Nursing Diagnosis for Risk of Drowning in Pediatric Care Plan: A Comprehensive Guide

What is Drowning and Why is it a Pediatric Concern?

Drowning remains a significant global public health issue, tragically ranking as the third leading cause of unintentional injury-related death worldwide. Annually, over 360,000 lives are lost to drowning, and while it affects all age groups, children are disproportionately vulnerable. Submersion in water initiates a rapid cascade of physiological events culminating in hypoxemia (Wyckoff et al., 2022). The term “near-drowning,” previously used to describe survival for at least 24 hours post-submersion, is now outdated. Current standardized terminology emphasizes clarity and uniformity, categorizing incidents as drowning (fatal or non-fatal) and rescue.

Drowning is defined by the World Health Organization as “the process of experiencing respiratory impairment from submersion or immersion in liquid.” Outcomes are classified as either fatal or non-fatal. Fatal drowning results in death, while non-fatal drowning involves survival after respiratory impairment is halted. Further classification of non-fatal drowning severity, based on immediate post-rescue respiratory status, includes: mild impairment (breathing, coughing, alert), moderate impairment (difficulty breathing, disorientation but conscious), and severe impairment (not breathing and/or unconscious), with the latter further categorized by morbidity (no, some, or severe decline in functional capacity). Rescue refers to interventions preventing drowning progression in a submerged individual who does not develop respiratory symptoms.

For pediatric populations, the risk of drowning is particularly acute. Children, especially those under five years old, are naturally curious and drawn to water, yet lack the physical and cognitive abilities to navigate aquatic environments safely. Factors such as underdeveloped motor skills, higher center of gravity, and limited understanding of risks contribute to their vulnerability. Furthermore, seemingly innocuous household items like buckets, bathtubs, and toilets can pose significant drowning hazards for infants and toddlers.

The primary risk factors contributing to pediatric drowning incidents are multifaceted and include: lack of swimming ability or overestimation of swimming skills, engagement in risky behaviors around water, and critically, inadequate adult supervision. Children who have experienced a drowning incident may present with a range of symptoms, from unresponsiveness to more subtle signs like cold or pale skin, abdominal distension, vomiting, cough with pink, frothy sputum, shortness of breath, lethargy, and chest pain. These symptoms reflect the physiological consequences of submersion, including hypoxemia, acidosis, and hypovolemia.

The type of water involved in drowning incidents also plays a role in the physiological sequelae. Freshwater drownings are more prevalent and often lead to surfactant loss, resulting in atelectasis. Saltwater aspiration, conversely, can cause pulmonary edema due to osmotic fluid shifts into the lungs. Regardless of water type, the critical immediate concern is respiratory impairment and the potential for hypoxic brain injury, underscoring the importance of prompt and effective nursing care, especially in pediatric cases. Recognizing and addressing the risk of drowning through comprehensive pediatric care plans is paramount to prevention and improved outcomes.

Child safety around water, emphasizing adult supervision.

Pediatric Nursing Care Plans & Management: Prioritizing Safety and Recovery

The nursing care and management of a child following a drowning incident are complex and require a multidisciplinary approach. Immediate priorities center on stabilizing the child’s airway, ensuring adequate oxygenation, and maintaining cerebral perfusion. Continuous monitoring, rewarming as needed, and prompt cardiopulmonary resuscitation (CPR) if indicated are crucial. Furthermore, vigilant assessment for and prevention of complications are integral to care. In the pediatric population, care plans must also encompass the emotional support of the child and family, as well as comprehensive education on drowning prevention to mitigate future risks.

Pediatric Nursing Problem Priorities in Drowning Incidents

For children who have experienced a submersion injury, the nursing priorities are specifically tailored to address their unique vulnerabilities and physiological responses:

1. Establish and Maintain a Patent Airway and Ensure Adequate Oxygenation: Pediatric airways are anatomically different and more susceptible to obstruction. Rapidly securing and maintaining airway patency is the foremost priority to counteract hypoxemia.
2. Optimize Gas Exchange and Ventilation: Children have smaller lung capacities and higher metabolic rates. Supporting effective gas exchange is critical to prevent respiratory failure and minimize hypoxic damage.
3. Monitor and Manage Potential Pediatric-Specific Complications: Children are at higher risk for certain complications such as aspiration pneumonia, pulmonary edema, neurological deficits (including seizures), and hypothermia due to their larger surface area to body mass ratio.
4. Provide Developmentally Appropriate Emotional Support: Drowning incidents are traumatic for children and families. Providing sensitive and age-appropriate emotional support is crucial for psychological well-being and recovery.
5. Educate Families on Pediatric Drowning Risk Reduction and Prevention Strategies: Given the preventable nature of many pediatric drownings, comprehensive family education on water safety, risk factors, CPR, and emergency response is essential to long-term prevention.

