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
Risk for Decreased Cardiac Output
- Risk for Decreased Cardiac Output
May be related to
- Decreased oxygenation
- Hypothermia-induced dysrhythmias
Possibly evidenced by
- [not applicable]
- Client will achieve an adequate cardiac output, as evidenced by strong peripheral pulses; normal vital signs; urine output greater than 30 ml per hour; warm. dry skin; and no further decrease in the level of consciousness.
|Monitor the skin temperature and color and peripheral pulses.||Peripheral vasoconstriction produces cool, pale, diaphoretic skin. Pulses may be weak with reduced output.|
|Monitor the client’s blood pressure.||Vasodilation occurs during rewarming and hypotension may happen unless the client is closely monitored with interventions as necessary. The direct intra-arterial monitoring of pressure should be anticipated for a continuing shock state.|
|Monitor client’s temperature.||Severe acute submersion hypothermia may be present. Myocardial contractility and vasomotor tone are decreased by hypothermia.|
|Assess for dysrhythmias.||Low perfusion state, acidosis, hypoxia, hypothermia, or electrolyte imbalance can result in cardiac dysrhythmia that can compromise stroke volume and cardiac output.|
|Monitor urine output.||Oliguria is a classic sign of inadequate renal perfusion from decreased cardiac output.|
|If hemodynamic monitoring is in place, assess the CVP, pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output.||These direct measurements serve as optimal guides for therapy. CVP provides information on filling pressures of the right side of the heart; PADP and PCWP reflect left-sided fluid volume.|
|Monitor for the increased actions of medications as rewarming occurs.||Rewarming results in vasodilation and increased blood flow. These circulatory changes will alter the pharmacokinetic activity of medications.|
|Administer inotropic agents: digoxin, amrinone, dobutamine, or dopamine as ordered||If hypotension occurs, these agents improve myocardial contractility, which increases cardiac output.|
|Rewarm the client as appropriate (e.g., warm humidified oxygen, blankets, head wrap, or over-the-bed heaters, and IV fluids warmed to 98.6° TO 104° F, as appropriate).||Depending on the length of time of submersion, water temperature, and ambient air temperature, the core body temperature may be quite low so the client should be rewarmed slowly to avoid the rapid release of metabolites.|
|Administer plasma volume expanders, as ordered.||Volume expanders may be indicated to correct fluid imbalance and optimize cardiac output.|
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