Last updated on May 17th, 2022 at 07:14 pm
Safety Nursing Care Plans Diagnosis and Interventions
Safety NCLEX Review and Nursing Care Plans
Safety is a discipline devoted to providing health care while minimizing patient risks, errors, and injury.
It includes protocols, clear policies, and safety enhancements designed to minimize accidents, injury, complications, and misdiagnoses. Clinical care entails all efforts by healthcare providers to avoid causing injury and to limit all hazards to patient safety.
Patient Safety: Environmental Safety and Basic Needs
Environmental safety encompasses the overall healthcare continuum from rehabilitative, palliative, and hospice care. These include nurse-patient interactions in hospitals, long-term care facilities, schools, homes, and clinics. Environmental modification is needed to improve the lives and survival of vulnerable populations such as elderly people, newborns, children, people with disabilities, impoverished and illiterate, and those who are ill.
- Basic Needs
The patient’s safety and health may be affected or jeopardized if physiological demands such as adequate nutrition, oxygen, and a suitable temperature are not met.
- Oxygen. The most basic survival requirement is oxygen. A person’s life will be cut short in a couple of minutes if their blood does not contain enough oxygen. In terms of environmental safety, it is critical to control since it has the potential to further ignite flames as it is a component of fire. As a result, healthcare facilities restrict its use and adhere to correct handling and storage procedures. Due to the potential for ignition, home medical oxygen presents a risk for burns and fire. Furthermore, ventilation is a necessary component in any facility as insufficient ventilation could lead to suffocation and increased work of breathing. Fuel-burning appliances can produce carbon monoxide, a toxic gas that reduces oxygenation to tissues due to fumes and inadequate ventilation. Typical signs and symptoms of reduced oxygenation or hypoxia include the following:
- Shortness of breath
- Nausea
- Dizziness
- Fatigue
- Headache
- Anxiety
- Nutritional intake. Meeting the nutritional requirements and demands of the body is critical for life and survival. In order to maintain bodily homeostasis, adequate fluids should be consumed while sufficient calories offer energy and increase immunity. Additionally, it supplies the body with the required components for healing and recovery.
The nurse should evaluate the patient’s safety, especially when the patient is suffering from a serious disease, lacks cognitive and physical function, or is included in the susceptible populations. A patient’s nutritional health might also be jeopardized by his/her refusal to eat, poor nutrient intake, inability to swallow or chew, nausea and vomiting, food allergies, and overeating. The following are examples of supportive care that can help with proper nutrition and fluid intake:
- Intravenous fluid infusion
- Intubation
- Oral feedings
Aside from physiologic factors affecting nutritional status, food contamination also poses a health risk. A patient’s risk of infection and food poisoning increases if food is improperly cooked, stored, or subjected to unhygienic conditions.
- Physical Hazards and Accidents. Motor vehicles, poisonings, and falls are examples of hazards that can put a person’s health and safety at risk.
- Poisoning. This refers to any substances that can jeopardize an individual’s health and survivability when absorbed, swallowed, or inhaled. Always exercise moderation in any substances or food items, as too much can be debilitating, harmful, or toxic. Medications, household disinfectants, personal hygiene products, detergents, cleaning supplies, gasses, and vapors are all potential sources of poisoning. When it enters the body through varying modes of transmission, it can impair or lead to organ failure. Accidental poisoning at home and even in the healthcare setting is possible. If a patient or a parent has questions about poisoning treatment, a poison control center is the best place to turn.
- Motor vehicles. Safety belts, child restraints, rear seat positioning, helmets, and the type of car used all reduce accidents and the devastating consequences.
- Fire. Smoking at home is the largest cause of fire-related death, alongside stoves that are the primary cause of house fires and fire-related accidents due to negligent use. For this reason, fire extinguishers, smoke, and carbon monoxide detectors must be situated throughout the residence.
- Temperature regulation. Health, productivity, and safety are all negatively impacted by temperature extremes. Cold exposure can induce frostbite and unintentional hypothermia. Extreme heat depletes the body’s electrolytes and elevates the core body temperature, leading to heatstroke.
Risk Factors to Patient Safety
- Physical and cognitive status
- Environmental factors (healthcare, inpatient, and home environment)
- Lifestyle choices
- Knowledge
- Safety awareness
- Current developmental level
- Deterioration of physical and mental function
- Impaired senses and mobility
- Age
- Underlying infection
- Substance abuse
- Smoking
- Isolation
- Unsafe housing and clothing
- Misdiagnoses
- Miscommunication
- Language Barrier
- Workplace safety issues
- Medications
- Physical disability
Nursing Considerations for Patient Safety
- Employ patient education on the importance of following through with the procedure or care plan.