Pediatric Nursing Assessment: Identifying Risks and Immediate Needs

A thorough and rapid assessment is paramount in pediatric drowning cases. This assessment includes both subjective and objective data, tailored to the pediatric context:

Subjective and Objective Data to Assess:

• Respiratory Distress: Coughing, gasping for air, difficulty breathing, shortness of breath. Note the presence of retractions, nasal flaring, or grunting – signs of increased work of breathing in children.
• Cyanosis: Bluish discoloration of skin or lips, indicating hypoxemia. In infants and young children, central cyanosis (around the mouth and trunk) is a more concerning sign.
• Altered Mental Status: Confusion, irritability, lethargy, decreased responsiveness, or loss of consciousness. Use age-appropriate assessment tools like the Pediatric Glasgow Coma Scale (pGCS).
• General Physical Signs: Fatigue, exhaustion, chest pain or discomfort (though often difficult to assess in young children), vomiting or foaming at the mouth, frothy, pink-tinged sputum.
• Thermoregulation Issues: Changes in skin temperature (cool and clammy skin), hypothermia (low body temperature). Infants and young children are particularly prone to hypothermia.
• Neurological Signs: Seizures, convulsions, coma, or unarousable state.
• Cardiopulmonary Status: Absence of breathing or signs of life (cardiopulmonary arrest), bradycardia or tachycardia, hypotension.

Factors Related to the Cause of Drowning (Submersion Injury) in Pediatrics:

• Type of Aspiration: Freshwater or saltwater aspiration. Consider potential contamination of water (e.g., pool chemicals, pond water).
• Physiological Responses: Bronchospasm, pulmonary capillary membrane damage, pulmonary edema, pulmonary surfactant elimination, cerebral edema, gas exchange insufficiency, increased intracranial pressure (ICP), prolonged hypoxemia.
• Specific Pediatric Risk Factors: Prolonged submersion, submersion in cold water, aspiration of contaminated water or gastric contents.
• Environmental and Supervision Factors: Lack of adult supervision, inadequate barriers to water access (e.g., unfenced pools), presence of hazards in the environment (e.g., buckets, open toilets).
• Pre-existing Conditions: Underlying medical conditions (e.g., seizure disorders, cardiac conditions) that may have contributed to the drowning incident.

Nursing Diagnosis: Addressing the Risk of Drowning in Pediatric Care

Based on a comprehensive pediatric assessment, a nursing diagnosis is formulated to guide individualized care. For pediatric patients at risk of drowning, or those recovering from a submersion injury, the primary nursing diagnosis is often:

Risk for Drowning as evidenced by:

• For At-Risk Children (Preventative Focus):

  • Age less than five years.
  • Lack of adult supervision near water.
  • Access to unsupervised water sources (bathtubs, pools, open water).
  • Lack of swimming ability.
  • Caregiver knowledge deficit regarding water safety.
  • Environmental hazards (unfenced pools, open buckets).

• For Children Post-Submersion Injury (Recovery Focus):

  • History of submersion in water.
  • Impaired respiratory function (hypoxemia, dyspnea).
  • Altered level of consciousness.
  • Potential for complications (pulmonary edema, aspiration pneumonia, neurological deficits).
  • Family anxiety and knowledge deficit regarding prevention.

While “Risk for Drowning” is a crucial diagnosis, other related nursing diagnoses that may be relevant in the pediatric drowning context include:

• Ineffective Airway Clearance: Related to aspiration of fluid and/or foreign material.
• Impaired Gas Exchange: Related to pulmonary edema, atelectasis, and surfactant loss.
• Risk for Aspiration Pneumonia: Related to aspiration of water and potential contaminants.
• Decreased Cardiac Output: Related to hypoxia, hypothermia, and electrolyte imbalances.
• Ineffective Thermoregulation: Related to submersion in cold water and impaired physiological regulation.
• Risk for Injury (Neurological): Related to hypoxic-ischemic brain injury.
• Anxiety (Child and/or Family): Related to the traumatic drowning event and uncertain prognosis.
• Deficient Knowledge (Caregiver): Related to water safety, drowning prevention, and CPR.

