Nursing Diagnosis: Risk for Injury Application of NANDA, NOC, NIC

Nursing Diagnosis: Risk for Injury
Betty J. Ackley

NANDA Definition: At risk of injury as a result of the interaction of environmental conditions interacting with the individual's adaptive and defensive resources

NOTE: This nursing diagnosis overlaps with other diagnoses such as Risk for Falls, Risk for Trauma, Risk for Poisoning, Risk for Suffocation, Risk for Aspiration and, if the client is at risk of bleeding, Ineffective Protection. See care plans for these diagnoses if appropriate.

Related Factors: See Risk Factors.

Risk Factors:

External

Mode of transport or transportation; people or provider (e.g., nosocomial agents, staffing patterns, cognitive, affective and psychomotor factors); physical (e.g., design, structure, and arrangement of community, building, and/or equipment); nutrients (e.g., vitamins, food types); biological (e.g., immunization level of community, microorganism); chemical (e.g., pollutants, poisons, drugs, pharmaceutical agents, alcohol, caffeine, nicotine, preservatives, cosmetics, and dyes)

Internal

Psychological (affective orientation); malnutrition; abnormal blood profile (e.g., leukocytosis/leukopenia); altered clotting factors; thrombocytopenia; sickle cell; thalassemia; decreased hemoglobin; immune-autoimmune dysfunction; biochemical, regulatory function (e.g., sensory dysfunction, integrative dysfunction, effector dysfunction, tissue hypoxia); developmental age (physiological, psychosocial); physical (e.g., broken skin, altered mobility)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Risk Control

·         Parenting: Social Safety

·         Fetal Status: Intrapartum

·         Maternal Status: Intrapartum

·         Immune Status

·         Safety Behavior: Home Physical Environment

·         Safety Behavior: Personal: Safety Status: Falls Occurrence

·         Safety Status: Physical Injury

Client Outcomes

·         Remains free of injuries

·         Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Health Education

·         Behavior Modification

·         Patient Contracting

·         Self-Modification Assistance

Nursing Interventions and Rationales

·         Thoroughly orient client to environment. Place call light within reach and show how to call for assistance; answer call light promptly.

·         Avoid use of restraints. Obtain a physician's order if restraints are necessary. Restrained elderly clients often experience an increased number of falls, possibly as a result of muscle deconditioning or loss of coordination (Tinetti, Liu, Ginter, 1992; Wilson, 1998). If the elderly are restrained and fall, they can sustain severe injuries, including strangulation, asphyxiation, or head injury from leading with their heads to get out of the bed (DiMaio, Dana, Bix, 1986; Evans, Strumpf, 1990). Restraint-free extended care facilities were shown to have fewer residents with activities of daily living (ADLs) deficiencies and fewer residents with bowel or bladder incontinence than facilities that use restraints (Castle, Fogel, 1998).

·         In place of restraints, use the following:

o    Alarm systems with ankle or wrist bracelets

o    Bed or wheelchair alarms

o    Increased observation of client

o    Locked doors to unit

o    Bed with wheels removed to keep bed low (NOTE: may not be acceptable with fire regulations)

These are alternatives to restraints that can be helpful for preventing falls (Commodore, 1995; Wilson, 1998).

·         If client is extremely agitated, consider using a special safety bed that surrounds client. If client has a traumatic brain injury, use the Emory cubicle bed. Special beds can be an effective alternative to restraints and can help keep the client safe during periods of agitation (Williams, Morton, Patrick, 1990).

·         If client has a new onset of confusion (delirium), provide reality orientation when interacting with him or her. Have family bring in familiar items, clocks, and watches from home to maintain orientation. If client has chronic confusion with dementia, use validation therapy that reinforces feelings but does not confront reality. Reality orientation can help prevent or decrease the confusion that increases risk of injury when the patient becomes agitated. Validation therapy is more effective for clients with dementia (Fine, Rouse-Bane, 1995). (See Interventions for Chronic Confusion.)

·         Ask family to stay with client to prevent client from accidentally falling or pulling out tubes.

·         Remove all possible hazards in environment such as razors, medications, and matches.

·         Place an injury-prone client in a room that is near the nurses' station. Such placement allows more frequent observation of the client.

·         Help clients sit in a stable chair with armrests. Avoid use of wheelchairs and geri-chairs except for transportation as needed. Clients 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. Wheelchairs do not increase mobility; people just sit in them the majority of the time (Lipson, Braun, 1993; Simmons et al, 1995).

