Which is the most appropriate nursing intervention to prevent further injury in the client who was injured in a tornado and is disoriented?

Use this nursing diagnosis guide to help you create a nursing care plan for patients at risk for injury.

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 include

The following are the common risk factors for injury:

• Internal factors
  • Abnormal blood profile
  • Autoimmune diseases
  • Impaired sensory function (secondary to diabetes mellitus, spinal cord injury)
  • Impaired psychomotor performance
  • Altered primary defense mechanism
  • Weakened immune system
  • Malnutrition
  • Hypoxia
• External factors
  • Changes in cognitive function
  • Exposure to toxic chemicals
  • Physical barriers
  • Inadequate nutritional source
  • Immunization within community level
  • Improper use of assistive devices (wheelchairs, canes, crutches)
  • Presence of home hazards (poor lighting, slippery floors, unanchored rugs, unsafe toys, loose electrical outlets)
  • Unsafe mode of transportation 
  • Lack of knowledge regarding environmental hazards

Desired outcomes and goals

Here are the common goals and expected outcomes:

• Within 8 hours of nursing intervention and treatment, the patient will determine the factors that increases their risk for injury and will demonstrate behaviors to avoid injury.
• Within 4 hours of nursing interventions and teaching, the patient will remain free of injuries.

Nursing Assessment and Rationales

A 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.
These factors play a role in the client’s ability to keep themselves safe from injury. Nurses must thoroughly assess each of these factors when formulating a plan of care or teaching the clients about safety measures. These factors are explained in detail below: 

• 1.1. Evaluate age and developmental stage.
  Infants and toddlers usually explore their surroundings using their senses (seeing, smelling, touching, and tasting) by placing items or objects in their mouths that put them at risk for choking. While older individuals have reduced sensory acuity and gait problems, which can contribute to the incidence of injury.
• 1.2. Assess for changes in health status and cognitive awareness. 
  A change in health status may increase a client’s risk of injury. For example, a postoperative patient may experience confusion, disorientation, and memory loss putting them at risk for falls/injury. Clients under certain medications (e.g., anti seizures, depressants, benzodiazepines, hypnotics, opioids) may impair one’s judgment.
• 1.3. Assess the client’s lifestyle. 
  Factor in the client’s lifestyle when identifying risk for injury. For example, unsafe working conditions, settling in a community with high crime rates, access to guns or weapons, unavailable safety equipment due to lack of funds, and misuse of prescription drugs. 
• 1.4. Assess for impairment in communication. 
  Communication problems such as language barriers and speech and hearing difficulties may affect the client’s ability to process information placing them at risk to experience an adverse event in the hospital.
• 1.5. Assess for sensory-perceptual impairment.
  Loss or impairment of senses (vision, taste, hearing, smell, and touch)  may affect how a person responds to environmental stimuli that place them at risk for injuries and falls. For example, a client with an olfactory impairment might be unable to detect a gas leak, or an individual with a deteriorating vision may be prone to slip or fall. 

2. Assess the client’s ability to ambulate and identify the risk for falls.
Alterations in mobility secondary to muscle weakness, paralysis, poor balance, and lack of coordination increase the risk of falls. The Morse Fall Scale (MFS) is a simple fall risk assessment tool commonly used among health care facilities. It uses a point scale system that checks on the six variables (history of falling within the three months, secondary diagnosis, use of assistive devices, IV/heparin lock, gait/transferring, and mental status. An MFS score of 0-24 (no risk) means no interventions are needed. A score of 25-50 (low risk) signifies that standard fall prevention interventions should be initiated. A score of >51 or high risk means that high-risk fall prevention interventions must be implemented (Lohse et al., 2021). 

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). 
These are indicators of a possible intentional injury or abuse that must be thoroughly assessed to ensure the client receives medical attention, is referred for additional support, and prevents further harm. All healthcare providers have a moral and legal obligation to identify these kinds of injuries, abuse and refer them immediately to the social welfare or Child Protective Services (CPS) (Gonzalez et al., 2021).

4. Conduct safety assessment in the client’s home or care setting. 
Nurses perform an environmental risk assessment to determine the presence of objects or items (e.g., cord, hooks) that could potentially be used in suicidal hanging. Therefore, it should be removed to ensure the client’s safety. 

