A mean to guard a person from injury
Risk For Injury Nursing Diagnosis
1 A mean to guard a person from injury
A risk assessment is a tool to help protect a person from injury. The goal of this nursing diagnosis is to identify and remove hazards, provide a safe environment, and teach the patient how to avoid injury at home.
- Risk Assessment: Identify potential risks, measure their severity and frequency by assessing the environment
- Risk Elimination: Remove potential risks from the environment (e.g., furniture in rooms that may fall over or cause tripping)
- Safe Environment/Safe Home: Provide items such as grab bars in bathrooms and ramps outside that can prevent falls or injuries caused by falls
2 Risk for Injury Interventions and Rationales
- Risk for Injury Interventions and Rationales
- Monitor the patient’s vital signs, particularly blood pressure and respiratory rate.
- Decrease your patient’s risk for injury by providing appropriate equipment, including bed rails or side rails on the bed if necessary.
- Encourage the patient to report any pain, discomfort or other symptoms that might indicate injury.
3 1. Assess the patient s environment to identify potential safety hazards such as improperly secured oxygen tubing, throw rugs, or excessive electrical cords. Remove the risks or assist the patient in removing them.
- Assess the patient s environment to identify potential safety hazards such as improperly secured oxygen tubing, throw rugs, or excessive electrical cords. Remove the risks or assist the patient in removing them.
- Use assistive devices such as a bed tray and/or walker to help patients ambulate safely when they cannot walk without assistance because of an injury or impairment that affects their mobility and balance (elderly person).
- Assist with transfers between surfaces like beds, chairs, etc., which increases the chance of falls for patients who have lower extremity injuries (elderly person).
4 It is important to identify and remove hazards before an injury occurs.
It is important to identify and remove hazards before an injury occurs. To do this, you must be able to answer the following questions:
- What are the physical or psychological circumstances that can result in harm?
- What actions could produce these circumstances?
- Where are these actions most likely to take place (e.g., patient care area)?
- Who may be involved (e.g., patients, visitors, staff members)?
Once you have identified possible hazards, you can take action to control them:
5 2. Explain precautions to the patient and family (eg, smoking, various medication restrictions)
- Smoking: It is important to ask the patient if they smoke, as it can have a major impact on their recovery.
- Medications: The patient may be restricted from certain medications or asked to stop taking them while in the hospital.
- Alcohol: The patient should be informed of his or her alcohol consumption and its impact on their recovery.
- Driving: It is important that your loved one avoids driving while recovering from this condition, as they may not be able to perform basic tasks such as stopping at a red light safely.
- Swimming: Your loved one should avoid swimming until he/she has recovered fully from any injuries received during an episode of risk for injury nursing diagnosis.
6 3. Establish a therapeutic relationship with patient and family based on trust and respect
Establishing a therapeutic relationship with the patient and family is crucial for communication, trust and respect. The nurse is often viewed as an authority figure in the hospital setting which can create barriers to establishing rapport with patients or families who may be reluctant to share information because of lack of trust. Building a relationship with the patient and family members allows them to feel comfortable enough to share details about their condition, treatment plan, pain levels, concerns or questions they may have. This is also important because some cultures may not want others involved in certain areas such as privacy issues (Buckley-Holmes & Gallahue, 2014).
The therapeutic nurse-patient relationship includes providing emotional support during stressful times; providing education about health status through teaching skills that promote independence; helping patients cope with anxiety related stressors during hospitalization; promoting self-determination through ownership over one’s care plan; assisting patients in maintaining independence while hospitalized by following directions given by clinicians regarding medication administration or diet restrictions so that they can continue these activities after discharge (Larson & Larson Carlson).
7 4. Instruct patient and family on emergency procedures
- Instruct patient and family on emergency procedures
- What to do in an emergency: If you are alone, call 911. If you are with someone else, call 911. If you are with someone else who has a medical emergency, call 911.*
- When to call 911: Anytime you feel that your life or the lives of others is imminently threatened by something that cannot otherwise be resolved without help from professionals trained in such situations (police officers, firemen/women), or anything serious enough that it might actually kill someone if left untreated (a broken bone).
8 5. Provide a safe environment by keeping areas free of clutter
Provide a safe environment by keeping areas free of clutter. This decreases the likelihood of tripping or falling, which can lead to injury and/or increase the severity of an injury if it does occur.
9 6. Perform accurate head-to-toe assessment periodically; check skin condition often and note any change in condition
Perform accurate head-to-toe assessment periodically; check skin condition often and note any change in condition.
Skin should be assessed every shift, after changes in condition or environment, after changes in activity level or nutrition intake, or after medication changes that affect the skin.
10 7. Assist the patient with activities of daily living as needed
- Assist the patient with activities of daily living as needed.
Assist the patient with ambulation as needed; assess level of ambulation tolerance; use appropriate assistive devices or orthotics as necessary (eg, walker, cane).
11 8. Assist the patient with ambulation as needed; assess level of ambulation tolerance; use appropriate assistive devices or orthotics as necessary (eg, walker, cane); ensure safe transfer techniques are used when moving the patient from one area to another.
Assist the patient with ambulation as needed; assess level of ambulation tolerance; use appropriate assistive devices or orthotics as necessary (eg, walker, cane); ensure safe transfer techniques are used when moving the patient from one area to another.
12 Risk for Injury Nursing Diagnosis
Risk for injury nursing diagnosis is a concern that the client will experience an injury due to a fall, burn or other accident. The client may be at risk for an accident because of age, physical condition and/or mental health status.
The nurse should assess the client’s level of risk for an accidental injury by asking questions about accidents or falls in the past 24 hours. The nurse should also assess if there are any injuries from previous accidents or falls that have not been treated properly. The nurse should observe how the client gets around without help and look for signs indicating that he or she might be at risk for falling such as unsteady gait when walking across the room; unsteadiness when getting up from sitting on a chair; weakness when standing up; slowness in getting dressed; difficulty holding onto objects such as plates while eating; poor vision (especially night blindness); hearing loss (especially when background noise is present)
Risk for injury is a common nursing diagnosis that can be challenging to assess. However, having an understanding of the risks and how they can be managed in various settings will help nurses identify and provide treatment for those at risk of injury. This article provides information on the diagnosis, as well as interventions and rationales that can be used by nurses when caring for patients who suffer from this condition.