Drowning is the third leading cause of unintentional injury death worldwide, accounting for more 360,000 deaths annually. Submersion in water leads to the rapid onset of hypoxemia (Wyckoff et al., 2022). Near-drowning is defined as survival for at least 24 hours from suffocation by submersion. Aspiration of water causes the plasma to be pulled into the lungs, resulting in hypoxemia, acidosis, and hypovolemia. Hypoxemia results from the decrease in pulmonary surfactant caused by the absorbed water leading to damage to the pulmonary capillary membrane. Severe hypoxia can also result from asphyxia related to submersion without aspiration of fluid.
Even so, consensus and society guidelines have standardized the definitions associated with drowning to provide a consistent guideline for writing, documenting, and studying these incidents. Terms such as “near-drowning,” “secondary drowning,” “wet drowning,” and “dry drowning” should no longer be used. Instead, drowning, fatal drowning, non-fatal drowning, and rescue provide more clarity, reliability, and uniformity for discussion and documentation.
Drowning is defined as “the process of experiencing respiratory impairment from submersion or immersion in liquid.” and drowning outcomes are fatal or non-fatal. Fatal drowning is a drowning event with a fatal outcome, whereas non-fatal drowning is a drowning event in which the process of respiratory impairment is stopped before death, and the victim survives.
The World Health Organization has proposed a framework to further classify non-fatal drowning based on the severity of respiratory impairment immediately after the drowning process has stopped:
- Mild impairment: breathing, involuntary distressed coughing, and fully alert.
- Moderate impairment: difficulty breathing and/or disoriented but conscious.
- Severe impairment: Not breathing and/or unconscious. It is further classified into morbidity category based upon any decline from previous functional capacity at the time of measurement.
- No morbidity: no decline
- Some morbidity: some decline
- Severe morbidity: severe decline.
The term rescue refers to an intervention that prevents progression to drowning in an individual who is submerged but at no time develops respiratory symptoms or impairment.
The three most important risk factors that contribute to drowning are the inability to swim or the overestimation of swimming capabilities, risk-taking behaviors, and inadequate adult supervision. A client who has drowned may be unresponsive. Other symptoms may include cold or pale skin, abdominal swelling, vomiting, cough with pink, frothy sputum, shortness or lack of breath, lethargy, and chest pain.
Freshwater drownings are far more common than saltwater drownings. Fresh water usually results in surfactant loss, hence, producing areas of atelectasis. Saltwater aspiration, on the other hand, results in pulmonary edema due to the osmotic effects of the salt within the lung.
Nursing Care Plans
Therapeutic goals for a client who has drowned include providing adequate oxygenation, maintaining a patent airway, maintaining cerebral perfusion, continuous monitoring, providing rewarming methods, and absence of complications.
Here are seven (7) nursing care plans and nursing diagnosis (NDx) for drowning (submersion injury):
- Impaired Gas Exchange
- Ineffective Cerebral Tissue Perfusion
- Deficient/Excess Fluid Volume
- Risk for Infection
- Risk for Decreased Cardiac Output
- Risk for Ineffective Thermoregulation
- Deficient Knowledge
Impaired Gas Exchange
Clients with prolonged hypoxic episodes are prone to alveolar fluid aspiration resulting in vagally mediated pulmonary vasoconstriction, hypertension, and fluid-induced bronchospasm. Freshwater is considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Destruction of surfactant produces alveolar instability, atelectasis, and decreased compliance, with marked ventilation/perfusion (V/Q) mismatching (Cantwell & Verive, 2021).
- Impaired Gas Exchange
May be related to
- Aspiration (freshwater or saltwater)
- Pulmonary capillary membrane damage
- Pulmonary edema
- Pulmonary surfactant elimination
Possibly evidenced by
- Abnormal arterial blood gases
- Abnormal breathing rate, depth, and rhythm
- Bluish, pale appearance
- Frothy, pink-tinged sputum
- The client will maintain optimal gas exchange, as evidenced by arterial blood gases (ABGs) within client’s usual range, oxygen saturation of 90% or higher, alert, responsive mentation or no further decline in the level of consciousness, relaxed breathing, and baseline heart rate for the client.
Nursing Assessment and Rationales
1. Assess the client’s level of consciousness.
Within three minutes of submersion, drowning clients are unconscious and are at risk for cerebral edema. Experienced swimmers may experience syncope secondary to hypoxia after hyperventilating to drive off carbon dioxide, while deep-water divers may succumb to “shallow-water blackout” as they ascend (Cantwell & Verive, 2021).
2. Assess the client’s respiratory rate, depth, and rhythm.
Changes in the respiratory rate and rhythm are early warning signs of impending respiratory difficulties. Impairment of gas exchange can result in both rapid, shallow breathing patterns and hypoventilation. Hypoxia is associated with increased breathing effort. Aspiration of as little as 1 to 3 ml/kg of fluid leads to significantly impaired gas exchange (Cantwell & Verive, 2021).
