7 Drowning (Submersion Injury) Nursing Care Plans

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).

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• Aspiration (freshwater or saltwater)
• Bronchospasm
• 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
• Hypoxemia
• Retractions
• Stridor

Desired Outcomes

• 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).