risk for injury

Risk For Injury 5 Nursing Care Plans

Risk For Injury Nursing Diagnosis and Interventions

5 Nursing Care Plans on Risk for Injury

Injury is defined as a damage to one more body parts due to an external factor or force. It can also be referred to as “physical trauma”, and can be caused by hits, falls, accidents, and other factors. A major injury can be described as a type of injury than can result to long-lasting disability or even death.

The Risk for Injury is a common NANDA diagnosis that can be used to describe a patient’s potential to obtain an injury or trauma from different causes, including accidents, medical conditions (such as dementia) and even invasive diagnostic tests (such as colonoscopy), medical procedures (such as catheter insertion) or surgery.

Risk for Injury often coincides with other nursing diagnoses, such as Risk for Falls, Risk for Impaired Mobility, and Self-Care Deficit, depending on the patient’s current situation.

Types of Injury

The International Classification of External Causes of Injury (ICECI) is a system of injury classification developed by The World Health Organization (WHO) and differentiates injuries based on the following:

  • mechanism of injury
  • objects/substances producing injury
  • place of occurrence
  • activity when injured
  • the role of human intent

Meanwhile, the Occupational Injury and Illness Classification System (OIICS) is a system of injury classification by The United States Bureau of Labor Statistics that can be used to assess an injury based on:

  • the nature of the injury
  • the body part affected
  • primary source and secondary source
  • event or exposure

Injuries can also be classified based on their modality, which includes:

  • Trauma – a shock or wound caused by a sudden physical movement or collision. Examples include bone fractures, blast injuries, catastrophic injuries, internal bleeding, and avulsion
  • Strain or Sprain – strains are injuries that involve the muscles and/or tendons, while sprains are injuries to one or more ligaments
  • Toxin or chemical-induced injuries – these are injuries caused by toxins, or adverse reaction to a medication
  • Radiation-induced injuries – these include microwave burns and radiation-induced lung injuries and skin burns
  • Injuries due to other external or internal causes – external causes may include burns or frostbite, while internal causes may involve a reperfusion injury

Causes of Risk for Injury

  1. Intentional – includes self-harm, suicide, acts of violence, and war
  2. Accidental – may result from falls, motor vehicles, falling debris, fires, animal bites, or natural causes like lightning or forest fires.

Nursing Care Plans for Risk for Injury

Fracture

Nursing Diagnosis: Risk for Injury related to acute problems in gait and balance secondary to hip fracture

Desired Outcome: The patient will be able to prevent injury by means of exercising falls prevention protocols and maintaining his/her treatment regimen in order to regain normal balance and facilitate bone healing.

InterventionsRationales
Complete a falls risk assessment, which includes:
Factors contributing to falls risk
Functional ability
Use of mobility devices
Use of bedrails
The use of a standard tool will help identify the status of the patient’s risk for falling and will help determine the factors contributing to the falls risk.
Provide identification to alert everyone of the high risk for fall.This will help healthcare staff, families and friends acknowledge the need for caution when dealing with the patient.
Put the bed at the lowest level.Low set beds reduce the possibility of injuries related to falls.
Explain the bed settings to the patient including how bed remote controls works.Allowing patients to set their own bed minimizes the risk of them jumping off the bed while it is at a higher position.
Place items within the patient’s reach.Items far away from the patient’s reach may contribute to falls and fall-related injuries.
Evaluate patient’s understanding of the use of mobility assistive devices such as crutches.Improper use of mobility devices may cause more harm than good.
Assess the proper size and height of the mobility device to the patient’s physique.Using the wrong size on mobility devices does not give full mobility support to patients and may even cause further problems such as fall-related injuries.
Maintain traction and monitor the applied cast.To effectively immobilize the affected body part, allowing the bone ends to realign and promoting healing.
Avoid using a heated fan.Heat may dry the outside layer of the cast, but it will keep the inner layer wet. It may also increase the risk for a burn injury of the skin.
Assess the need for pain medications.Patients that had recent fracture/s may experience pain upon movement, and pain leads to unstable gait and mobility.
Refer to physiotherapy and occupational therapy.Patients with fracture may need therapies to help them regain independence and lower their risk for injury.

Sprain

Nursing Diagnosis: Risk for Injury related to acute problems in gait and balance secondary to knee sprain

Desired Outcome: The patient will be able to prevent injury by means of maintaining his/her treatment regimen in order to regain normal balance and gait.

