodys first line of defense. Patient has midline thoracic
incision, Foley, chest tube and
peripheral IV access.
Normal WBC is 4-11 mm3. Rising WBC indicates the Patients WBC are within the
bodys attempt to combat pathogens. normal range.
Redness, swelling, increased pain, or purulent drainage All areas are without signs of
is suspicious of infection and should be cultured. infection.
In the first 24-48 hours fever up to 38 degrees C Temperature is less than
(100.4F) is related to the stress of surgery. After 48 37.7C. No sweating or chills
hours fever above 37.7C (99.8F) suggests infection. present.
High fever with sweating and chills suggests septicemia.
Yellow or yellow-green sputum indicates a respiratory Patient coughs up only thin
infection. clear secretions.
Cloudy, foul-smelling urine, with sediments indicates a Urine is clear yellow with no
urinary tract or bladder infection. sediments.
Strict asepsis is necessary to prevent cross- No further infections are noted.
contamination and nosocomial infections.
catheter care; and venous access devices.
Wash hands and teach others to wash
hands before and after patient care.
Encourage fluid intake of 2000ml
3000ml of water per day (unless
contraindicated).
Encourage intake of protein and calorie
rich foods. Provide enteral feeding in
patients who are NPO.
Encourage coughing and deep breathing.
Administer and teach the use of
antimicrobial drugs as ordered.
Hand washing reduces the risk of transmitting pathogens No further infections are noted.
from one area of the body to another as well as from one
patient to another.
Fluids promote frequent emptying of the bladder, Patient drinks 2000 -3000 ml of
reducing stasis of urine and risk of urinary tract and fluid. No presence of urinary
bladder infections. tract or bladder infections.
Optimal nutritional status promotes wound healing. Wounds are well approximated.
Reduces stasis of pulmonary secretions, reducing the Patient coughs up thin clear
risk of pneumonia. secretions.
All agents are either toxic to the pathogens or retard the WBC within normal limits. No
pathogens growth. Ideally medications should be further infections noted.
selected based on a culture from the infected area. A
broad-spectrum agent may be started until culture
reports are available.

Nursing Diagnosis Long Term Goal

Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t Patient will maintain optimal
hypovolemia, decreased arterial flow & cerebral edema 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 Early detection facilitates prompt, effective treatment.
decreased tissue perfusion.
Signs may be:
Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool
to touch; mottling; prolonged capillary refill No signs of decreased
Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, perfusion noted.
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
Monitor vital signs for optimal Adequate perfusion to vital organs is essential. A mean arterial blood All vital signs within normal
cardiac output. pressure of at least 60 mmHg is essential to maintain perfusion. limits.
Administer fluids and blood Aids in maintaining adequate circulating volume to prevent Fluids infusing. Vital signs,
products as ordered. irreversible ischemic damage. urine output and mentation all
within normal limits.
Anticipate the need for If an obstruction to the area has developed an embolectomy, Heparin infusing. PTT within
possible antithrombolytic heparinzation, or thrombolytic therapy may be necessary to restore therapeutic range.
therapy. flow and prevent ischemia
Assess for compartment Compartment syndrome develops as the tissue swells and the fascial No signs of compartment
syndrome if peripheral covering over the muscles can not yield to the pressure. Blood flow syndrome noted.
circulation is impaired (pain, to the extremity is drastically reduced. An emergent fasciotomy may
palor, pulselessness, paralysis, need to be performed to restore flow.
parathesia).
Administer oxygen as Oxygen saturates circulating hemoglobin and increases the Patient receiving
prescribed. Titrate oxygen effectiveness of blood that reached the ischemic tissues. Thus oxygen. Pulse Oximetry 90
based on continuous pulse improving tissue perfusion. 100%.
oximetry levels.
Monitor ABGs, especially for Metabolic acidosis and hypoxia indicate that tissues are not ABGs within normal limits.
metabolic acidosis and adequately being perfused.
hypoxia.
If Patient complains of angina; NTG causes vasodilation, decreases preload and afterload and thus NTG administer. Patient
improves perfusion to the myocardium. reports relief of angina.
1. administer nitroglycerin
(NTG) sublingually.

If cerebral perfusion is
compromised:
Patient awake and alert with
1. Ensure proper no change in mentation.
functioning of
Promotes venous outflow from brain and helps reduce pressure.
intracranial pressure
(ICP) catheter if present. No seizures noted.
2. Elevate head of bed 30 -
45 degrees.
3. Avoid measures that
may trigger increased
Straining, coughing, neck or hip flexion and lying supine may
ICP increase ICP and further reduce blood flow.
4. Administer Reduces the risk of seizures, which may result from cerebral edema
anticonvulsants as or ischemia.
needed.

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