These diagnoses provide a framework for organizing pediatric nursing care, although in clinical practice, the application of specific diagnostic labels may be less emphasized than a holistic, individualized approach to care planning. The nurse’s clinical judgment and expertise are paramount in tailoring the care plan to meet the unique needs of each child and family.

Pediatric Nursing Goals: Promoting Recovery and Preventing Recurrence

The goals of pediatric nursing care in drowning incidents are multifaceted, aiming for both immediate stabilization and long-term prevention. Expected outcomes may include:

• Optimal Gas Exchange: The child will maintain optimal gas exchange, evidenced by age-appropriate arterial blood gases (ABGs) within normal limits, oxygen saturation ≥95% (or child’s baseline), age-appropriate respiratory rate and effort, and clear breath sounds.
• Adequate Cerebral Tissue Perfusion: The child will maintain adequate cerebral tissue perfusion, evidenced by age-appropriate level of consciousness, neurological status (pGCS score), absence of seizures, and age-appropriate pupillary response.
• Stable Vital Signs: The child will maintain stable vital signs within age-appropriate ranges, including heart rate, blood pressure, respiratory rate, and temperature.
• Fluid and Electrolyte Balance: The child will maintain fluid and electrolyte balance, evidenced by age-appropriate urine output, stable weight, balanced intake and output, and serum electrolytes within normal limits.
• Absence of Infection: The child will be free from infection, evidenced by normal temperature, absence of purulent drainage, and normal white blood cell count.
• Effective Thermoregulation: The child will achieve effective thermoregulation, evidenced by a stable core body temperature within the normal range for age.
• Family Understanding and Prevention Strategies: The child’s caregivers will verbalize understanding of drowning risks, prevention strategies, CPR, and emergency response.
• Reduced Risk of Recurrence: The family will implement necessary safety measures to reduce the risk of future drowning incidents.
• Age-Appropriate Emotional and Psychological Well-being: The child and family will demonstrate adaptive coping mechanisms and receive appropriate emotional support.

Pediatric Nursing Interventions and Actions: Evidence-Based Care for Children

Therapeutic interventions and nursing actions for children who have experienced drowning (submersion injury) are evidence-based and tailored to the pediatric population:

1. Optimizing Gas Exchange in Pediatric Patients

Children are physiologically distinct from adults, and respiratory management requires specific considerations. Hypoxemia in pediatric drowning is often exacerbated by surfactant disruption and atelectasis, leading to ventilation/perfusion mismatch.

Pediatric-Specific Nursing Interventions for Improving Gas Exchange:

1. Assess Pediatric Level of Consciousness (pLOC): Use the Pediatric Glasgow Coma Scale (pGCS) to monitor changes in LOC, which is a sensitive indicator of cerebral hypoxia. Infants and young children may present with irritability, lethargy, or poor feeding as early signs.
2. Monitor Pediatric Respiratory Rate, Depth, and Effort: Age-appropriate respiratory rates vary significantly in children. Tachypnea, retractions, nasal flaring, and head bobbing are signs of respiratory distress in infants and children.
3. Auscultate Pediatric Lung Sounds: Crackles, wheezing, or diminished breath sounds may indicate pulmonary edema, bronchospasm, or atelectasis. Infants and young children may have referred breath sounds, making careful auscultation in multiple locations crucial.
4. Observe for Signs of Respiratory Distress Specific to Children: Nasal flaring, stridor (especially in younger children with smaller airways), retractions (substernal, intercostal, supraclavicular), and use of accessory muscles are key indicators.
5. Monitor for Worsening Pediatric Pulmonary Edema: Pink, frothy sputum is a late sign. Early signs in children may include increased work of breathing, restlessness, and decreased oxygen saturation.
6. Continuously Monitor Pediatric Oxygen Saturation and ABGs: Pulse oximetry is essential. However, in infants and young children, probe placement and movement artifacts can be challenges. ABGs provide a more accurate assessment of oxygenation and ventilation.
7. Review Pediatric Chest X-ray Readings: Chest X-rays are vital to assess aspiration, pulmonary edema, and atelectasis. Radiographic findings may lag behind clinical presentation, requiring serial X-rays.
8. Maintain Pediatric Airway Patency and Assist with Ventilation: Use age-appropriate airway adjuncts (nasopharyngeal or oropharyngeal airways). Bag-valve-mask ventilation may be necessary. Cervical spine immobilization is crucial, especially in older children and adolescents who may have sustained trauma.
9. Administer Pediatric Oxygen Therapy: Use appropriate oxygen delivery devices based on age and severity of respiratory distress (nasal cannula, face mask, non-rebreather mask, high-flow nasal cannula). Humidified oxygen is essential, especially in infants and young children.
10. Consider Pediatric Nasogastric/Orogastric Tube Insertion: To decompress the stomach and prevent aspiration, especially if the child is intubated or has altered mental status. Orogastric route may be preferred in infants and young children.
11. Anticipate Pediatric Intubation and Mechanical Ventilation: Early intubation and mechanical ventilation may be necessary for severe respiratory distress, hypoxemia unresponsive to supplemental oxygen, or altered mental status.
12. Assist with Pediatric Endotracheal Intubation: Use appropriately sized endotracheal tubes and laryngoscope blades for pediatric intubation. Rapid sequence intubation may be indicated.
13. Utilize Positive End-Expiratory Pressure (PEEP) in Pediatric Mechanical Ventilation: PEEP can improve oxygenation and lung compliance in children with ARDS or pulmonary edema. Pediatric ventilators require specific settings and modes.
14. Consider Extracorporeal Membrane Oxygenation (ECMO) in Severe Pediatric Cases: ECMO may be a life-saving intervention in children with refractory hypoxemia despite maximal conventional ventilation.