InterventionsRationales
Follow the R.I.C.E. approach in treating sprain:
Rest the affected body part
Put Ice on it for 15 to 20 minutes, every 2 to 3 hours
Compress the affected body part with elastic bandage to reduce swelling
Elevate the body part above the level of the heart
Appropriate treatment of a sprain through the R.I.C.E. method will promote faster healing and reduce the risk for further injury.
Complete a falls risk assessment, which includes:Factors contributing to falls riskFunctional abilityUse of mobility devicesUse of bedrailsThe use of a standard tool will help identify the status of the patient’s risk for falling and will help determine the factors contributing to the falls risk.
Place items within the patient’s reach.Items far away from the patient’s reach may contribute to falls and fall-related injuries.
Evaluate patient’s understanding of the use of mobility assistive devices such as crutches.Improper use of mobility devices may cause more harm than good.
Assess the proper size and height of the mobility device to the patient’s physique.Using the wrong size on mobility devices does not give full mobility support to patients and may even cause further problems such as fall-related injuries.
Assess the need for pain medications.Patients with sprain may experience pain upon movement, and pain leads to unstable gait and mobility.

Seizure

Nursing Diagnosis: Risk for Injury related to loss of sensory coordination and muscular control secondary to seizure

Desired Outcome: The patient will be able to prevent injury by means of maintaining his/her treatment regimen in order to control or eliminate seizure activity.

InterventionRationale
Explore the usual seizure pattern of the patient and enable to patient and carer to identify the warning signs of an impending seizure.To empower the patient and his/her carer to recognize a seizure activity, and help protect the patient from any injury or trauma. To reduce the feeling of helplessness on both the patient and the carer.  
Create a seizure chart, a falls risk assessment, and a bed rails assessment.To effectively assess and monitor the patient’s seizure activity and falls risk, as well as the need to use bed rails.
Place the bed in the lowest position. Put pads on the bed rails and the floor.To prevent or minimize injury in a patient during a seizure.
Advise the carer to stay with the patient during and after the seizure.To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.
Administer anti-epileptic drugs as prescribed.To prevent the occurrence of seizures and treat epilepsy.
During seizure, turn the patient’s head to the side, and suction the airway if needed. Do not leave the patient. Ask for another member of staff for help as needed.To maintain a patent airway and to promote patient’s safety during seizure.      

Diabetic Retinopathy

Nursing Diagnosis: Risk for Injury related to loss of vision or reduced visual acuity secondary to diabetic retinopathy

Desired Outcome: The patient will be able to prevent trauma or injury by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision capacity.

InterventionsRationales
Assess the patient’s degree of visual impairment.To establish a baseline of visual acuity and gain useful information before modifying the patient’s environment.  
Place the bed in the lowest position. Place the call bell within reach (if there’s any) and keep the visual aids and patient’s phone and other devices within reach.To prevent or minimize injury of the patient.
Promote adequate lighting in the patient’s room.To promote safety measures and support to the patient in doing ADLs optimally.
Ensure that the floor is free of objects that can cause the patient to slip or fall.To promote safety measures and support to the patient in doing ADLs optimally.
Advise the patient to wear sunglasses especially when going outdoors.To reduce glare and help protect the eyes.

Alzheimer’s

Nursing Diagnosis: Risk of falls related to cognitive impairment secondary to the disease process of Alzheimer’s Disease

 Desired Outcome: The patient will maintain the ability to perform activities of daily living without having an injury.

InterventionsRationale
Complete falls risk assessment.Creating an accurate status of the patient’s falls risk will help determine the needed interventions to help prevent injuries and falls from happening.
Assess cognitive ability.Alzheimer’s Disease can affect the neurocognitive status of the patient. This assessment of their cognitive ability will help identify the gaps and lapses in memory and judgment which will lead the care plan and identify care needs.
Assess the patient’s environment.Trip hazards can increase the risk of the patient falling and/or getting injured. Also, making the environment familiar will improve navigation for the patient.
Assess ability to complete activities of daily living and assist as needed.Alzheimer’s Disease can also affect the patient’s ability to perform simple tasks. Identifying the lapses in personal care will help identify the patient’s changing care needs.
Ensure the availability of mobility assistive devices.Mobility aids should be kept within the patient’s reach to avoid accidental falls.
Ensure the safety of the patient’s environment through the following:
Declutter the space
Avoid wet floors
Provide adequate lighting
Provide proper shoes/slippers
Bed at the lowest level
Valuables should be within reach
The safety of the environment plays a vital role in providing safety and avoiding injuries.
Provide an adequate time when completing a task.Dementia diseases like AD greatly affects the person’s movement. Tasks may take longer to perform.
Ensure regular intake of medications.The regular intake of medications may help maintain the patient’s gait and muscle coordination which lessens the risk of injury.
Refer to physiotherapy and occupational therapy.PT and OT are helpful in promoting patient’s mobility and independence.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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