Near-drowning is defined as survival for at least 24 hours from suffocation by submersion. Aspiration of water causes 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 that leads to damage of the pulmonary capillary membrane. Severe hypoxia can also result from asphyxia related to submersion without aspiration of fluid.
Factors associated with near-drowning include an inability to swim, accidents/injuries, alcohol use, underlying seizure disorder or cardiac dysrhythmia, hyperventilation, and hypothermia. A client who has nearly 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, and 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 nearly drowned include providing adequate oxygenation, maintaining a patent airway, maintaining cerebral perfusion, continuous monitoring, providing rewarming methods, and absence of complications.
Here are five (5) nursing care plans and nursing diagnosis (NDx) for near-drowning:
- Impaired Gas Exchange
- Ineffective Cerebral Tissue Perfusion
- Deficient/Excess Fluid Volume
- Risk for Infection
- Risk for Decreased Cardiac Output
Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis
- Ineffective Tissue Perfusion
May be related to
- Cerebral edema
- Gas exchange insufficiency
- Increased intracranial pressure (ICP)
- Prolonged hypoxemia
Possibly evidenced by
- Altered level of consciousness
- Changes in behavior
- Changes in motor response
- Changes in pupillary response
- Deficit in cranial nerve response
Desired Outcomes
- Client will maintain optimal cerebral tissue perfusion, as evidenced by alert, responsive mentation; absence of neurological deficits; normoreactive pupils; normal or baseline motor function.
| Nursing Interventions | Rationale |
|---|---|
| Using the Glasgow Coma Scale (GCS), assess the level of consciousness. | The GCS measures changes in the level of consciousness based on the verbal, motor, and pupillary responses. Early signs of cerebral hypoxia are restlessness and anxiety, leading to agitation, confusion, lethargy, and coma. |
| Monitor for any signs of seizure activity. | Any cerebral irritation or trauma places the client at risk of seizure. Seizure increases cerebral metabolism and oxygen demand. Seizure precautions may need to be instituted. |
| Monitor client’s environment for the degree of stimulation. | Environmental stimuli may precipitate increased ICP episodes. |
| Assess cranial nerve responses especially the vagus nerve. | Absence of the cranial nerve X indicates a need for artificial airway maintenance. |
| Monitor ethanol levels and the toxicology screen results. | Recreational alcohol or drug use may be associated with near-drowning accidents; its effects may mask true loss of consciousness. |
| Institute a seizure precautions such as side rails up and padded, the bed in low position, head protection if needed. | Client’s safety is a priority. Keeping the bed in the lowest position reduces the risk of falls during seizure activity. Side rails and protective headgear reduces the risk of injury during tonic-clonic seizures. |
| Maintain the head of bed elevated; Maintain a midline head and body alignment. | This position promotes venous drainage from the brain to reduce ICP. |
| Decrease the client’s exposure to unnecessary stimuli. | Attention to reducing environmental stimuli (noise reduction, curtain closing, avoiding unnecessary nursing activities) reduces the risk of seizures. |
| Decrease the frequency of suctioning. | Hypoxia and the Valsalva maneuver associated with suctioning may elevate ICP and place the client at further risk for seizures. |
| Administer anticonvulsants as ordered. | Drug therapy is the primary approach to preventing and managing seizure activity. |
| For clients with signs of increased ICP: | |
|
Adequate oxygenation prevents further hypoxemic damage. |
|
Hyperventilation blows off carbon dioxide to control cerebral blood flow and, in turn, controls the increase in ICP. This reduces the risk for seizures. |
See Also
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Basic and General Nursing Care Plans
Miscellaneous nursing care plans that don’t fit other categories:
