Nursing diagnosis – RISK FOR PERIOPERATIVE POSITIONING INJURY

RISK  FOR  PERIOPERATIVE-POSITIONING

INJURY

DEFINITION

At risk for inadvertent anatomical and physical changes as a result

of posture on equipment used during an invasive/surgical procedure

RISK FACTORS

• Disorientation

• Muscle weakness

• Edema

• Obesity

• Emaciation

• Sensory–perceptual

• Immobilization

disturbances from anesthesia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Fluid/electrolytes

• Risk management

• Pharmacological function

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing patterns.

• Maintain adequate cardiac output.

• Have surgical positioning that facilitates gas exchange.

• Not show evidence of neurologic, musculoskeletal, or vascular

compromise.

• Maintain tissue integrity.

SUGGESTED NOC OUTCOMES

Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-

logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue

Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral

INTERVENTIONS AND RATIONALES

Determine: Document and report the results of the preoperative

nursing assessment. Identify factors predisposing patient to tissue

injury. This information guides interventions.

Perform: Use the appropriate mode of patient transportation

(stretcher, patient bed, wheelchair, or crib) to ensure patient safety.

Make sure an adequate number of staff members assist with

transferring patient—obtain at least two for moving patient onto an

operating room bed and at least four for moving anesthetized

patient off operating room bed. Adequate staffing enhances safety.

Check the operating room bed before surgery for proper function-

ing. Intraoperative bed malfunction can result in increased anesthe-

sia time and a more difficult surgical approach.

Ensure proper positioning (follow institutional policies):
– Check patient’s neck and spine for proper alignment to avoid
trauma.
– Check that patient’s legs are straight and ankles uncrossed.
Crossed ankles cause pressure on tissue, vessels, and nerves.

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–  Place a safety strap 29 (5 cm) above patient’s knees, tight
enough to restrain without compromising superficial venous
return. Applied too tightly, the safety strap may cause venous
thrombosis or compression of tibial, peroneal, or sciatic nerves.
–  Secure patient’s arms at his sides with a draw sheet, with palms
down, making sure that no part of the arm or hand extends
over the mattress. Hyperextension can cause injury to the
brachial plexus. Supination of palms minimizes pressure.
Apply eye pads if patient’s eyelids don’t remain closed or if

surgery is being performed on his head, neck, or chest. If allowed to

remain open, the eyes may dry out and become infected. Corneal

abrasions may result from drapes and other foreign material rubbing

against the eyes.

If surgery is expected to last more than 2 hr or if patient is pre-

disposed to a pressure injury, place padding under his occiput,

scapulae, olecranon, sacrum, coccyx, and calcaneus to protect poten-

tial pressure points. Apply a padded footboard to support patient’s

feet. Avoid plantarflexion, and prevent stretching of the tibial nerve

and subsequent foot drop.

Assess patient position following each positional change to ensure

proper body alignment and adequate padding and support.

Inform: Tell patient about positioning measures planned to reduce

preoperative anxiety.

Attend: Assure patient that careful positioning of the body will be

carried to reduce worry about possible injury.

Manage: Consult with a physical or occupational therapist if special

protective equipment is needed to ensure safety for the patient.

SUGGESTED NIC INTERVENTIONS

Circulatory Care: Mechanical Assist Device, Circulatory

Precautions; Infection Control: Intraoperative; Positioning: Intraoper-

ative; Skin Surveillance; Surgical Precautions; Temperature

Regulation: Intraoperative

Reference

Millsaps, C. C. (2006, January). Pay attention to patient positioning! RN,

69(1), 59–63.

Nursing diagnosis – RISK FOR INJURY

DEFINITION

At risk for injury as a result of environmental conditions interacting

with the individual’s adaptive and defensive resources

RISK FACTORS

External

Internal

• Biological: Community immu-

• Abnormal blood profile:

nization level; microorganisms

Altered clotting factors;

• Chemical: Cosmetics; drugs,

decreased hemoglobin; leuko-

pharmaceutical agents; dyes;
alcohol, nicotine, preservatives;
poisons

cytosis/leucopenia; sickle cell;
thalassemia; thrombocytopenia
• Biochemical dysfunction

• Human: Nosocomial agents;

• Immune or autoimmune

staffing patterns; cognitive,
affective, psychomotor factors

disorder
• Developmental age: physiologi-

• Nutritional: Food types,

cal and/or psychosocial

vitamins

• Tissue hypoxia

• Physical: Design, structure, and

arrangement of community,
building, and/or equipment

• Mode of transport

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Emotional

• Risk management

EXPECTED OUTCOMES

The patient will

• Acknowledge presence of environmental hazards in their everyday

surroundings.

• Take safety precautions in and out of home.

• Instruct children in safety habits.

• Childproof house to ensure safety of young children and

cognitively impaired adults.

SUGGESTED NOC OUTCOMES

Immune Status; Risk Control; Safety Behavior: Home Physical Envi-

ronment; Safety Behavior: Personal; Safety Status: Falls Occurrence;

Safety Status: Physical Injury

INTERVENTIONS AND RATIONALES

Determine: Help patient identify situations and hazards that can

cause accidents to increase patient’s awareness of potential dangers.

Perform: Arrange environment of patient with dementia to minimize

risk of injury:

–  Place furniture against walls.
–  Avoid use of throw rugs.

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Maintain lighting so that patient can find her way around room

and to bathroom. Poor lighting is a major cause of falls.

Prevent iatrogenic harm to hospitalized patient by following the

2007 National Patient Safety goals. This resource provides compre-

hensive measures designed to prevent harm.

Follow agency policy regarding the use of restraints—they are

generally used as a last resort after other measures have failed.

Agency policies will provide clear direction to use restraints safely.

Inform: Encourage adult patient to discuss safety rules with children

to foster household safety. For example:

–  Don’t play with matches.
–  Use electrical equipment carefully.
–  Know location of the fire escape route.
–  Don’t speak to strangers.
–  Dial 911 in an emergency.

Attend: Encourage patient to make repairs and remove potential

safety hazards from environment to decrease possibility of injury.

Manage: Refer patient to appropriate community resources for more

information about identifying and removing safety hazards. This

enables patient and family to alter environment to achieve optimal

safety level.

SUGGESTED NIC INTERVENTIONS

Environmental Management: Safety; Fall Prevention; Health Educa-

tion; Parent Education: Adolescent; Parent Education: Childrearing

Family; Risk Identification; Surveillance: Safety

References

Bright, L. (2005, January). Strategies to improve the patient safety outcome

indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1),
29–36.

Yuan, J. R., & Kelly, J. (2006, February). Falls prevention, or “I think I can, I

think I can”: An ensemble approach to falls management. Home Healthcare
Nurse, 24(2), 103–111.