- Ask the patient to remove any restrictive clothing articles and jewelry that may increase the risk of falls.
- Monitor temperature to rule out infection.
- Patients receiving digoxin should be regularly monitored on their level of serum digoxin. Patients experiencing complications should be advised to immediately inform the handling physician about potential digoxin toxicity. Moreover, they should be urged to take medication as directed.
- Perform skin examination and take note of its characteristics.
- Install handrails and safety sheets for patients with impaired cognitive and physical function. Educate the patient about fall prevention techniques.
- Assist patients with visual impairments and physical disabilities during activities of daily living (ADLs).
- Document parent-child interaction for suspected child abuse. Provide the opportunity for communication and identify verbal and non-verbal cues which may indicate child abuse and neglect.
Nursing Process for Patient Safety (ADPIE)
- Assessment
Assessment, the first step of the Nursing Process (ADPIE), entails collecting data and information. Data collection could be in subjective or objective data. Subjective data is gathered through the verbal statement of the patient. Meanwhile, objective data are observable and measurable using the five (5) senses, such as vital signs, temperature, blood pressure, height, and weight. Nursing care plans rely heavily on assessment, and if the assessment is incorrect, the diagnosis will be inaccurate.
The assessment of patient safety includes:
- Patient Identification
- Communication and Inquiries
- Risk assessment
- Assessment of the effect of an underlying illness
- Medical History
2. Diagnosis
A nursing diagnosis is developed using the information acquired during the assessment. Nursing diagnoses are developed to assist in the planning and delivery of patient care. Moreover, it must be developed using Maslow’s Hierarchy of Needs as a framework. During this stage, the nurse diagnoses the patient’s level of safety by means of identifying actual problems and potential issues or risks, such as the risk for falls, risk for injury, risk for poisoning, deficient knowledge, the risk for trauma, and risk for suffocation.
3. Planning
Following the nursing diagnosis, the healthcare team plans for promoting and maintaining the patient’s safety. The healthcare providers will work together to plan an appropriate treatment approach for the patient. In formulating care plans, nurses have particular goals (SMART) to ensure a favorable outcome. SMART goals stand for Specific, Measurable, Attainable, Realistic, and Time-Bound. For the nurse to develop SMART goals, he/she has to communicate with the patients about their hesitations, preferences, personal care goals, and emotional state. This stage includes setting nursing goals, desired outcomes, and interventions.
4. Implementation
The implementation stage has commonly employed direct care and indirect care. Direct care is the relationship between a healthcare practitioner and a patient. It entails active involvement and hands-on care of the healthcare professional to assist the patient in meeting their goals towards the promotion and maintenance of patient safety. On the other hand, indirect care services do not require the presence or interaction with the patients.
5. Evaluation
Evaluation is the stage where the healthcare professional critically weighs the results of the nursing action to know if the desired outcome has been met. In terms of patient safety, the main question for evaluation of the nursing plan and actions taken is: “Is the patient safe during the shift/upon discharge?” During the evaluation phase, nurses determine whether their actions had a beneficial or negative effect towards patient safety. A nursing plan and implementation is considered effective if the care plan is appropriate or beneficial to the patient’s condition. On the other hand, if the patient’s condition does not improve or worsen, the nursing procedure is ineffective. Some examples of evaluation of patient safety include:
- The patient verbalizes understanding of safety risks.
- The patient is free from injury and complications.
- Breathing is effortless and unobtrusive.
- The patient minimizes exposure to toxic substances and harmful agents.
Safety Nursing Diagnosis
Safety Nursing Care Plan 1
Nursing Diagnosis: Risk for Falls related to altered sensory perception and loss of muscle strength, secondary to possible compromise in patient safety.