5. Check on the home environment for threats to safety.
Patients experiencing impaired mobility, impaired visual acuity, and neurological dysfunction, including dementia and other cognitive functional deficits, are at risk for injury from common hazards. Older individuals with a history of falls or functional impairment associate their slips, trips, or falls inside the home due to household hazards (Fares, 2018). The client’s home may be inspected for the following that puts them at risk for injury: throw rugs, clutter, improper storage of cleaning products or chemicals, improper storage of medications, dim lighting, etc. Check out the Recommended Resources section below for a checklist by the CDC of common hazards found in homes.

6. Assess whether exposure to community violence contributes to risk for injury.
Exposure to community violence has been associated with increases in aggressive behavior and depression. Some health care facilities participate in community-building programs that address the needs of vulnerable individuals and prioritize violence prevention or programs that can help minimize some of the causes of violence (Van Den Bos et al., 2017). 

Nursing Interventions

The 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.
The patient should be familiar with the layout of the environment to prevent accidents from happening. Items that are too far from the patient may cause hazards. 

2. Enhance safety through the use of medical alarm systems. Recognize and watch out for alarm fatigue.
Medical alert systems are triggered to alert an emergency that a patient is experiencing physiological changes necessitating immediate treatment. However, alarm fatigue, a common safety issue among health facilities, occurs when an excessive number of monitor alarms overwhelms the health care provider, resulting in missing true clinically important alarms. According to the National Patient Safety Goals 2022, to reduce alarm fatigue and other issues, health care organizations should treat alarm system safety as a priority, determine the most important alarm signals to attend, establish systematic guidelines for handling alarms, and provide education and training to health care members in safe alarm management (The Joint Commission, 2022).

3. Avoid the use of physical and chemical restraints. Obtain a health care provider’s order if restraints are needed.
Restraints can cause injuries such as strangulation, asphyxiation, trauma, or head injury. If restraint is needed, ethical principles of proportionality and purposefulness should be applied (Chuang et al., 20. The principle of proportionality states that the level of coercive measures is limited to what is least allowed for a patient’s condition, and the principle of purposefulness states that coercive measure is applied if a specified purpose has been established beforehand (Hammervold et al., 2019).

4. Utilize alternatives to restraints that can be used to prevent falls and injuries. 
Alternatives to restraints may include alarm systems with ankle or wrist bracelets, alarms for bed or wheelchairs, close and frequent monitoring of the patient, locked doors to the unit, keeping the bed low, etc.

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.
Special beds can be an efficient and useful alternative to restraints and help keep the patient safe during periods of confusion and anxiety. Enclosure beds that require a health care provider’s order can also be used to prevent falls and to provide a safer environment for clients who are confused, agitated, or restless but are contraindicated for clients who are combative and claustrophobic (Walters, 2017).

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.
Reality orientation can help limit or decrease the confusion that increases the risk of injury when the patient becomes agitated. Validation therapy is a useful approach and form of communication to a person with a mild-moderate stage of dementia. It relieves clients’ stress and minimizes behavioral disturbances (Berg-Weger & Stewart, 2017).

7. Ask family or significant others to be with the patient to prevent the incidence of accidental falling or pulling out tubes.
This is to prevent the patient from accidental injury, falling, or pulling out tubes. Parents of hospitalized children have a big role in ensuring safety and protecting their children against potential medical errors (Duhn et al., 2020).

8. Avoid extremes in temperature (e.g., heating pads, hot water for baths/showers).
Patients with decreased cognition or sensory deficits cannot discriminate between extremes in temperature. Age-related physiological changes (e.g., loss of dermal appendages, dermal atrophy, and loss of insulating subcutaneous fat) and cognitive conditions such as dementia, peripheral artery disease, and diabetes that affect a person’s mobility and judgment are prone to burn injury (Sasor & Chung, 2019). 

9. Place the patient in a room near the nurses’ station.
Moving the client’s room closer to the nurse station allows the health care provider to closely observe patients at high risk for injury and falls and promptly provide interventions. 

10. Validate the patient’s feelings and concerns related to environmental risks.
Validation lets the patient know that the nurse has heard and understands the information and concerns. It also helps promote the nurse-patient relationship.