2. Maintaining Cerebral Tissue Perfusion and Cardiac Output in Pediatric Patients

Hypoxic-ischemic brain injury is a devastating consequence of drowning, particularly in children. Rapid restoration of cerebral perfusion is critical to minimize neurological damage.

Pediatric-Specific Nursing Interventions for Cerebral Perfusion and Cardiac Output:

1. Assess Pediatric Level of Consciousness Using pGCS: Early and frequent neurological assessments are crucial. Monitor for subtle changes in responsiveness, tone, and reflexes.
2. Monitor for Pediatric Seizure Activity: Seizures are common after hypoxic brain injury. Observe for subtle seizure activity in infants and young children. EEG monitoring may be necessary.
3. Minimize Environmental Stimuli in the Pediatric Environment: Reduce noise and light to minimize agitation and potential increases in ICP.
4. Assess Pediatric Cranial Nerve Responses: Pupillary response, gag reflex, and corneal reflexes are important indicators of neurological function. Note that hypothermia can affect pupillary responses.
5. Continuously Monitor Pediatric Blood Pressure: Hypotension is a serious concern. Age-appropriate blood pressure ranges must be considered. Invasive blood pressure monitoring may be necessary.
6. Closely Monitor Pediatric Temperature: Hypothermia is common and can exacerbate neurological injury. Rewarming protocols must be implemented carefully.
7. Monitor Pediatric Skin Temperature, Color, and Peripheral Pulses: Assess capillary refill time, which is a more sensitive indicator of perfusion in children than in adults.
8. Palpate Pediatric Peripheral Pulses: Brachial and femoral pulses are more easily palpable in infants and young children. Assess pulse quality and rate.
9. Assess for Pediatric Dysrhythmias: ECG monitoring is essential. Bradycardia, especially in hypothermic children, is common. Treat underlying causes (hypoxia, hypothermia, electrolyte imbalances).
10. Monitor Pediatric Urine Output: Oliguria is a sign of decreased renal perfusion. Age-appropriate urine output norms must be used. Weigh diapers in infants to accurately measure output.
11. Monitor Pediatric Glucose Levels: Both hypoglycemia and hyperglycemia are detrimental to the injured brain. Maintain normoglycemia.
12. If Hemodynamic Monitoring is in Place, Assess Pediatric CVP and Arterial Pressures: These parameters guide fluid resuscitation and vasoactive medication management.
13. Perform Pediatric ECG Monitoring: Assess for arrhythmias and ST segment changes.
14. Position the Pediatric Patient Appropriately: Initially, prone positioning may facilitate drainage. Once stabilized, position for comfort and to optimize ventilation.
15. Rewarm the Pediatric Patient Using Age-Appropriate Methods: Warm humidified oxygen, warming blankets, radiant warmers, and warmed IV fluids. Avoid rapid rewarming, which can cause complications.
16. Initiate Pediatric Vasopressor Infusion if Indicated: Dopamine or epinephrine are commonly used vasopressors in pediatric resuscitation. Dosage adjustments based on weight are critical.
17. Administer Pediatric Inotropic Agents as Ordered: Dobutamine or dopamine may be used to improve cardiac contractility.
18. Administer Pediatric Plasma Volume Expanders as Ordered: Isotonic crystalloids (normal saline or lactated Ringer’s) are typically used for volume resuscitation. Bolus administration (20 ml/kg) may be repeated.
19. Assist with Extracorporeal Cardiopulmonary Resuscitation (ECPR) in Severe Pediatric Cases: ECPR may be considered in children with refractory cardiac arrest.
20. Provide Supplemental Pediatric Oxygenation: Maintain age-appropriate oxygen saturation targets.
21. Institute Pediatric Seizure Precautions: Padded side rails, bed in low position, close monitoring. Seizure precautions are essential in children with altered mental status.
22. Elevate Head of Bed and Maintain Midline Head Position in Pediatric Patients: To promote venous drainage and reduce ICP.
23. Minimize Pediatric Suctioning Frequency: To avoid increasing ICP. Pre-oxygenate before suctioning.
24. Administer Pediatric Anticonvulsants as Ordered: Phenytoin or fosphenytoin, or levetiracetam are commonly used. Monitor for side effects.
25. Manage Increased ICP in Pediatric Patients (if present):
    • Maintain oxygenation.
    • Monitor EEG.
    • Monitor serum electrolytes.
    • Consider hyperosmolar therapy (mannitol or hypertonic saline) with caution, as pediatric fluid and electrolyte balance is delicate.

