Nursing DiagnosisAcute Pain r/t trauma

Long Term GoalPatient 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):

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.

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:

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 life-threatening 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.

 

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 DiagnosisIneffective 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 auscultatePatient will be free of dyspneaPatient 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:

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

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:

1. assess for potential hemorrhage and disruption of the larynx or trachea

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

Patient is free of signs of hemorrhage or disruption.  CT scan reveals no injury to the larynx.

2. prepare the patient for CT scan

as soft tissue neck films are not sensitive to these injuries.

Nursing DiagnosisImpaired Gas Exchange r/t altered oxygen supply

Long Term GoalPatient 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 35-45Pts 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

Patient is normotensive with heart rate 60 – 100 bpm and

all increase.  As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue.

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:

1. Assess for paradoxical chest movements.

 

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

 

No paradoxical movements are noted.Patient reports pain as <3 on 0-10 scale.

2. Provide adequate pain

3. relief.

        Assess breath sounds.

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.

Bilateral breath sounds present in all lobes.

If Pneumothorax or Hemothorax exist:

1. obtain chest x-ray

2. 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.