While all patients are at some risk of injury, there are some patient populations that are at a much higher risk of serious injuries. The nurse should be aware of the risks for injuries both in inpatient and outpatient settings. They should also take action to minimize the risk of injury for the patient and teach the patient about safety. An injury is considered any type of damage to one’s body. A comprehensive list of potential injuries a nurse may encounter with a patient would be quite extensive. However, some examples of potential injuries include:
- Fractures
- Sprains or strains
- Burns
- Skin tears or cuts
- Bruises and contusions
- Head and brain injuries
- Violent injuries
- Pressure ulcers
- Self-inflicted injuries
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
The following are common risk factors for injury:
- Impaired mobility
- Malnutrition
- Impaired senses (vision or hearing)
- Mental health illness
- Young children and elderly people
- Occupation
- Medications that affect cognition, balance, or coordination
- Substance misuse
- Lack of safety behavior (not wearing a seat belt, reckless driving or not wearing a helmet)
- Environmental factors (poor lighting, tripping hazards, or ice)
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for risk for injury:
- Patient will remain free from falls.
- Patient will engage in safe behavior and take action to reduce chance of injury.
- Patient will remain free from any form of self-harm.
- Patient will remain free from any skin breakdown or impairment in skin integrity.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for injury.
1. Assess knowledge of safety and hazards.
It is important that the nurse understands the patient’s understanding of safe and unsafe behavior. This will also help the nurse assess what patient teaching is necessary to complete.
2. Assess patient’s current mobility level.
Understanding the patient’s current level of mobility is imperative to providing a safe environment for the patient. This allows the nurse to identify if additional mobility equipment (i.e. walker, cane) is necessary for the patient.
3. Assess patient’s understanding of their activity level and mobility restrictions.
This allows the nurse to understand if the patient perceives himself or herself at risk of potential injury and if the patient has an appropriate understanding of his or her current activity level.
4. Assess patient’s environment.
Assessing the environment will assist the nurse in identifying potential risk factors for injury.
5. Complete a throughout head-to-toe assessment.
A head-to-toe assessment will allow the nurse to gather a complete picture of the patient and his/her medical condition and what within that could put the patient at risk of injury.
6. Review patient’s chart thoroughly, including all vital signs and lab work.
This allows the nurse to identify additional potential risk factors (i.e. malnutrition, abnormal lab values, abnormal vital signs).
7. Utilize appropriate screening tools (i.e., Morse Fall Scale and Braden Scale).
These tools further assist the nurse in assessing the patient’s risk factors for specific types of injuries, such as falls or skin breakdown.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for injury.
1. Monitor vital signs.
Abnormal vital signs could put the patient at risk of falls resulting in injury due to low blood pressure.
2. Monitor mental status.
Altered mental status could increase a patient’s risk of injury as the patient may not be fully aware of their surroundings and what is considered safe.
3. Implement fall precautions as appropriate.
Patients at an increased risk of falling are also at an increased risk of injury. By identifying patients at an increased risk of falls, the nurse can implement measures to prevent falls. Measures the nurse can take include utilizing bed and chair alarms, putting fall mats on the floor beside the bed, and applying signage to the patient’s door indicating the risk of falls.
4. Assist patient with frequent position changes.
Patients with impaired mobility may be at an increased risk of skin breakdown and skin injury. Assisting with frequent position changes will decrease the potential risk of skin injuries.
5. Provide a safe environment (i.e. remove tripping hazards such as rugs or anything on the floor, remove any cords or sharp objects from rooms of individuals displaying risk of self-harm, and ensure the patient’s belongings are within appropriate reaching distance).
Providing a safe environment for patients will decrease the risk of potential injuries. Safe environments should be personalized to each individual patient and their individual risk factors based on the nursing assessment.
6. Complete hourly rounds and ensure the call light is within reach.
This allows the nurse to check on the patient frequently and assist the patient in getting anything that is needed thereby reducing the potential risk of injury. This is particularly important for patients with impaired mobility.