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).
Lighting an unfamiliar environment helps increase visibility if the patient must get up at night. Using bright colors and assigning them with objects allows patients with vision impairment to safely navigate the environment since bright colors are easier to recognize visually.

12. Perform handwashing and hand hygiene. 
Hand hygiene is the single most effective technique to prevent infection.

Interventions promoting patient safety through proper identification

1. Establish (or follow agency protocols) protocols for identifying clients correctly.
Utilize at least two identifiers (such as name, date of birth, assigned identification number, or phone number) to verify the client’s identity during hospital admission or transfer and before administering medications, blood products, or nursing care. This will improve the reliability of the client’s identification system and prevent nursing errors. It will ensure safety to all patients, especially when verbal communication is not possible (e.g., newborn, unconscious, or confused patients).

2. Identify clients correctly.
Utilize at least two identifiers (such as name, date of birth, medical record number, or phone number) to verify the client’s identity during hospital admission or transfer and before administering medications, blood products, or when providing treatment or when providing treatment procedures. This will improve the reliability of the client’s identification system and prevent the incidence of misidentification. 

3. Provide medical identification bracelets for patients at risk for injury.
Such identification is vital for patients at risk for injury, especially those with dementia, seizures, or other medical disorders. Acknowledgment of the condition can help the nurse implement appropriate interventions to promote the patient’s safety. 

4. Establish a standardized system when identifying clients who lack identification and differentiating the identity of clients with a similar name.
Further clarification of details such as date of birth or address should be done to ensure the health care provider is handling the right patient. Furthermore, when accessing a client’s record through a computer, an alert should be activated if another client has the same name. 

5. Use non-verbal approaches such as biometrics when identifying unconscious or confused patients.
If verbal communication is not possible, using a biometric positive patient ID can prevent client misidentification.

6. Label blood and other specimen containers in front of the patient.
To ensure accurate identification, each specimen container must be labeled properly in the patient’s presence containing important information: patient’s full name, date and time of collection, and collector’s identification. Barcoding is an effective approach in minimizing identification errors on the patient specimens and laboratory testing in hospital settings and is suggested as an evidence-based best practice (Snyder et al., 2012).

7. Use active communication if possible during patient identification.
Ask the patient to state their name verbally and date of birth as opposed to the “yes” or “no” question in confirming patient identification before the start of any procedure (Beyea, 2003).

Interventions preventing the risk of injury due to medication errors.

1. Administer medications using the “10 Rights of Medication Administration”. 
Understanding the 10 Rights of Drug Administration can help prevent many medication errors. 

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.
Any medications or solutions removed from the original packaging and transferred to another container should be properly labeled to be considered safe (Saufl, 2009). Discard all unlabeled medications or solutions. Label medications or solutions that will not be immediately given. The label should contain the following information: drug name or solution, concentration, amount of medication, diluent name, and volume.

3. Ensure accurate and complete medication information transfer from admission, transfer, and discharge.
Medication reconciliation compares the medications a client is currently taking with newly prescribed medications (Barnsteiner, 2008). This reconciliation is designed to prevent different medication discrepancies such as contraindications, omissions, duplications, incorrect doses or dosage forms, and adverse drug events (ADEs). Medication reconciliation involves five steps:

1. Obtain a complete list of medications the patient is currently taking
2. Obtain a list of medications to be prescribed
3. Compare and reconcile all medications identified
4. Make clinical judgment based on the comparison
5. Communicate the updated list to the patient and other health care team involved in the care.

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.
This consideration is applied for patients undergoing long-term anticoagulant therapy such as pulmonary embolism, atrial fibrillation, deep vein thrombosis, and mechanical heart valve implant. Prolonged anticoagulant therapy may result in bleeding risk and other adverse drug events due to complex dosing, inadequate monitoring, and inconsistent patient compliance.

5. Review the client’s medication regimen for possible side effects and potential interactions that may increase the risk of injury.
Polypharmacy or the use of multiple medications (sedatives, psychotropics, hypoglycemics, antihypertensive, anti-arrhythmic, diuretics, and anticonvulsants) puts the patient at a greater risk for gait disturbances, falls, and burn-related injuries among older individuals (Esechie, Masel, et al., 2019). 