3. Auscultate the lung for breath sounds such as crackles and wheezing.
Crackles are caused by fluid accumulation in the airways and by pulmonary edema. Wheezing is related to bronchospasm. The presence of water in the airways triggers coughing and laryngospasm. When laryngospasm stops, the client may then aspirate larger volumes of water.
4. Monitor for signs of respiratory difficulties such as nasal flaring, stridor, retractions, and the use of accessory muscles.
The breathing pattern alters to increase chest excursion to facilitate effective breathing. The period of hypoxia or hypoxemia is initially limited to the duration of hypopnea or apnea and may resolve with initial rescue efforts (Cantwell & Verive, 2021).
5. Assess for any signs of worsening pulmonary edema.
Pink, frothy sputum is a classic sign of pulmonary edema; this necessitates the need for mechanical ventilation. Postobstructive pulmonary edema following laryngospasm and hypoxic neuronal injury with resultant neurogenic pulmonary edema may also occur. Acute respiratory distress syndrome (ARDS) from altered surfactant effect and neurogenic pulmonary edema often complicate management (Cantwell & Verive, 2021).
6. Monitor oxygen saturation and ABGs as ordered.
Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be at 90% or greater. Decreasing PaO2 and pulse oximetry readings and increasing PaCo2 are signs of respiratory failure. ABG analysis is probably the most reliable clinical parameter in clients who are asymptomatic or mildly asymptomatic. ABG analysis should include co-oximetry to detect whether methemoglobinemia and carboxyhemoglobinemia (Cantwell & Verive, 2021).
7. Monitor chest-x-ray readings.
Chest X-ray reports on all submersion victims are done to assess the degree of aspiration and lung injury. Radiographic studies of lung water lag behind the clinical presentation by 24 hours. A chest x-ray may also detect evidence of aspiration, pulmonary edema, or segmental atelectasis, suggesting the presence of foreign bodies (Cantwell & Verive, 2021).
Nursing Interventions and Rationales
1. Maintain the client’s airway and assist with ventilation as needed while protecting the cervical spine.
Maintaining a patent airway is always the first priority. Cervical spine injuries should always be considered in victims of drowning, especially after a dive. Management of the client with a submersion injury is based on the degree of cerebral insult. The first priority is to restore oxygen delivery to the cells and prevent further hypoxic damage.
2. Provide oxygenation as ordered.
If the client has spontaneous breathing, supplemental oxygenation is administered by mask. Early use of intubation and PEEP, or CPAP/bilevel PEEP (BiPAP) in the awake, cooperative, and less hypoxic individual, is warranted if hypoxia or dyspnea persists despite 100% oxygen (Cantwell & Verive, 2021).
3. Insert nasogastric tube as indicated.
Nasogastric tube placement can be used for the removal of swallowed water and debris. The orogastric route may be used if head or facial trauma is present (Cantwell & Verive, 2021).
4. Anticipate the need for intubation and mechanical ventilation.
The outcomes of pulmonary injury are a clinical picture of acute respiratory distress syndrome: pulmonary edema, atelectasis, hyaline membrane formation, and pulmonary capillary injury. Early intubation and mechanical ventilation are suggested to prevent full decompensation of the client. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation (Cantwell & Verive, 2021).
5. Assist in endotracheal intubation.
Intubation may be required in order to provide adequate oxygenation in a client unable to maintain a PO2 of greater than 60 to 70 mm Hg on 100% oxygen by facemask. In the alert, cooperative client, a trial of BiPAP/CPAP, if available, may be provided for adequate oxygenation before intubation (Cantwell & Verive, 2021).
6. Use positive end-expiratory pressure (PEEP) for clients in mechanical ventilation.
Intubated clients with submersion injury may require PEEP with mechanical ventilation to maintain adequate oxygenation. PEEP has been shown to improve ventilation patterns in the noncompliant lung in several ways (Cantwell & Verive, 2021).
7. Monitor the client placed on extracorporeal membrane oxygenation (ECMO) closely.
ECMO has been shown to be beneficial in selected clients. It may be considered in the following circumstances: respiratory compromise resulting from a lack of response to conventional mechanical ventilation or high-frequency ventilation, a reasonable probability of the client recovering neurologic function, and persistent hypothermia from cold-water drowning (Cantwell & Verive, 2021).
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to respiratory system disorders:
- Asthma | 9 Care Plans UPDATED!
- Bronchiolitis | 7 Care Plans UPDATED!
- Bronchopulmonary Dysplasia (BPD) | 7 Care Plans UPDATED!
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans UPDATED!
- Cystic Fibrosis | 6 Care Plans UPDATED!
- Hemothorax, Pneumothorax, and Pleural Effusion | 5 Care Plans UPDATED!
- Influenza (Flu) | 6 Care Plans UPDATED!
- Lung Cancer | 7 Care Plans UPDATED!
- Mechanical Ventilation & Endotracheal Intubation | 10 Care Plans UPDATED!
- Drowning (Submersion Injury) | 7 Care Plans UPDATED!
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans
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