7. Educate patient.
Tailor patient education to each individual patient and what measures the patient can take either while hospitalized or at home to prevent accidents or injuries from occurring.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for risk for injury.
Care Plan #1
Diagnostic statement:
Risk for injury related to effects of muscle relaxants.
Expected outcomes:
- Patient will report an understanding of the effects of muscle relaxants.
- Patient will practice precautionary measures to prevent injury.
Assessment:
1. Assess muscle strength and gross and fine motor coordination.
These data will be used to gather baseline data and compare it with therapy response.
2. Review the patient’s current medication.
Medications or substances such as alcohol, central nervous system depressants, and St. John’s wort can induce synergistic effects if used concomitantly with muscle relaxants. These substances should be avoided or taken with precaution while taking prescribed muscle relaxants.
3. Assess understanding of prescribed muscle relaxants.
Understanding the side effects of muscle relaxants will prompt the patient to initiate proper precautionary measures.
Interventions:
1. Educate the patient and family regarding the use of muscle relaxants as prescribed.
Knowledge about the medication will prevent inappropriate use and the development of adverse reactions. It is also important to know if there are some activities the patient should not engage in such as operating heavy machinery.
2. Encourage them to perform ankle-strengthening exercises daily or to walk at least two or three times a week.
Ankle strengthening and a walking program can improve balance, increase ankle strength, improve walking speed, decrease falls and fear of falling, and increase confidence in performing activities of daily living.
3. Eliminate environmental hazards.
In addition to the risk of falls due to decreased muscle strength, the risk of injury rises when there is also an environmental hazard along the patient’s way.
4. Provide a medical bracelet indicating that the patient is at risk for a fall.
The medical bracelet will notify other team members to always implement fall precautions for this patient.
Care Plan #2
Diagnostic statement:
Risk for injury related to household hazards (throw rugs and inadequate lighting).
Expected outcomes:
- Patient will identify potential environmental hazards to cause injury.
- Patient will demonstrate behaviors to eliminate environmental hazards.
Assessment:
1. Ascertain knowledge of securing safety needs, preventing injury, and the motivation to perform preventive measures at home.
Information will reveal areas of incorrect information, misconception, inadequate knowledge, and further teaching.
2. Perform home assessment and identify safety issues, such as:
- Cluttered rugs
- Unlocked medication cabinets
- Absence of handrails, ramps, bathtub safety tapes
- No electrical outlet covers
- Exposed matches, smoking materials, and knobs from the stove
- Improperly placed lights, alarms, and fire extinguishers
Recognizing present safety issues will help determine needed resources and interventions to be prioritized.
3. Assess resources available to improve or modify the environment.
Lack of resources or financial constraints may hinder improving or modifying a home. The nurse should assess if modifications are feasible for the patient.
Interventions:
1. Orient or reorient the client to the environment as needed.
Patients are at increased risk of injury if they are not familiar with the environment.
2. Teach the client to remove household clutter.
Teach the patient the importance of creating a safe environment, particularly if they are at a higher risk of falls. The likelihood of injury decreases when environmental hazards are reduced:
- Eliminate throw rugs and litter
- Avoid highly polished floors
- Use commercially available traction tapes to ensure non slip surfaces in the bathtub or shower
- Install hand grips in the bathroom
- Install railings in hallways and on stairs
- Remove protruding objects (e.g., coat hooks, shelves, light fixtures) from stairway walls
3. Instruct the family to ensure adequate lighting, especially at night.
Proper lighting especially will provide the patient with better visualization of surroundings and avoid environmental hazards.
4. Encourage the patient and family to attend community education programs (e.g., correct use of child safety seats, home hazard information, firearm safety, fall prevention, CPR and First Aid, use of helmets, etc.).
Community education programs can provide safety resources, increase safety awareness, and adequate knowledge to prevent injury.
References
- Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Medline Plus. (September 2021). Wounds and injuries. https://medlineplus.gov/woundsandinjuries.html
- Nanda. (2020). Nanda nursing diagnosis list. http://www.nandanursingdiagnosislist.org/functional-health-patterns/high-risk-of-injury/
