downing, downing intervention, downing nursing care plan

downing first aid and nursing intervention

1. Drowning Moa’ath Alswedat RN.

2. Circumstances of the Body In Water Died from natural disease before falling into the water Died from natural disease while already in the water Died from injury before being thrown into the water Died from injury while in the water Died from effects of immersion other than drowning Died from drowning. 2

3. Phases in the Drowning A. Breath Holding Lasts for a variable length of Carbon dioxide accumulation Stimulation of the respiratory centre in the brain Inevitable inhalation of large volumes of water. B. Swallowing Of Water Coughing, vomiting progressive loss of consciousness Escape of air remaining In the lungs and replaced by water

4. Phases in the Drowning cont … C. Profound unconsciousness and convulsions Gasping Respiratory standstill Failure of heart Irreversible changes in the brain Death

5. Signs of Immersion Maceration of the skin in warm water ‘Washer-woman’s skin Keratin of hands and feet peels off in ‘glove and stocking’ fashion Nails and hair loosened Cutis anserina – or ‘goose-flesh’ –cold water. Float with buttocks uppermost, head and limbs down 5

6. (‘washer-woman’s hands’) after 2 weeks’ 6 Wrinkled fingers, palms, and feet, half a day to 3 days

7. Decomposition Often first in the dependent head and neck, abdomen and thighs: 4–10 days Bloating of face and abdomen with marbling of veins and peeling of epidermis on hands and feet, and slippage of scalp: 2–4 weeks Gross skin shedding, muscle loss with skeletal exposure, partial liquefaction: 1–2 months. 7

8. What is drowning? Drowning is a form of asphyxial death due to aspiration of fluid into the air passages by submersion of the body in water or fluid medium. Complete submersion not necessary, submersion of nose and mouth is enough. 8

9. Certain factors make drowning more likely Not being able to swim. Many adults and children report that they can't swim or are weak swimmers. ... Missing or ineffective fences around water. ... Lack of close supervision. ... Location. ... Not wearing life jackets. ... Drinking Alcohol. ... Using drugs and prescription medications. 9

10. Classification A . Typical drowning Obstruction of air passages and lungs by inhalation of fluid and is known as “ Wet drowning ”. Typical signs are found at autopsy. B. Atypical drowning Conditions in which there is very little or no inhalation of water or fluid in the air passages. Dry drowning. Immersion syndrome(vagal inhibition). Submersion of the unconscious. Secondary drowning syndrome/near-drowning. 10

11. A. Typical drowning Fresh water drowning. Salt water drowning. Fresh water drowning Water cross the alveolar membrane into the circulation. Produces marked hypervolaemia . Red cells swell or burst- hemolysis -liberation of potassium. Circulation will suffer 50% dilution within 2-3 min. The heart is submitted to the insult of anoxia, hypervolaemia , potassium excess and sodium deficit. Ventricular fibrillation due to anoxia and potassium excess within 4-5 min. 11

12. A. Typical drowning cont … ii. Salt water drowning Marked hyper tonicity of the inhaled water cause loss of fluid from circulation into the lungs-fulminating pulmonary edema and progressive hypovolaemia . Circulatory shock and cardiac arrest. 12

13. Atypical drowning A. Dry drowning Intense laryngeal spasm due to entry of water into nasopharynx and larynx. Very little water enters into lungs. Best case for resuscitation. B. Immersion syndrome Due to sudden impact with very cold water and causes death from cardiac arrest. Victims are young people with excess of alcohol. It also result from falling or diving with feet or duck diving by the inexperienced swimmers. Loss of consciousness instantaneous and death occurs in few minutes. Autopsy disclose non of the usual signs of drowning. 13

14. Atypical drowning cont … C. Submersion of the unconscious Commonly seen if the victim is suffering from disease like epilepsy,heart diseases and is drunk or head injury during fall. Ballooning of the lungs may be absent. Formation of the foam my be negligible. Complete picture of death by drowning is not found. 14

15. Atypical drowning cont … D. Secondary drowning/near-drowning Its mainly due to infection from inhalation of contaminated water. Lung complications, oxygen lack, tired heart muscle and cerebral edema. A victim look alert and breathing, may respond to initial resuscitation. Late stage-respiratory distress, hypotension and cardiac arrhythmia may cause death. 15

16. Vicious cycle of drowning 16 Deep inspiration Water enters resp. passage Cough Reflex Air driven out of lungs Need for air

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18. Get Help Notify a lifeguard, if one is close. If you are alone, follow the steps below. 18

19. Move the Person Take the person out of the water.

20. Call 911

21. Check for Breathing Place your ear next to the person's mouth and nose. Do you feel air on your cheek? Look to see if the person's chest is moving.