Desired Outcome: The patient will demonstrate the use of fall prevention techniques.
| Nursing Interventions for Safety | Rationale |
| Assess for any factors that enhance the patient’s chance of falling, especially when there is a physical or cognitive function change. | Both internal and environmental factors can estimate the risk of falling. Since falls can result in injury, risk assessment can identify whether or not patient safety is in concern. Individuals who suffer from diminished awareness and disorientation may be ignorant of their whereabouts. There’s a chance they’ll get disoriented and end up in a dangerous situation. Meanwhile, patients with visual and auditory disabilities have difficulties noticing and hearing potential risks in their surroundings. In contrast, age-related macular degeneration makes it more probable for elderly patients to fall and sustain other injuries. |
| Evaluate the patient’s ambulation and take note of any movement difficulties. | The assessment will help with patient management. It would also allow the nurse to tailor or adjust the care plan to meet the patient’s specific needs. |
| Evaluate the use of assistive equipment for mobility. | Using a cane or a walker incorrectly increases the danger of tripping and falling. Furthermore, it can lead to energy depletion, shakiness in movement, and even joint damage if misused. As a result, education programs on the proper operation of ambulatory devices for daily living activities (ADLs) should be available. |
| Examine for unsafe clothing | An increased risk of falling can be attributed to poor-fitting or excessively tight clothing and footwear. |
| Observe the patient’s physical surroundings. | Individuals unfamiliar with their surroundings, such as when furniture and equipment are relocated, are more likely to trip and fall. Environmental risks contribute significantly to falls owing to exposure to fall hazards. |
Safety Nursing Care Plan 2
Risk for Poisoning
Nursing Diagnosis: Risk for Poisoning related to insufficient knowledge and precautions, secondary to possible compromise in patient safety.
Desired Outcomes:
- The patient will be able to identify symptoms of digitalis poisoning and the onset of complications.
- The patient will be free of drug or chemical toxicity/poisoning.
| Nursing Interventions for Safety | Rationale |
| Assess the patient’s environmental conditions. If necessary, childproof potentially dangerous areas. | For safety reasons, common house cleaners and medications are kept out of reach of children. For example, a 1-year-old patient is prone to putting objects in his/her mouth. Pediatric patients will be less likely to be exposed to potentially hazardous substances if areas that could pose a hazard are childproofed. |
| Remove or label all potentially toxic materials from the patient’s home environment, including alcohol, disinfectants, pharmaceuticals, household cleaners, and pesticides. | Notifying parents of potentially hazardous materials will effectively safeguard pediatric patients from exposure to harmful toxins. |
| Set up carbon monoxide detectors in every area of the patient’s home. | Carbon monoxide poisoning can happen in a couple of seconds after inhalation of toxic fumes. |
| For patients with congenital heart failure (CHF) and heart arrhythmias: | |
| Educate the patient on the type of digitalis prescribed, how it is used therapeutically, and the risk of digitalis toxicity. | There are numerous preparations of digitalis, each with its unique name, dosage, mechanism of action, and onset. In order to avoid confusion, it is critical to describe the precise type of digitalis provided to the patient. Additionally, patient education contributes to the development of a fundamental understanding of the disease and its treatment. |
| Educate the patient about the consequences of modifying medication doses. | Increases or decreases in dose will influence the drug’s activity, mode of action, and therapeutic effect, and in the worst-case scenario, will result in toxicity and complications. |
| Instruct the patient to report any signs or symptoms of poisoning as soon as they are noticed. | The presence of nausea, diarrhea, lethargy, drowsiness, changes in mentation, blurred vision, dyspnea, and altered color perception may suggest the need for prompt intervention. |
Safety Nursing Care Plan 3
Risk for Suffocation
Nursing Diagnosis: Risk for Suffocation related to inadequate air available for inhalation, secondary to possible compromise in patient safety.
Desired Outcome: The patient will demonstrate preventive strategies for maintaining a patent airway.
| Nursing Interventions for Safety | Rationale |
| Examine the patient for changes in skin color, severe dyspnea, lethargy, elevated pulse, and intercostal retractions during inhalation | It provides data on the increasing blockage of the airways, which could potentiate the risk of suffocation. Moreover, evident chest retractions and work of breathing often denote impaired gas exchange. |
| Monitor the patient’s oxygen levels and administer oxygen as needed. | This prevents hypoxemia and promotes oxygen delivery. |
| Monitor for the presence of abnormal respiratory sounds (e.g., bubbling gurgling) and air hunger. | Severe complications could be avoided if treated promptly. |
| Explain the patient’s treatment and interventions in plain language, including the need for emergency intubation, mechanical ventilation, and tracheostomy. | Patients with existing respiratory complications may require intubation devices and assisted ventilation in promoting patent airway and ventilation. It also establishes the airway in respiratory failure and asphyxia, thereby ensuring the patient’s welfare. |
| Place pregnant patients in semi-fowler and fowler positions to ensure adequate oxygenation. | These positions ensure that the mother and fetus receive optimal oxygenation and circulation. It also alleviates acid reflux symptoms, leading to dyspnea and choking. |
Safety Nursing Care Plan 4
Risk for Trauma
Nursing Diagnosis: Risk for trauma related to situational exposure or encounter, secondary to possible compromise in patient safety.
