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BSN IV
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
Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.
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
Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes.
Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered.
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.
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
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.
Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis.
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
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.
To prevent decrease in venous outflow with increase in ICP. Exceptions include shock and cervical spine injuries.
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
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
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.