Natividad, Michael John F.

BSN IV
Nursing Care Plan for Gunshot Wound to the Head

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient After 4 hours of Palpate pulses: carotid, If carotid and femoral
>N/A: Patient is Fluid Volume nursing brachial, radial, femoral, pulses are palpable, After 8 hours of
unconscious related to intervention, popliteal and pedal. Note then the blood pressure nursing intervention,
active fluid patient will be patient was able to
quality and rate. is usually at least 60 –
loss able to maintain maintain adequate
Objective: (bleeding) adequate fluid 80 mmHg systolic. If
peripheral pulses are fluid volume and
>Profuse bleeding secondary to volume and
of the wounded gunshot electrolyte present, the blood electrolyte balance
head wound to the balance as pressure is usually as evidenced by
>BP: 80/50 head evidenced by higher than 80 mmHg urine output >30 ml
>HR: 117 urine output >30 systolic. Pulses may be per hr, normotensive
>Decreased Urine ml per hr, blood pressure (BP),
weak and irregular.
output normotensive heart rate (HR) 100
>unconscious blood pressure
Cool, pale, diaphoretic beats per min, and
>pallor (BP), heart rate
>cool, clammy (HR) 100 beats Assess skin color and skin suggests normal skin turgor.
skin per min, and temperature. ineffective circulation
normal skin due to hypovolemia.
turgor.
Monitor patient for active Active fluid and/or
blood loss from wounds, blood loss adds to
tubes, etc. Control any Hypovolemic state and
external bleeding. must be accounted for
when replacing fluids.
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

Sinus tachycardia may

Monitor vital signs.
occur with
(T,P,R,B/P)
hypovolemia to
maintain cardiac
output. Hypotension is
a hallmark of
hypovolemia. Febrile
states decrease body
fluids through
perspiration and
increase respiratory
rate.

Monitor blood pressure for Greater than 10 mmHg

orthostatic changes. drop signifies that
circulating volume is
reduced by 20%.
Greater that 20 – 30
mmHg drop signifies
blood volume is
decreased by 40%.

Auscultate heart tones and Abnormally flattened

inspect jugular veins. jugular veins and
distant heart tones are
signs of ineffective
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head
Assess mental status.
Assess skin turgor over the
sternum or inner thigh; and
assess moisture and
condition of mucous
membranes.
Assess color and amount of
urine.
Initiate two large bore
intravenous catheters (IVs)
and start intravenous fluid
replacements as ordered.
circulation.
Loss of consciousness
accompanies
ineffective circulating
blood volume to the
brain.
Dry mucous
membranes and tenting
of the skin are signs of
hypovolemia. The
sternum and inner thigh
should be used for skin
turgor due to loss of
elasticity with aging.
Concentrated urine and
output <30cc for two
consecutive hours
indicate insufficient
circulating volume.
14 -16 gauge catheters
are preferred in case
fluids need to be given
rapidly. Parenteral
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head
Obtain a serum specimen
for type and cross match
Administer blood and blood
products as ordered.
During treatment monitor
for signs of fluid overload.
fluids are necessary to
restore volume.
Lactated Ringers is
usually the fluid of
choice due to its
isotonic properties and
close resemblance to
the electrolyte
composition of plasma.
Blood and blood
products will be
necessary for active
blood loss. If there is
no time to wait for
cross matching, Type O
blood may be
transfused.
Due to large amounts
of fluids administered
rapidly, circulatory
overload can occur.
Headache, flushed skin,
tachycardia, venous
distention, elevated
hemodynamic
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

pressures (CVP,
PCWP), increased
blood pressure,
dyspnea, crackles,
tachypnea and cough
are all signs of
overload.

Assist the physician with Provides for more

insertion of a central venous effective fluid
line and arterial line if replacements and
indicated. accurate monitoring of
hemodynamic picture.
 Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Assess respirations:  Rapid, shallow breathing and
Subjective: Impaired Gas After 2 hours quality, rate, pattern, hypoventilation affect gas After 2 hours of
>N/A: Patient is exchange of nursing depth and breathing effort. exchange by affecting CO2 nursing
unconscious related to intervention, levels. Flaring of the intervention,
altered oxygen oximetry nostrils, dyspnea, use of oximetry results
supply results within accessory muscles, tachypnea within normal
Objective: normal range and /or apnea are all signs of range
>RR: 7 CPM severe distress that require
>O2 Sat: 85% immediate intervention.
>BP: 80/50
>HR: 117 Maintain client on bed  to reduce oxygen demands
>Decreased Urine rest during acute respiratory
output distress
>unconscious
>pallor  Absence of ventilation,
>cool, clammy asymmetric breath sounds,
skin dyspnea with accessory
>Profuse bleeding Assess for life-threatening
muscle use, dullness on chest
of the wounded problems. (i.e. resp arrest,
percussion and gross chest
head flail chest, sucking chest wall instability (i.e. flail chest
>gunshot wound to wound). or sucking chest wound) all
the occiput require immediate attention.
penetrating to the
periorbital area  Absence of lung sounds, JVD
Auscultate lung sounds.
and / or tracheal deviation
Also assess for the could signify a
presence of jugular vein Pneumothorax or
distention (JVD) or Hemothorax.
tracheal deviation.
 Tachycardia, restlessness,
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

Assess for signs of diaphoresis, headache,

hypoxemia. lethargy and confusion are all
signs of hypoxemia.

