Use this nursing diagnosis guide to help you create a nursing care plan for patients at risk for injury. Show Patient safety, according to the World Health Organization, is defined as a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in healthcare that consistently and sustainable lower risks, reduce the occurrence of avoidable harm, and makes error less likely and reduces its impact when it does occur. Healthcare-related injuries greatly impact the well-being of the patient. On average, it is estimated one in 10 patients is subject to an adverse event while receiving hospital care in high-income countries. About 134 million adverse events occur due to unsafe care in hospitals in low- and middle-income countries, contributing to around 2.6 million deaths every year. Recent estimates suggest that the social impact of patient harm can be valued at 1 trillion to 2 trillion U.S. dollars per year (WHO Global Patient Safety Action Plan 2021-2030). Nurses play a major role in providing effective, safe, and patient-centered care and implementing favorable injury prevention programs in the healthcare setting. Risk factors may includeThe following are the common risk factors for injury:
Desired outcomes and goalsHere are the common goals and expected outcomes:
Nursing Assessment and RationalesA detailed nursing assessment guide identifies the individual’s risk for injury and assists with the clinical decision by indicating which interventions should be included in the care plan. 1. Determine the client’s age, developmental stage, health status, lifestyle, impaired communication, sensory-perceptual impairment, mobility, cognitive awareness, and decision-making ability.
2. Assess the client’s ability to ambulate and identify the risk for falls. Please visit our nursing diagnosis guide for a complete assessment and interventions for Risk for Falls. 3. Note the client’s age and observe for signs of physical injury (bruises, burns or scalds, history of fractures, lacerations, bite marks, social withdrawal, fearfulness). 4. Conduct safety assessment in the client’s home or care setting. 5. Check on the home environment for threats to safety. 6. Assess whether exposure to community violence contributes to risk for injury. Nursing InterventionsThe following are the therapeutic nursing interventions for patients at risk for injury: 1. Guide the patient to their surroundings. Put the call light within reach and teach how to call for assistance. 2. Enhance safety through the use of medical alarm systems. Recognize and watch out for alarm fatigue. 3. Avoid the use of physical and chemical restraints. Obtain a health care provider’s order if restraints are needed. 4. Utilize alternatives to restraints that can be used to prevent falls and injuries. 5. If a patient is notably disoriented, consider using a special safety bed that surrounds the patient. If a patient has a traumatic brain injury, use the Emory cubicle bed. 6. If a patient has a new onset of confusion (delirium), render reality orientation when interacting with them. Have family or significant other bring in familiar objects, clocks, and watches from home to maintain orientation. If a patient has chronic confusion with dementia, use validation therapy that reinforces feelings but does not confront reality. 7. Ask family or significant others to be with the patient to prevent the incidence of accidental falling or pulling out tubes. 8. Avoid extremes in temperature (e.g., heating pads, hot water for baths/showers). 9. Place the patient in a room near the nurses’ station. 10. Validate the patient’s feelings and concerns related to environmental risks. 11. For patients with visual impairment, educate them and their caregivers to use labels with bright colors such as yellow or red in significant places in the environment that must be easily located (e.g., stair edges, stove controls, light switches). 12. Perform handwashing and hand hygiene. Interventions promoting patient safety through proper identification 1. Establish (or follow agency protocols) protocols for identifying clients correctly. 2. Identify clients correctly. 3. Provide medical identification bracelets for patients at risk for injury. 4. Establish a standardized system when identifying clients who lack identification and differentiating the identity of clients with a similar name. 5. Use non-verbal approaches such as biometrics when identifying unconscious or confused patients. 6. Label blood and other specimen containers in front of the patient. 7. Use active communication if possible during patient identification. Interventions preventing the risk of injury due to medication errors. 1. Administer medications using the “10 Rights of Medication Administration”. You can learn more about the “10 Rights of Medication Administration” here. 2. Put a label on all medications, drug containers (medicine cups, bottles, syringes, basin), or other solutions on or off the sterile area. 3. Ensure accurate and complete medication information transfer from admission, transfer, and discharge.
A written discharge instruction about medications is given to the patient, family, or caregiver explaining the medication name, purpose, dose, frequency, and route. 4. Provide extra caution to clients receiving anticoagulant therapy. 5. Review the client’s medication regimen for possible side effects and potential interactions that may increase the risk of injury. Interventions to prevent trauma or injury during seizures. 1. Teach patients and significant others to identify and familiarize warning signs for seizures. Educate on how to care for patients during and after seizure attacks. 2. Monitor and record type, onset, duration, and characteristics of seizure activity. 3. Avoid using thermometers that can cause breakage. Use a tympanic thermometer when taking a temperature reading. 4. Uphold strict bedrest if prodromal signs or aura experienced. 5. Turn head to side during seizure activity to allow secretions to drain out of the mouth, minimizing the risk of aspiration and suction airway as indicated. 6. Support head, place on a padded area, or assist to the floor if out of bed. 7. Put away all possible hazards in the room, such as razors, medications, and matches. 8. Do not restrain the patient. 9. Monitor and document anti-epileptic drug levels, corresponding side effects, and frequency of seizure activity. 10. Maintain a lying position on, flat surface. Turn head to side during a seizure to help maintain the tongue from blocking the airway. Remove any objects near the patient. 11. Loosen clothing from neck or chest and abdominal areas; suction as needed. 12. Supervise supplemental oxygen or bag ventilation as needed postictally. 13. Enforce education about the disease. Visit our nursing care management guide for patients with seizures here. Interventions preventing the risk of injury due to impaired mobility 1. Aid the patient when sitting and standing up from a chair or chair with an armrest. Limit the use of wheelchairs and Geri-chairs except for transportation as needed. 2. To ensure propulsion with legs or arms and the ability to reach the floor, ensure that the chair or wheelchair fits the patient’s build, abilities, and needs, eliminating footrests and minimizing problems with shearing. 3. Limit the use of wheelchairs as much as possible because they can serve as a restraint device. Most patients in wheelchairs have limited ability to move. 4. Use assistive devices (pillows, gait belts, slider boards) during transfer. 5. Consider the principles of proper body mechanics before any procedure, such as raising the head of the bed and tucking elbows in. 6. Coordinate with a physical therapist for strengthening exercises and gait training to increase mobility. Contact occupational therapists for assistance with helping patients perform ADLs. 7. Educate patients about safety ambulation at home, including using safety measures such as grab bars in the bathroom, use of nonslip, well-fitting footwear, and encourage clients to request assistance. Home safety should be assessed, discussed with clients and caregivers, and considered frequently when making decisions regarding the future of the client’s care towards maximizing their health outcomes. Educating the client and the caregiver about the modification of the home environment is essential in the promotion of functional and independent living and the prevention of injury. Recommended LinksResources you can use to improve your nursing care for patients with risk for injury. Recommended ResourcesRecommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.
See alsoOther recommended site resources for this nursing care plan: References and SourcesRecommended references and sources to further your reading about Risk for Injury.
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