3. Promoting Optimal Fluid Balance in Pediatric Patients

Fluid management in children is nuanced due to their higher proportion of body water and immature renal function. Both hypovolemia and fluid overload can be detrimental.

Pediatric-Specific Nursing Interventions for Promoting Fluid Balance:

1. Accurately Assess Pediatric Intake and Output: Meticulous I&O monitoring is crucial. Weigh diapers in infants. Consider insensible losses, which are proportionally higher in children.
2. Monitor Pediatric Urine Specific Gravity: To assess hydration status. Normal ranges vary with age.
3. Assess for Crackles and Shortness of Breath in Pediatric Patients: Pulmonary edema may present with subtle signs in infants and young children.
4. Note Pediatric Heart Rate and Blood Pressure Changes: Tachycardia and hypotension are signs of hypovolemia. Bradycardia may indicate fluid overload or electrolyte imbalances.
5. Monitor Pediatric Laboratory Values: Hematocrit, serum electrolytes (especially sodium, potassium, calcium), and renal function tests. Pediatric normal ranges differ from adults.
6. Monitor Pediatric Central Venous Pressure (if available): CVP provides valuable information about fluid status.
7. Insert and Maintain Pediatric Indwelling Urinary Catheter (if indicated): For accurate urine output monitoring in critically ill children. Use appropriately sized catheters.
8. Provide Oral Fluids to Conscious, Stable Pediatric Patients: Encourage age-appropriate oral rehydration solutions or clear fluids. Monitor for signs of aspiration.
9. Assist with Central Venous and Arterial Line Insertion in Pediatric Patients (if indicated): For fluid administration and hemodynamic monitoring. Pediatric-sized catheters and insertion techniques are required.
10. Administer Pediatric Fluid Volume Expanders as Ordered: Isotonic crystalloids are typically used. Calculate bolus doses carefully based on weight (20 ml/kg).
11. Administer Pediatric Inotropic Agents as Prescribed: To support cardiac output and renal perfusion.

4. Pediatric Medication Administration and Pharmacologic Support

Medication dosages in children must be meticulously calculated based on weight or body surface area. Pharmacokinetics and pharmacodynamics also differ in children.

Pediatric-Specific Pharmacologic Considerations:

1. Dobutamine: Use as temporary inotropic support for cardiogenic shock. Dosage and infusion rates are weight-based. Monitor heart rate and blood pressure closely.
2. Sodium Bicarbonate: Correct metabolic acidosis. Use with caution, as rapid correction can cause complications. Dosage is weight-based. Monitor ABGs and serum electrolytes.
3. Broad-Spectrum Antibiotics: For suspected aspiration pneumonia. Choice of antibiotic depends on age, local resistance patterns, and suspected pathogens. Dosages are weight-based.
4. Antifungals: Consider in cases of contaminated water aspiration and suspected fungal infections (e.g., Scedosporium). Voriconazole or amphotericin B may be used. Pediatric dosing and monitoring are essential.
5. Anticonvulsants: Phenytoin, fosphenytoin, or levetiracetam for seizure management. Load