Primary Nursing Diagnosis

Ineffective airway clearance related to airway obstruction secondary to tissue trauma

OUTCOMES. Respiratory status: Ventilation; Respiratory status: Gas exchange; Symptom control behavior; Medication management; Comfort level; Knowledge: Treatment regimen

INTERVENTIONS. Airway insertion and stabilization; Airway management; Airway suction-ing; Anxiety reduction; Artificial airway management; Mechanical ventilation; Oxygen therapy; Positioning; Respiratory monitoring; Surveillance; Ventilation monitoring; Vital signs monitoring

U PLANNING AND IMPLEMENTATION Collaborative

Maintaining a patent airway, maintaining oxygenation and ventilation, and supporting the circulation are the first priorities. Assist with endotracheal intubation and mechanical ventilation. Maintain the PaO2 at greater than 100 mm Hg and the PaCO2 at 35 to 45 mm Hg. The patient may require placement of a tube thoracostomy to drain blood and relieve a pneumothorax.

Restoring fluid volume status is critical in maximizing tissue perfusion and oxygenation; the use of pressure infusers and rapid volume/warmer infusers for trauma patients requiring massive fluid replacement is essential. Administering warm blood products and crystalloids assists in maintaining normothermia. Be prepared to administer vasopressors after fluid volume status is stabilized. Patients who require massive fluid resuscitation are at risk for developing hypothermia, which exacerbates existing coagulopathy and compounds their hemodynamic instability.

392 Gunshot Wound

Paramount in managing patients is a rapid fluid resuscitation with blood, blood products, colloids, and crystalloids through a large-bore peripheral intravenous (IV) catheter or a large-bore trauma catheter.

Patients frequently require surgical exploration to identify specific injuries and control hemorrhage. After surgical exposure is obtained, any of the following may be required: assessment of structures, control of hemorrhage, d├ębridement, resection, or amputation. If definitive surgical intervention is not possible because of the patient's instability, a temporizing method known as "damage control" may be instituted. Damage control consists of the placement of packing to achieve a temporary tamponade, correction of coagulopathy, and aggressive management of hypothermia. The patient is then transferred to the critical care unit for continued monitoring and stabilization. The "second look" surgical exploration is generally done in 24 hours for definitive surgical intervention.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Antibiotics: prophylactic antibiotic use is controversial; surgeons follow culture results and institute antibiotics sensitive to the organism that was cultured

Varies with drug

Second-generation cephalosporins or cephamycin

Prevent gram-negative infections when there is traumatic violation of the gastrointestinal (GI) tract

Heparin

5000 units SQ q 8-12 hr

Anticoagulant

Prevent thromboembolism during periods of immobility after hemorrhage is controlled; not generally administered in patients with neural injuries

Other: Many trauma surgeons may choose to administer a tetanus booster to patients with chest trauma whose immunization history indicates a need or whose history is unavailable.

Independent

In the emergency phase of treatment, maintain the patient in a supine position unless it is con-traindicated because of other injuries. Ensure adequate airway and breathing in this position. Avoid Trendelenburg's position because it may have negative hemodynamic consequences, increase the risk of aspiration, and interfere with pulmonary excursion. If the patient can tolerate the position, elevate the head of the bed to limit the risk of aspiration and to improve gas exchange.

Wound care varies, depending on the severity of wounds, whether an open fracture is present, and what type of fixation device is applied. Wounds and any exposed soft tissue and bone are covered with wet, sterile saline dressings. Standard Betadine-soaked dressings may not be used because of the need to limit iodine absorption and skin irritation. To decrease the risk of infection of the patient, use a gown, mask, gloves, and hair covers in caring for patients with extensive wounds. Document the size, description, and healing of the wound each day, and notify the surgeon if there are signs of wound infection. Use universal precautions in handling all bloody drainage.

If another person has initiated the violence toward the patient, consider assigning him or her a pseudonym for all hospital records to prevent another assault. Do not provide any information about the patient over the phone unless you are sure of the caller's name and relationship to the patient. If you fear for the patient's safety, talk to hospital security about strategies to ensure the patient's safety. If the patient has a self-inflicted injury, make a referral to a clinical nurse specialist or discuss a psychiatric consultation with the surgeon. If the patient is self-destructive, initiate suicide precautions according to unit protocol.

If the patient is being held by police, remember that the patient receives competent and compassionate care even when under arrest. Determine from hospital policy the regulations about visitors if the patient is held by the police. Provide a supportive atmosphere to promote healing of the injury, but use care to avoid being drawn into the legal aspects of the patient's arrest.

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