22. If the Person is Not Breathing, Check Pulse

23. If There Is No Pulse, Start CPR

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25. Is CPR For Drowning Different? 25 Though CPR for drowning does not necessarily look “different” in how it is performed, mouth-to-mouth CPR is the only method that should be used. Compression-only CPR should not be considered. This is because cardiac arrests that are respiratory in origin require rescue breaths for successful resuscitation.

26. IN HOSPITAL

27. Nursing Care Plans & Management Nursing Problem Priorities Maintain airway patency and adequate oxygenation Assist with measures to facilitate gas exchange Assess and monitor potential complications such as pulmonary edema , aspiration pneumonia, and neurological deficits Provide emotional support and reassurance to the patient and the family Educate the patient and the family on water safety measures, prevention of drowning incidents, and the importance of learning CPR.

28. Nursing Care Plans & Management cont … Assess for the following subjective and objective data: Coughing or gasping for air Difficulty breathing or shortness of breath Bluish skin or lips (cyanosis) Altered mental status or  confusion Fatigue  or  exhaustion Chest  pain  or discomfort Vomiting  or foaming at the  mouth Frothy, pink-tinged sputum Changes in skin temperature (cool and clammy skin)

29. Nursing Care Plans & Management cont … Assess for the following subjective and objective data: Loss of consciousness Severe respiratory distress or complete respiratory failure Hypothermia (low body temperature) Seizures or convulsions Absence of breathing or no signs of life (cardiopulmonary arrest) Coma or unarousable state

30. Nursing Care Plans & Management cont … Assess for the following subjective and objective data: Loss of consciousness Severe respiratory distress or complete respiratory failure Hypothermia (low body temperature) Seizures or convulsions Absence of breathing or no signs of life (cardiopulmonary arrest) Coma or unarousable state

31. Nursing Care Plans & Management cont … Assess for factors related to the cause of drowning (submersion injury): Aspiration (freshwater or saltwater) Bronchospasm Pulmonary capillary membrane damage Pulmonary edema Pulmonary surfactant elimination Cerebral edema Gas exchange insufficiency Increased intracranial pressure (ICP) Prolonged hypoxemia

32. Nursing Care Plans & Management cont … Assess for factors related to the cause of drowning (submersion injury): Saltwater aspiration Fluid shift from intravascular to interstitial space Contaminated water aspiration Gastric contents aspiration Increased secretions Conductive heat loss Submersion in cold water for a prolonged period of time

33. Nursing Care Plans & Management cont … Nursing Goals The client will maintain optimal gas exchange, as evidenced by arterial blood gases (ABGs) within the client’s usual range, oxygen saturation of 90% or higher, alert, responsive mentation or no further decline in the level of consciousness, relaxed breathing, and baseline heart rate for the client. The client will maintain optimal cerebral tissue perfusion, as evidenced by alert, responsive mentation; absence of neurological deficits; normoreactive pupils; normal or baseline motor function. The client will demonstrate stable vital signs and the absence of signs of increased ICP.

34. Nursing Care Plans & Management cont … Nursing Goals The client will maintain adequate fluid volume, as evidenced by urine output greater than 30 ml per hour, normotensive blood pressure, and heart rate of less than 100 beats per minute. The client will display intake and output balance, good skin turgor, moist mucous membranes, palpable peripheral pulses, stable weight, and electrolytes within the normal range. The client will be free of infection, as evidenced by normal vital signs and the absence of purulent drainage from wounds, incisions, and tubes. The client will identify interventions to prevent and reduce the risk and spread of a secondary infection.

35. Nursing Care Plans & Management cont … Nursing Goals The 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. The client will display decreased episodes of dysrhythmias. The client will participate in behaviors and activities that reduce the workload of the heart. The client will display effective thermoregulation through stable temperature and pulse rate. The client will be free from cardiovascular and neurological injury.

36. Nursing Care Plans & Management cont … Nursing Goals The client and/or caregiver will verbalize understanding of the condition, its effects, and potential complications. The client and/or caregiver will correctly perform necessary procedures and explain reasons for actions. The client and/or caregiver will initiate necessary lifestyle changes.