 Initially with hypoxia and

Monitor vital signs.
hypercapnia blood pressure
(BP), heart rate and
respiratory rate all increase.
As the condition becomes
more severe BP may drop,
heart rate continues to be
rapid with arrhythmias and
respiratory failure may ensue.

 Increasing PaCO2 and

decreasing PaO2 are signs of
Monitor ABGs. respiratory failure.

 Pulse oximetry is useful in

detecting changes in
Place the patient on oxygenation. Oxygen
continuous pulse saturation should be
oximetry. maintained at 90% or greater.

 Lack of oxygen delivery to

Assess skin color for
development of cyanosis,
especially circumoral
cyanosis.
the tissues will result in
cyanosis. Cyanosis needs
treated immediately as it is a
late development in hypoxia.
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

 Early supplemental oxygen is

Provide supplemental
oxygen, via 100% O2
non-rebreather mask.
essential in all trauma
patients since early mortality
is associated with inadequate
delivery of oxygenated blood
to the brain and vital organs.

Prepare the patient for  Early intubation and

intubation. mechanical ventilation are
necessary to maintain
adequate oxygenation and
ventilation, prior to full
decompensation of the
patient.

Treat the underlying  Treatment needs to focus on

the underlying problem that
injuries with appropriate
leads to the respiratory
interventions. failure.
 Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Assess neurologic status Deteriorating neurological signs
Subjective: Ineffective After4 hour of as follows: LOC per indicate increased cerebral
>N/A: Patient is cerebral tissue nursing After1 hour of
Glasgow Coma Scale-- ischemia.
unconscious perfusion interventions, nursing
pupil size, symmetry, and interventions,
related to brain patient will
injury maintain reaction to light; patient was able to
Objective: optimal extraocular movement establish method
>gunshot wound cerebral tissue (EOM); gaze preference; of communication
to the occiput perfusion, as speech and thought in which needs can
penetrating to the evidenced by processes; memory; be understood.
periorbital area ICP<10 mm motor-sensory signs and
>Profuse bleeding Hg, CGS>13,
drift; increased tone;
of the wounded and CPP from
head 60 mm Hg to increased reflexes;
>O2 Sat: 85% 90 mm Hg Babinski reflex.
>BP: 80/50
Monitor vital signs. Continually increasing ICP
>HR: 117
>Decreased Urine results in life-threatening
output hemodynamic changes; early
>unconscious recognition is essential to
>pallor survival.
>cool, clammy
skin
Monitor arterial blood
A PaCO2<20 mm Hg may
gases (ABGs) and/or
decrease CBF because of
pulse oximetry.
profound vasoconstriction that
Recommended
produces hypoxia. PaCO2>45
parameters of PaO2>80
mm Hg induces vasodilation
mm Hg and PaCO2<35
with increase in CBF, which
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

mm Hg with normal ICP. may trigger increase in ICP.

If patient's lungs are being
hyperventilated to
decrease ICP, PaCO2
should be between 25 and
30 mm Hg.

Monitor input and output May indicate decreased renal

with urine-specific perfusion and possible
gravity. Report urine- associated decrease in CPP.
specific gravity >1.025 or
urine output <1.50
ml/kg/hr.

Monitor ICP if
measurement device is in
place. Report ICP>15 mm Should be approximately 90 mm
Hg for 5 minutes. Hg to 100 mm Hg and not <50
mm Hg to ensure blood flow to
Calculate cerebral brain.
perfusion pressure (CPP)

To prevent decrease in venous

Elevate head of bed 30 outflow with increase in ICP.
degrees, and keep head in Exceptions include shock and
neutral alignment. cervical spine injuries.
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

Avoid Valsalva's increases intrathoracic pressure

maneuver and CBF, thereby increasing
ICP.

If ICP increases and fails

to respond to
repositioning of head in
neutral alignment and
head elevation, recheck
equipment. If ICP is
increased, one or more of
the following may be
prescribed by the
physician:

Hyperventilate the patient to decrease PaCO2 to between

25 mm Hg and 30 mm Hg; this
induces vasoconstriction and a
decrease in CBF.

Administer mannitol 0.25 This is a hyperosmotic agent and

to 1.0 g per kg given over needs to be given with caution.
30 to 60 minutes. It is contraindicated with
hypovolemic symptoms (e.g.,
hypotension, tachycardia, CHF,
renal failure, hypernatremia). A
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

diuretic response can be

anticipated within 30 to 60
minutes. A Foley catheter
should be in place. An
intravenous (IV) filter should be
used when mannitol is infused.
Electrolytes, osmolality, and
serum glucose must be
monitored during mannitol
infusion.

Administer barbiturates
and additional diuretics
such as furosemide
(Lasix) if ICP is
refractory to
hyperventilation and
mannitol regimen.

If patient is intubated, To reduce shivering, coughing,

administer neuromuscular bucking, Valsalva's maneuver.
blocking agent. Remember, however, that
neuromuscular blocking agents
have no effect on cerebration;
therefore, the patient should
receive short-acting sedation
Natividad, Michael John F.
BSN IV
Nursing Care Plan for Gunshot Wound to the Head

before noxious stimulation.

Administer a short-acting Pain response includes increased

pain reliever (e.g., blood pressure.
morphine [Demerol] or
midazolam [Versed]),
before painful stimulation
or stress-related care such
as suctioning or IV line
changes.
To reduce the inflammatory
Administer response seen in acute brain
corticosteroids. injury.