Nursing Diagnosis Acute Pain r/t trauma Short Term Goals / Outcomes: Patient will report pain less

than 3 on 0-10 scale. Patients vital signs will be within normal limits. Interventions Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors. Monitor vital signs. Assess for non-verbal signs of pain. Give analgesics as ordered and evaluate the effectiveness. Assess the patients expectations of pain relief. Rationale A good assessment of pain will help in the treatment and ongoing management of pain.

Long Term Goal Patient will be free of pain

Evaluation Patient reports pain as 3 or less on 0-10 scale; intermittent and sharp in incision area.

Tachycardia, elevated blood pressure, tachypnea and fever may accompany 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. Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration. Some patients are content with reduction in pain, others may expect complete elimination. This effects the patients perception of the effectiveness of treatment.

Vital signs within normal limits. No non-verbal signs of pain noted. Analgesics given as ordered. Patient reports satisfactory pain relief after administration. Patient states I want some relief. I know some pain will still exist. No complications of analgesia noted.

Assess for complications to Excessive sedation and respiratory depression are severe side effects analgesics, especially respiratory that need reported immediately and may require discontinuation of depression. medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated. Anticipate the need for pain relief and respond immediately to complaints of pain. Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation. 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 patients anxiety regarding having their needs met and demonstrates caring. Outside sources of stress, anxiety and lack of sleep all may exaggerate the patients perception of pain.

Patient reports pain as soon as it starts.

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. PCA infusing without complications. Patient and family understand purpose and use of PCA. Patient is getting adequate pain relief with current dose.

If patient is on patient controlled Drug interaction may occur, if dedicated line is not possible consult analgesia (PCA): pharmacist before mixing drugs. 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 analgesia sign over head of bed. In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing. If demands for the drug are frequent the basal or lock-out dose may need to be increased to cover the patients 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.

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.

Narcan on unit if needed. Sign placed in room for safety

Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction 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 Assess airway for patency by asking the patient to state his name. Inspect the mouth, neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Assess respiratory quality, rate, depth, effort and pattern. Assess for mental status changes. Assess changes in vital signs. Monitor arterial blood gases (ABGs). Administer supplemental oxygen. Position Patient with head of bed 45 degrees (if tolerated). Assist Patient with coughing and deep breathing Rationale 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. Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction. Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.

Long Term Goal: Patient will maintain a patent airway

Evaluation Patient is able to state their name without difficulty. No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline. Patients lungs sounds are clear to auscultation throughout all lobes. Patient is free of signs of distress.

Increasing lethargy, confusion, restlessness and / or irritability can Patient is awake, alert and oriented X3. be early signs of cerebral hypoxia. Tachycardia and hypertension occur with increased work of breathing. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. 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. Promotes better lung expansion and improved gas exchange. Assist patient to improve lung expansion, the productivity of the cough and mobilize secretions. Patient is normotensive with heart rate 60 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. Patient is receiving oxygen. SaO2 via pulse oximetry is 90 100%. Patients rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.

techniques (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). Confirm placement of the artificial airway. 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.

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 If neck trauma is present: 1. assess for potential hemorrhage and disruption of the larynx or trachea 2. prepare the patient for CT scan

The patient with maxillofacial trauma is usually more comfortable Patient exhibits normal respiratory rate and depth sitting up. Any time there is trauma to the maxillofacial area there in sitting position. Patient is free of wheezing, is the possibility of a compromised airway. stridor and facial edema. Noting swelling is important as a baseline for comparison later.

Hemorrhage or disruption of the larynx and trachea can be seen as Patient is free of signs of hemorrhage or hoarseness in speech, palpable crepitus, pain with swallowing or disruption. CT scan reveals no injury to the coughing, or hemoptysis. The neck should be also assessed for larynx. ecchymosis, abrasions, or loss of thyroid prominence. Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries.

Nursing Diagnosis Impaired Gas Exchange r/t altered oxygen supply 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 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. 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.

Long Term Goal Patient will maintain optimal gas exchange

Evaluation Patient is free of signs of distress. ABGs show PaCO2 between 35-45 Pts respirations are of a normal rate and depth.

Assess for lifethreatening 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. Assess for signs of hypoxemia. Monitor vital signs.

Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities. Patients lungs sounds are clear to auscultate throughout all lobes.

Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.

Patient is free of signs of hypoxia.

Initially with hypoxia and hypercapnia blood Patient is normotensive with heart pressure (BP), heart rate and respiratory rate all rate 60 100 bpm and respiratory increase. As the condition becomes more severe rate 10-20. BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue.

Assess for changes in Restlessness is an early sign of hypoxia. orientation and Mentation gets worse as hypoxia increases due behavior. to lack of blood supply to the brain. Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2 non-rebreather mask. Prepare the patient for intubation. 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.

Patient is awake, alert and oriented X3. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. SaO2 via pulse oximetry remains at 90 100%.

Lack of oxygen delivery to the tissues will result Patient is free of cyanosis. in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia. 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%.

Early intubation and mechanical ventilation are Artificial airway is placed and necessary to maintain adequate oxygenation and maintained without complications. ventilation, prior to full decompensation of the patient. Treatment needs to focus on the underlying problem that leads to the respiratory failure. Appropriate injury specific treatment has been started.

Treat the underlying injuries with appropriate interventions. If rib fractures exist: 1. Assess for paradoxical chest movements. 2. Provide adequate pain 3. relief.

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 mechanical ventilation and aggressive pulmonary care. Pain relief is essential to enhance coughing and deep breathing. Absence of bilateral breath sounds in the

No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.

Assess breath sounds. 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. Position patient with head of bed 45 degrees (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed.

presence of a flail chest, indicates a pneumo/hemo thorax.

A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and Chest tube is placed and re-inflates the lung tissue. connected to 20cm wall suction with good tidaling and no air leak A three sided dressing gives the accumulated air or SQ emphysema noted. a way to escape, thereby decreasing thoracic pressure and preventing a tension Three-sided dressing maintained. Pneumothorax. A chest tube must then be No further cardiopulmonary inserted. decompensation noted in patient.

Promotes better lung expansion and improved gas exchange.

Patients rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.

Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts.

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. Patients SaO2 remained >90% during suctioning.

Hyperoxygenate patient with 100% before and after

Prevents alteration in oxygenation during suctioning.

suctioning. Keep suctioning to 10-15 seconds. 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.