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.

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