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
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. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023Â (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See Also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
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 | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans