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Nursing Care Plan | NCP Gunshot Wound

Penetrating trauma from a gunshot wound (GSW) can cause devastating injuries. The most commonly injured organs and tissues are the intestines, liver, vascular structures, spleen, and intrathoracic structures. Evaluating injuries is difficult; it is important to determine the type of weapon, energy dissipated from the weapon, firing range of the weapon at the time of injury, and characteristics of the injured tissue. Gunshot wound can lead to the need for extensive d├ębridement, resection, or amputation. Among the many complications are sepsis, exsanguination, and death. In the United States, gunshot wound account for approximately 30,000 deaths a year. Approximately 57% of gun deaths are suicides, 39% are homicides, and the rest are from other causes, primarily an unintentional death. In the Unied States, 4% of the world’s population possesses 50% of the world’s privately owned firearms. Gunshot wound can be perforating, when the bullet exits the body, or penetrating, when the bullet is retained in the body.

The energy of the missile is dissipated into tissues of the body, causing destruction of vital and nonvital structures. When the missile enters the body, it creates a temporary cavity, which stretches, distorts, and compresses the surrounding anatomic structures. The cavity that is produced often has a greater diameter than the missile itself. In a situation called “blast effect” or “muzzle blast,” damage occurs in structures outside the direct path of the missile. High-velocity missiles (bullets from shotguns, rifles, or high-caliber handguns) cause extensive cavitation and significant tissue destruction, while low-velocity missiles (bullets from low-caliber handguns) have limited cavitation potential with less tissue destruction. Another characteristic of missiles is the yaw, which is the amount of tumbling and movement of the nose of the missile that occurs. The more yaw, the greater the tissue damage.

Nursing care plan assessment and physical examination
Establish a history of the weapon, including the type, caliber, and range at which it was fired. Determine if the gunshot woundwas self-inflicted, as well as the patient’s hand dominance and tetanus immunization history.

The initial evaluation is always focused on assessing the airway, breathing, circulation, disability (neurological status), and exposure (completely undressing the patient), which are done simultaneously by the trauma resuscitation team. The secondary survey is a head-to-toe assessment, including vital signs. After completing the primary survey, begin the secondary survey with a complete head-totoe assessment. Examine the patient’s entire skin surface carefully for abrasions, open wounds, powder burns, and hematomas, paying special attention to skin folds, groin, and axillae. Assess the patient’s abdomen, back, and extremities for lacerations, wounds, abrasions, and deformities. Some high-velocity weapons may cause extensive tissue destruction and fractures. Inspect the patient for both entrance and exit wounds.

Perform a thorough fluid volume assessment on at least an hourly basis until the patient is stabilized. This assessment includes hemodynamic, urinary, and central nervous system parameters. Notify the physician of overt bleeding and of any early indications that hemorrhage is continuing; this includes delayed capillary refill, tachycardia, urinary output less than 0.5 mL/kg per hour, and alterations in mental status, including restlessness, agitation, and confusion, as well as decreases in alertness. Body weights are helpful in indicating fluid volume status; note that many of the critical care beds have incorporated bed scales.

The violent and often unexplained nature of this type of trauma can lead to ineffective coping for both the patient and the family. Determine if the patient is at risk from herself or himself or others by questioning the patient, significant others, or police. If the patient is on police hold, determine the patient’s and family’s response to the pending legal charges.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to airway obstruction secondary to tissue trauma.

Nursing care plan intervention and treatment
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.

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.

In the emergency phase of treatment, maintain the patient in a supine position unless it is contraindicated 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.

Nursing care plan discharge and home health care guidelines
To prevent complications of wound infection and impaired wound healing, review wound care instructions with the patient and family. Verify that they can demonstrate proper care with understanding and accuracy. Verify that the patient understands all medications, including dosage, route, action, and adverse effects. Provide written instructions to the patient or family. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed. Make sure that patients with self-inflicted wounds have counseling and support before and after the discharge.
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