37. Nursing Care Plans & Management cont … Nursing Interventions and Actions Improving Gas Exchange Assess the client’s level of consciousness. Assess the client’s respiratory rate, depth, and rhythm Auscultate the lung for breath sounds such as crackles and wheezing Monitor for signs of respiratory difficulties such as nasal flaring, stridor, retractions, and the use of accessory muscles Assess for any signs of worsening pulmonary edema Monitor oxygen saturation and ABGs as ordered

38. Nursing Care Plans & Management cont … Nursing Interventions and Actions Improving Gas Exchange Monitor chest-x-ray readings Maintain the client’s airway and assist with ventilation as needed while protecting the cervical spine Provide oxygenation as ordered Insert nasogastric tube as indicated Anticipate the need for intubation and mechanical ventilation Assist in endotracheal intubation Use positive end-expiratory pressure (PEEP) for clients in mechanical ventilation Monitor the client placed on extracorporeal membrane oxygenation (ECMO) closel

39. Nursing Care Plans & Management cont … Nursing Interventions and Actions B. Maintaining Cerebral Tissue Perfusion & Cardiac Output Using the Glasgow Coma Scale (GCS), assess the level of consciousness Monitor for any signs of seizure activity. Monitor the client’s environment for the degree of stimulation Assess cranial nerve responses, especially the vagus nerve Monitor the client’s blood pressure Monitor the client’s temperature . Monitor the skin temperature and color and peripheral pulses Palpate peripheral pulses.

40. Nursing Care Plans & Management cont … Nursing Interventions and Actions B. Maintaining Cerebral Tissue Perfusion & Cardiac Output Assess for dysrhythmias. Monitor urine output. Monitor ethanol levels and the toxicology screen results. Monitor glucose levels. If hemodynamic monitoring is in place, assess the CVP, pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output. Perform ECG monitoring. Place the client in a prone position after pulling from the water. Promote a position of comfort once stabilized.

41. Nursing Care Plans & Management cont … Nursing Interventions and Actions B. Maintaining Cerebral Tissue Perfusion & 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). Initiate a vasopressor infusion. Administer inotropic agents: digoxin, amrinone, dobutamine, or dopamine as ordered Administer plasma volume expanders , as ordered. Assist in extracorporeal cardiopulmonary resuscitation (ECPR). Provide supplemental oxygenation.

42. Nursing Care Plans & Management cont … Nursing Interventions and Actions B. Maintaining Cerebral Tissue Perfusion & Cardiac Output Institute seizure precautions such as side rails up and padded, the bed in a low position, and head protection if needed. Maintain the head of the bed elevated and maintain a midline head and body alignment. Decrease the client’s exposure to unnecessary stimuli. Decrease the frequency of suctioning. Administer anticonvulsants as ordered. For clients with signs of increased ICP: Maintain oxygenation levels. Monitor electroencephalography (EEG) results as indicated. Monitor serum electrolytes as indicated

43. Nursing Care Plans & Management cont … Nursing Interventions and Actions C. Promoting Optimal Fluid Balance Assess the client’s intake and output. Monitor urine-specific gravity. Assess for crackles and shortness of breath Note any changes in heart rate and blood pressure Monitor the client’s laboratory values, such as hematocrit , serum electrolytes, and renal function tests as ordered Monitor the client’s central venous pressure. Insert and maintain indwelling urinary catheter Make fluids accessible to the conscious, stable client Assist with the insertion of a central venous line and arterial line as ordered.

44. Nursing Care Plans & Management cont … Nursing Interventions and Actions C. Promoting Optimal Fluid Balance Administer fluid volume expanders as ordered. Administer inotropic agents as prescribed. See Pharmacologic Management

45. Nursing Care Plans & Management cont … Nursing Interventions and Actions E. Initiating Measures for Infection Control & Management Assess the client’s temperature. Assess for any signs of respiratory difficulties. Auscultate breath sounds. Monitor the client’s sputum including the amount, color , and odor . Monitor the client’s white blood cell count and culture studies. Monitor chest X-ray results as ordered. Encourage proper hand hygiene techniques. Institute isolation precautions as appropriate.

46. Nursing Care Plans & Management cont … Nursing Interventions and Actions E. Initiating Measures for Infection Control & Management Encourage adequate rest and nutritional intake. Encourage using an incentive spirometer when the client is neurologically stable. Maintain the client in an upright position. Maintain body temperature with cooling or warming blankets as indicated. Suction secretions as needed only. Provide a sputum sample for culture and sensitivity test. Perform chest physical therapy as needed. Administer antifungals as prescribed

47. Nursing Care Plans & Management cont … Nursing Interventions and Actions F. Managing Hypothermia and Preventing Cold-Injuries Monitor client temperature. Monitor environmental temperature. Monitor the level of consciousness closely using the Glasgow Coma Scale (GCS). Assess the client’s vital signs. Assess blood glucose levels. Monitor laboratory test results. Monitor ECG pattern changes. Observe oxygenation cautiously Perform cardiopulmonary resuscitation (CPR) as indicated, whether in the field or the Emergency Department.

