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.
- Impaired Gas Exchange
- Ineffective Cerebral Tissue Perfusion
- Deficient/Excess Fluid Volume
- Risk for Infection
- Risk for Decreased Cardiac Output
Deficient/ Excess Fluid Volume
- Deficient Fluid Volume
- Excess Fluid Volume
May be related to
- Saltwater aspiration
- Fluid shift from intravascular to interstitial space
- Freshwater aspiration
- Fluid shift from interstitial to intravascular space
Possibly evidenced by
- Dark colored urine
- Decreased urine output less than 30 ml per hour
- Decreased blood pressure
- Increase heart rate
- Decreased hemoglobin and hematocrit levels
- Distention of jugular vein
- Increased blood pressure
- Increased central venous pressure (CVP)
- Weight gain over a short period
- Client will maintain adequate fluid volume, as evidenced by urine output greater than 30 ml per hour, normotensive blood pressure, and heart rate less than 100 beats per minute.
|Assess for any changes in weight.||Body weight is a more sensitive indicator of fluid volume status than intake and output. 2.2 pounds of weight gain is equivalent to 1 liter of fluid.|
|Assess client’s intake and output; Monitor urine specific gravity.||Although total fluid intake may be sufficient, shifting of fluid out of the intravascular and into the extravascular spaces may lead to dehydration and decrease output. Specific gravity measurement provides information on the degree of fluid concentration or dilution.|
|Assess for crackles and shortness of breath.||These signs are caused by fluid accumulation in the lungs. However, the presence of crackles on auscultation or pulmonary congestion on x-ray film may not indicate fluid overload if the client has a saltwater aspiration, which pulls water from the circulation into the alveoli.|
|Note for any changes in heart rate and blood pressure.||Freshwater aspiration entering the circulation will expand the blood volume and increase HR and BP|
|Assess for distended neck veins.||Clients with expanded volume will exhibit elevated CVP and distended neck veins.|
|Monitor client’s laboratory values, as ordered:|
||This assessment determines the level of hemodilution or concentration.|
||Dehydration is a hyperosmolar state in which serum sodium levels rise. Serum sodium levels decline with hemodilution.|
||Hypokalemia may result from the increase in urinary output.|
||Acidosis and alkalosis require correction. Specific change guide the treatment approach.|
|Monitor the client’s central venous pressure.||This direct measurement serves as an optimal guide for therapy. Severe hypovolemia will cause decreasing CVP, indicating the need for volume expanders. Fluid excess increases CVP.|
|Assist the physician with the insertion of a central venous line and arterial line as ordered.||These measures allow for more effective fluid administration and facilitate hemodynamic monitoring.|
|Administer IV fluids as ordered.||Fluids are given to maintain hydration status in clients with a fluid deficit.|
|Administer fluid volume expanders as ordered.||Volume expanders are the intravenous fluid solutions that are used to increase or retain the volume of fluid in the circulating blood. It can also correct fluid imbalances.|
|Administer sodium bicarbonate as ordered.||Metabolic acidosis is corrected by the administration of sodium bicarbonate.|
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