A patient approximately 20 years of age without identification presents to the trauma unit on a backboard with cervical collar in place. The patient was ejected from the driver’s side of the car. The patient was oriented ×3 at the scene and able to move all four extremities. The patient stated he passed out and regained consciousness quickly. Within 5 minutes, the patient became lethargic, had slurred speech, and the right pupil was unequal and sluggish. Before becoming comatose, the patient had complained of chest pain when he breathed, and there was an imprint of the steering wheel on his chest in the form of a bruise. As he breathed, paradoxical chest movements were noted on the right side of the chest. The trachea is deviated to the right side. The trauma team, consisting of the trauma surgeon directing the team, two nurses and a resident, provided care. The initial vital signs were as follows: temperature, 100°F; blood pressure, 78/42 mm HG; heart rate, 70 bpm; respiratory rate, 28 breaths/min, uneven rapid breathing with periods of apnea. The pulse oximetry reading is 85% on room air. Two large IVs are established, and labs, including arterial blood gases, are obtained and sent to the lab for immediate processing. An indwelling urinary catheter is inserted, and 300 mL of amber-colored urine without sediments is noted. An initial survey is completed to assess for obvious problems, and steps are taken to prioritize the needs of the patient and provide emergent treatment. (Learning Objective 2)

Using the scenario, create a nursing care plan using the guidelines