48. Nursing Care Plans & Management cont … Nursing Interventions and Actions F. Managing Hypothermia and Preventing Cold-Injuries Remove wet clothing from the client and start rewarming immediately Assist with core rewarming techniques Initiate active external rewarming for moderate to severe hypothermia Start rewarming from the trunk before the extremities Prepare the client for thoracotomy. Insert central venous access carefully as indicated Administer antibiotics as prescribed

49. Nursing Care Plans & Management cont … Nursing Interventions and Actions G. Providing Patient Education & Health Teachings Assess the client’s or caregiver’s knowledge about water safety. Identify risk factors that contribute to drowning Instruct caregivers to supervise their children at all times when around bodies of water. Correct misperceptions of parents and caregivers regarding drowning situations. Reinforce the importance of a properly fenced pool. Encourage parents and other caregivers to learn CPR Promote the use of flotation devices, especially among children. Provide examples of anti-entrapment and anti-entanglement measures.

50. Nursing Care Plans & Management cont … Nursing Interventions and Actions G. Providing Patient Education & Health Teachings Encourage parents to enroll their children in swimming lessons and water survival training and competency. Educate about boating safety.

51. References and Sources Al Sawaf , A., Arya, K., & Murr , N. (2022, August 29). Seizure Precautions – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 28, 2022. Ashkar , H., Adnan, G., & Makaryus , A. N. (2022, September 27). Dobutamine – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 28, 2022. Cantwell, G. P., & Verive , M. J. (2021, October 21). Drowning: Background, Etiology , Epidemiology. Medscape Reference. Retrieved December 27, 2022. Cardoso, S. (2022, August 18). Inotropes And Vasopressors – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 30, 2022. Chandy , D., & Richards, D. (2022). Drowning (submersion injuries). UpToDate. Crumlett , H., & Johnson, A. (2017). Critical Care Nursing Certification: Preparation, Review, and Practice Exams, Seventh Edition. McGraw-Hill Education. Denny, S. A., Quan, L., Gilchrist, J., McCallin , T., Shenoi , R., Yusuf, S., Weiss, J., & Hoffman, B. (2021). Prevention of Drowning. Pediatrics , 148(2). Felix, A., & Campbell, D. D. (2022, June 10). Extracorporeal Cardiopulmonary Resuscitation: The Golden Hour EMRA. EMRA. Retrieved December 30, 2022. Hamilton, K., Keech, J. J., Peden , A. E., & Hagger, M. S. (2018). Alcohol use, aquatic injury, and unintentional drowning: A systematic literature review. Drug and Alcohol Review.

52. References and Sources cont … Nandanwar , R. R., Singh, R., Karanjkar , S. M., & Bhagwani , R. S. (2022). The Impact of Pulmonary Rehabilitation in a Case of Acute Respiratory Distress Syndrome With Bronchopneumonia: A Case Report. Cureus , 14(12). Senewiratne , N. L., Woodall, A., & Can, A. S. (2022, September 12). Sodium Bicarbonate – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 28, 2022. Shokohi , T. (2021). Fatal pulmonary Scedosporium aurantiacum infection in a patient after near-drowning: A case report. NCBI. Retrieved December 30, 2022. Slota , M. C. (Ed.). (2018). AACN’s Core Curriculum for Pediatric High Acuity, Progressive, and Critical Care Nursing. Springer Publishing Company, LLC. Submersion injuries/drowning. (2015). In J. H. Brice, J. B. Myers, D. C. Cone, & T. R. Delbridge (Eds.), Emergency Medical Services: Clinical Practice and Systems Oversight, 2 Volume Set. John Wiley & Sons Incorporated. Topjian , A. A., Berg, R. A., Bierens , J. J. L. M., Branche , C. M., Clark, R. S., Friberg, H., Hoedemaekers , C. W. E., Holzer, M., Katz, L. M., Knape, J. T. A., Kochanek , P. M., Nadkarni, V., van der Hoeven , J. G., & Warner, D. S. (2012, September 6). Brain Resuscitation in the Drowning Victim. Neurocritical Care, 14, 441-467.

53. References and Sources cont … Wilson, D., Rodgers, C. C., & Hockenberry, M. J. (Eds.). (2018). Wong’s Nursing Care of Infants and Children. Elsevier. World Health Organization. (2014). Global Report on Drowning: Preventing a Leading Killer. World Health Organization. World Health Organization. (2021, May 5). WHO calls for better hand hygiene and other infection control practices. World Health Organization (WHO). Retrieved December 30, 2022. Wyckoff, M. H., Singletary, E. M., Soar, J., Olasveengen , T. M., Greif, R., Liley , H. G., Zideman , D., Bhanji , F., Andersen, L. W., & Avis, S. R. (2022, March). 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation, 145(9). Zafren , K., & Mechem , C. C. (2022). Accidental hypothermia in adults. UpToDate.

54. THANKS ANY QUESTIONS