·         To ensure propulsion with legs or arms and ability to reach the floor, ensure that the chair or wheelchair fits the build, abilities, and needs of the client, eliminating footrests and minimizing problems with shearing. The seating system should fit the needs of the client so that the client can move the wheels, stand up from the chair without falling, and not be harmed by the chair or wheelchair. Footrests can cause skin tears and bruising, as well as postural alignment and sitting posture problems (Lipson, Braun, 1993).

·         Avoid use of wheelchairs as much as possible because they can serve as a restraint device. Most people in wheelchairs do not move. Wheelchairs can be effective restraints. In one study, only 4% of residents in wheelchairs were observed to propel them independently and only 45% could propel them, even with cues and prompts. This study found that no residents could unlock the wheelchairs without help, wheelchairs were not fitted to residents, and residents were not trained in propulsion (Simmons et al, 1995).

·         Refer to physical therapy for strengthening exercises and gait training to increase mobility. Refer to occupational therapy for assistance with helping clients perform ADLs. Gait training in physical therapy has been shown to effectively prevent falls (Galinda-Ciocon, Ciocon, Galinda, 1995; Wilson, 1998).

Pediatric

·         Teach parents the need for close supervision of all young children playing near water. If child has epilepsy, recommend showers instead of tub baths, and no unsupervised swimming ever. Most drowning accidents involving children are preventable if basic safety measures are taken (Bolte, 2000).

Geriatric

·         Encourage client to wear glasses and hearing aids and to use walking aids when ambulating.

·         If client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, sitting down immediately if feeling dizzy, and trying to have someone present when standing. The elderly develop decreased baroreceptor sensitivity and decreased ability of compensatory mechanisms to maintain blood pressure when standing up, resulting in postural hypotension (Aaronson, Carlon-Wolfe, Schoener,

·         1991; Matteson, McConnell, Linton, 1997).

Multicultural

·         Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).

·         Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of risk for injury. What the client considers risky behavior may be based on cultural perceptions (Leininger, 1996).

·         Assess whether exposure to community violence is contributing to risk for injury. Exposure to community violence has been associated with increases in aggressive behavior and depression (Gorman-Smith, Tolan, 1998). Minority students, especially African-American and Latino students in lower grades, may participate in and may more often be victims of school violence (Hill, Drolet, 1999).

·         Use culturally relevant injury prevention programs whenever possible. The Make It Safe program is a bilingual, culturally sensitive educational presentation for Hispanic families that focuses on living and working safely in a rural environment (Nawrot, Wright, 1998).

·         Validate the client's feelings and concerns related to environmental risks. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·         Assess home environment for threats to safety: clutter, inappropriate storage of chemicals, slippery floors, scatter rugs, unsafe stairs and stairwells, blocked entries, dim lighting, extension cords across pathways, unsafe electrical or gas connections, unsafe heating devices, unsafe oxygen placement, high beds without rails, excessively hot water, pets, and pet excrement. Clients suffering from impaired mobility, impaired visual acuity, and neurological dysfunction, including dementia and other cognitive functional deficits, are at risk for injury from common hazards.

·         Instruct client and family or caregivers in correcting identified hazards. Refer to occupational therapy services for assistance if needed. Notify landlord or code enforcement office of any structural building hazards.

·         Refer to physical therapy services for client and family education in safe transfers and ambulation and for strengthening exercises for ambulation and transfers.

·         Avoid extreme hot and cold around clients at risk for injury (e.g., heating pads, hot water for baths/showers). Clients with decreased cognition or sensory deficits cannot discriminate extremes in temperature.

·         Provide a signaling device for clients who wander or are at risk for falls. If client lives alone, provide a Lifeline or similar call device. Orienting a vulnerable client to a safety net relieves anxiety of the client and caregiver and allows for rapid response to a crisis situation.

·         Provide medical identification bracelet for clients at risk for injury from dementia, seizures, or other medical disorders.

Client/Family Teaching

·         Teach how to safely ambulate at home, including using safety measures such as handrails in bathroom.

·         If client has visual impairment, teach client and caregiver to label with bright colors such as yellow or red significant places in environment that must be easily located (e.g., stair edges, stove controls, light switches).

·         Teach clients winter safety information:

o    Burn only untreated wood for heat

o    Keep portable space heaters at least 3 feet from anything that can burn

o    Install smoke alarms and carbon monoxide alarm near bedrooms

o    Check the chimney and flue each year

o    Avoid sitting in an idling car in winter when snow can obstruct the exhaust pipe

o    Follow safety guidelines for use of snow blowers

Winter presents many safety challenges both indoors and out. These safety tips can help increase safety (National Center for Injury Prevention and Control, 2000).