Drowning: Interventions with Delayed Respiratory Complications (Nursing)

00:01 So, you're going to need to do something, right? We're going to have to escalate, get more help.

00:06 So we'll contact the health care provider and we'll start supplemental oxygen.

00:11 We're going to make sure we titrate that oxygen to maintain a set of greater than 94%. Now you may need to contact the healthcare provider.

00:19 Or you may already have that order to start supplemental oxygen.

00:23 If the stat drops below 94.

00:25 Either way, it's a good idea to let the healthcare provider know.

00:29 Now, if you need to, you might consider high flow nasal cannula or even a CPAP or BiPAP if that's necessary.

00:36 If things progress and continue to deteriorate, the patient may need to be intubated and put on a mechanical ventilator if they're on a mechanical ventilator.

00:45 Keep in mind they'll probably order PEEP positive end expiratory pressure because that's going to help prevent alveolar collapse.

00:53 And that's what got us into this problem in the first place.

00:55 Now the medications you're likely to see are what we've already talked about in the other situations You're likely to see bronchodilators for bronchospasm, corticosteroids if they have significant inflammation, and antibiotics if we feel they had aspiration pneumonia.

01:11 Again, the best positioning for any patient who's having respiratory issues is to have the head of their bed elevated 30 to 45 degrees.

01:19 And in some of the most severe cases, prone positioning is even considered.

01:24 Now we're managing their fluids closely because we don't want to exacerbate or make that pulmonary edema worse.

01:30 We may even give diuretics if they are in a really severe case of fluid volume overload. Now you're always watching.

01:37 Which way is the patient going? When you're monitoring them, they're either holding steady, getting worse or getting better.

01:45 And it's your job as a nurse to know right where they are.

01:49 So as you're monitoring them, you're going to monitor them more frequently.

01:52 So you do vital signs more frequently.

01:54 You have a continuous pulse ox on.

01:56 You might even get a series of ABGs and you may consider transferring to a higher level of care if you're not already in intensive care.

02:06 So, the monitoring requirement for the initially asymptomatic patient. Remember, this is who we are talking about.

02:12 This is one of the most challenging aspects of drowning management.

02:15 Determining which seemingly well patients require observation and for how long. But the best advice is to always err on the side of safety. Do what will keep this patient the safest.

02:28 But I thought you might want to know. Okay, so who is at the highest risk for these delayed effects? Well, there are several things that we do know if the patient was submerged for more than a minute, they have a high risk.

02:40 If they required any resuscitation, if they lost consciousness during the event. If they had initial hypoxemia, even if it's resolved,now, if you hear abnormal lung sounds, even if they're mild.

02:54 If it's a child under five years or if they could have aspirated contaminated water. Now lower risk is going to be kind of the opposite of that.

03:02 If they are brief submersion less than one minute, they didn't have any loss of consciousness.

03:07 They have no respiratory symptoms at presentation.

03:10 They have a normal initial exam and vital signs.

03:12 And they could be an older child or an adult.

03:15 They're considered to be at lower risk.

03:18 Now the observation protocols are pretty standard.

03:20 So let's talk about how long observation lasts or the duration of observation.

03:25 It's a minimum of 4 to 6 hours for all submersion patients even if they're not symptomatic. 12 to 24 hours for patients with any initial symptoms or high risk factors, and inpatient admission for patients with persistent symptoms of abnormal imaging. Now, in regards to the frequency of monitoring, the minimum you should do is vital signs including respiratory rate should be done every 1 to 2 hours for these clients.

03:51 Make sure you check their oxygen saturations at least every hour.

03:55 Or honestly, a continuous monitoring pulse ox would be best.

03:59 Listen to their lungs.

04:00 Do a full lung auscultation every 2 to 4 hours and document what you hear. Compare this assessment to all your previous assessments to note if there's any changes. Look at the respiratory effort.

04:13 Put eyes on them at least hourly and assess how they're doing with respiratory effort. Are they working harder this time than the previous time that you assess them? Monitor their temperature closely, particularly if they have hypothermia or fever. And again, watch that fluid intake and output very closely. Now diagnostics for these patients while they're being observed and you're watching them, they might have serial chest x rays if they have symptoms or some abnormal initial findings.

04:41 We talked about the pulse ox.

04:43 But you also want them to do that with walking before they're discharged.

04:46 So you see how they do when their body is requiring more energy than it takes to walk and repeat the arterial blood gases if there's any deterioration noted.

04:56 Now, these are the criteria we're looking for. Before a patient goes home after experiencing drowning.

05:01 We want to make sure these criteria are met.

05:03 Want to make sure the patient can maintain normal vital signs throughout the whole observation period? They don't develop any respiratory problems.

05:10 They have a normal oxygen set on room air, including with activity, like walking. We want their chest x ray to be normal or improving.

05:19 We want to make sure they can adequately take in oral fluids and food, and they have a normal mental status.

05:25 Let's also be sure they have someone reliable to go home with them.

05:29 Who knows what to look for in case the client needs to return, and make sure they have the ability to come back promptly if symptoms develop.

05:37 Now, if educating the patient is, you're getting them ready to be discharged after this drowning incident and the close monitoring, you want to make sure the caregiver knows that they need to come back, notify the health care provider if this patient has any breathing difficulties, or starts breathing rapidly.

05:53 If they have a cough they can't get rid of, it's just persistent.

05:56 If they have chest pain, if they tell you they feel unusually tired or really lethargic. If you notice blue coloration on the lips or skin, that's cyanosis and a very severe sign that they're not being oxygenated or if they develop a fever.

06:11 So they should have this in writing and know that if any of these things happen, you need to call us and you need to come back and see a health care provider.

06:20 Remember, the timeline for this is delayed effects typically occur within the first 24 hours, usually a time period within that, but they're at risk up to 24 hours. Make sure they know when they should have their follow-up appointment and know exactly what to look for.

06:36 Because this aspect of drowning management highlights the importance of standardized observation protocol for all submersion victims.

06:43 Make sure the emergency department and primary care providers know about delayed manifestations, and you'll need clear communication with the patients and family about the warning signs they need to look for.

06:55 By understanding and properly managing these delayed effects, healthcare providers and you as a nurse can prevent the rare but potentially catastrophic scenario of a patient being discharged too early, and subsequently developing life-threatening respiratory failure at home.