Desired Outcome: The patient will not be subjected to maltreatment or abuse
| Nursing Interventions for Safety | Rationale |
| Assess parental responses, expectations, and sentiments to their child’s behavior and evaluate their abilities to console the child. | Reveals possible exploitation and abuse that puts patient safety at risk. |
| Evaluate the patient’s environment. Add padding to the side rails and raise them while the bed is in the lowest position. Secure the bed, stretcher, or even wheelchair’s brakes. | These actions promote safety and protect the patient from self-harm or accidental injury. Patients with post-traumatic stress disorder (PTSD) or a traumatic childhood are more likely to indulge in self-harm. |
| Obtain a thorough record of events and history. | Provides information that can be utilized in court proceedings involving allegations of abuse. In the event of a court case, medical records need to be as accurate, factual, and objective as possible. These include documents without comments, impressions, and interpretations. Factual records include: health records, thorough description of condition, photographs documenting injuries, child’s verbal responses to parents and others, description of behaviors and interactions |
| Encourage positive behavior by providing feedback and occasional incentives. | This encourages good behavior and conduct, reducing the likelihood of trauma relapse. |
| Notify authorities of any suspected child abuse and neglect (CAN) | Child abuse documentation and reporting will vary by state. It is mandatory to comply with the state regulations and raise CAN suspicions. |
| Promote a therapeutic environment. | Encourages self-expression and assists patients in making sense of their thoughts and feelings to cope more effectively with the consequences of childhood abuse. |
| Support the child in dealing with grief if foster care is necessary | When a child is placed in foster care, he/she may experience mixed emotions of remorse, relief, and shame. The child’s progress and development are enhanced when healthcare providers help them through the grieving process. |
| Refer families to child protection and social service agencies for assistance. | The type of abuse and the requirements of the parents are taken into consideration while developing social activities, education, and support. In addition, it helps alleviate the cause of neglect. |
Safety Nursing Care Plan 5
Nursing Diagnosis: Risk for Injury related to changes in mental and health condition, secondary to possible compromise in patient safety.
Desired Outcomes:
- The patient will maintain safe conditions with no reported injuries.
- The patient will be free of injuries, and he/she will modify the environment to guarantee safety.
| Nursing Interventions for Safety | Rationale |
| Evaluate changes in health condition and cognition. | Injuries might occur when a patient’s health situation changes. A postoperative patient may become disoriented or forgetful, putting him/her in danger of falling and suffering an injury. Loss or impairment of one or more senses may limit a person’s response to environmental stimuli that put patient safety at risk for falls and injuries. |
| Determine the client’s level of ambulation and risk of fall using the Morse Fall Scale (MFS). | Falls are more likely to occur when a person’s mobility is impaired due to muscle weakness, paralysis, poor balance, or a lack of coordination. Measuring their mobility using an assessment tool will aid in determining the degree of impairment and the need for intervention. |
| Conduct a risk assessment of the patient’s environment. | Dementia and other forms of cognitive dysfunction put patients at risk for injury from commonplace hazards (including the home and care setting). The patient’s environment may be inspected for items that put them at risk of injuries, such as having clutter and inadequate lighting. Moreover, it aims to identify objects or items that could be utilized in suicidal hanging. |
| Safeguard the patient with a medical alarm system and closely observe for alarm fatigue | Medical alert systems are activated in emergencies to notify medical personnel that a patient is undergoing physiological changes that require rapid treatment. Meanwhile, alarm fatigue or alert fatigue is a prevalent safety issue in healthcare facilities. This happens when one is subjected to many regular alarms (alerts) and overwhelms the healthcare provider, resulting in subsequent desensitization. |
| Refrain from using physical or chemical constraints. | Physical restraints should only be used as a last resort when other less restrictive methods have failed, and the patient is at risk of injuring themselves or others. |
| Acknowledge the patient’s worries about environmental hazards. | Patients can feel validated when they receive verbal confirmation that the nurse has heard and understood their concerns. It also enhances the relationship between the nurse and the patient. |
| Assist visually impaired patients and their caregivers in comprehending the importance of using labels in high-contrast colors, such as yellow or red, to denote critical areas of their surroundings (e.g., stair edges, light switches). | People with vision impairments can safely navigate the environment by assigning bright colors to objects because they are easier to perceive visually. Patients who have to get up in the middle of the night may find it helpful to set the lighting in certain areas to aid their vision. |
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. (2022). 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, 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 intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