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.
Enables patients to protect themselves from injury and recognize changes requiring healthcare providers’ notification and further intervention. Knowing what to do when a seizure occurs can prevent injury or complications and decrease significant others’ feelings of helplessness.

2. Monitor and record type, onset, duration, and characteristics of seizure activity.
Seizure activity should be documented to guide the treatment and differentiation of the type of seizure and recognition of triggering factors. 

3. Avoid using thermometers that can cause breakage. Use a tympanic thermometer when taking a temperature reading.
Reduces the risk of a patient biting and breaking the glass thermometer if a sudden seizure occurs. 

4. Uphold strict bedrest if prodromal signs or aura experienced. 
Patients may feel restless or need to ambulate or even defecate during the aural phase, thereby inadvertently removing themselves from a safe environment and easy observation. 

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. 
Helps keep airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result.

6. Support head, place on a padded area, or assist to the floor if out of bed. 
Supporting the extremities lessens the risk of physical injury when the patient lacks voluntary muscle control.

7. Put away all possible hazards in the room, such as razors, medications, and matches.
This prevents the patient from any unpleasant experience due to hazardous objects. Medicines should be properly stored up and away and out of sight where a child cannot reach them (Budnitz & Salis, 2011).

8. Do not restrain the patient. 
Instead of restraining, support the patient’s movement gently during seizure activity to help prevent injury caused by flailing.  

9. Monitor and document anti-epileptic drug levels, corresponding side effects, and frequency of seizure activity.
A standard therapeutic level may not be optimal for an individual patient if untoward side effects develop or seizures are not controlled.

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.
Helps maintain airway patency and protect the patient’s body from injury.

11. Loosen clothing from neck or chest and abdominal areas; suction as needed.
Constrictive clothing may cause trauma and hypoxia to the patient.

12. Supervise supplemental oxygen or bag ventilation as needed postictally.
May lessen cerebral hypoxia resulting from decreased circulation or oxygenation secondary to vascular spasm during a seizure.

13. Enforce education about the disease. 
Review pathology and prognosis of condition and lifelong need for treatments as indicated; discuss patient’s particular trigger factors (flashing lights, hyperventilation, loud noises, video games, TV viewing); know and instill the importance of good oral hygiene and regular dental care; review medication regimen, the necessity of taking drugs as ordered, and not discontinuing therapy without health care provider’s supervision; include directions for a missed dose.

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.
Patients are likely to fall when left in a wheelchair or Geri-chair because they may stand up without locking the wheels or removing the footrests. 

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.
The seating system should fit the patient’s needs so that the patient can move the wheels, stand up from the chair without falling, and not be harmed by the chair or wheelchair. Wheelchairs are often prescribed to clients without the proper guidance of an occupational therapist or another specialist that can conduct a clinical assessment and make recommendations for proper seating and wheeled mobility. As a result, many residents have poorly fitting wheelchairs that can create additional health, mobility, and function issues. 

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.
Only use restraint devices as a last resort and only when the potential benefits outweigh the potential harm. A poorly-fitted wheelchair risks shoulder injuries from continuous stress and sacral or ischial breakdown (Sabol, 2006).

4. Use assistive devices (pillows, gait belts, slider boards) during transfer.
Transferring a patient is considered a high-risk maneuver due to the possible risk of injury to the client and the health care provider. The use of assistive devices such as slider boards is helpful among clients with mobility problems to be safely transferred between a bed and chair. It is commonly used for clients with balance and strength deficits in lower extremities, paraplegia, and amputated lower extremities.

5. Consider the principles of proper body mechanics before any procedure, such as raising the head of the bed and tucking elbows in.
Proper body mechanics minimizes the risk of muscle and bone injury and promotes body movement to facilitate physical mobility without muscle strain and without using excessive energy (Kochitty & Devi, 2015).

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.
Gait training in physical therapy has been proven to prevent falls effectively. Safety is accomplished from the collaborative efforts by both individuals that provide direct or indirect care to clients and the healthcare system. 

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 Links

Resources you can use to improve your nursing care for patients with risk for injury. 

Recommended Resources

Recommended 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.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

References and Sources

Recommended references and sources to further your reading about Risk for Injury.

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