We use cookies to improve your experience on our site. By using our site you agree to our consent. Learn more.

RISK FOR INJURY Nursing Care Plan

I never forgot the day when my son got an injury. That day I was in my workplace doing my routine job while suddenly the phone rang. My boss called and she said that my wife called and said that there so much blood in my son. My mind was gone crazy that time and I immediately went out of my office and it made me a half-day work. I called my wife immediately after I go outside of my office building and I heard they are crying so loud that I almost didn't understand what she was saying. I asked her if it’s an emergency, if she needs a urgent help and encouraged her to call 911 but she said it’s not necessary but she insist that I must go home so we can go to the hospital. I said to her that she should go to the hospital and we would meet there because it is the fastest way to admit my son. When we met at the hospital, I learned that my son was punctured with a pencil in his back part of his mouth near the uvula. It was occurred when my daughter was writing on a card board paper with a pencil and my son steal the pencil that led my daughter to be mad at her sibling. She slapped her sibling with the card board not knowing what could happen. Fortunately, it was just a mild injury.

But Mrs. Amber's case is different. She is 48 years old, working as a managerial position on a government agency. Recently, she was diagnosed with vertigo and with that, she was also diagnosed with risk for injury. Below is the sample of nursing care plan about risk for injury of Mrs. Amber.

 

Assessment:

Subjective: "Why is my world spinning? I feel so dizzy." as verbalized by the patient.

Objectives:

- Jerking eye movements or nystagmus

- Headache

- Sweating

- Ringing of the ear

- Dizziness

- Cannot stand firm

 

Diagnosis:

Risk for injury related to dizziness as evidenced by cannot stand firm.

 

Planning:

After 2 hours of nursing intervention, the patient will relate no injuries by identifying factors that increase risk for injury. The patient will relate intent to use safety measures to prevent injury. The patient will relate intent to practice selected prevention measures.

 

Interventions:

- Reduce or eliminate causative factors on Mrs. Amber's vertigo, if possible.

 

- Closely supervise Mrs. Amber, the patient, during the first few nights to assess her safety. Encourage Mrs. Amber to always use light during night. Encourage the patient to request assistance if she needs to get something or to do something during night. Keep bed at lowest level during the night. Provide her safe illumination and teach Mrs. Amber to ensure adequate lighting in all rooms, with soft light at night. Have a light switch easily accessible to her, next to her bed is a very good place. Provide her with background light that is soft. Teach Mrs. Amber how to reduce glare by avoiding glossy surfaces like glass or highly polished floors. Use diffuse rather than direct light; use shades that darken the room. Turn her head away when switching on a bright light. Wear sunglasses or hats with brims, or carry umbrellas, to reduce glare outside. Teach Mrs. Amber to avoid looking directly at bright lights like headlights or bulbs. Teach the patient or her family to provide sufficient color contrast for visual discrimination. Avoid white walls, dishes, and counters. Avoid clear glasses. Avoid colors that merge. Paint doorknobs with bright colors.

 

- Teach Mrs. Amber, the patient, to eliminate throw rugs, litter, and highly polished floors. Teach the patient to ensure nonslip surfaces in bathtub or shower by applying commercially available traction tapes. Teach her to install handgrips in bathroom. Teach the patient to install railings in hallways and on stairs. Teach her to remove protruding objects like coat hooks, shelves, and light fixtures from stairway walls. Instruct staff to keep side rails on bed in place and bed at the lowest position when Mrs. Amber is left unattended. Instruct staff to keep the bed at the lowest position with wheels locked when stationary. Instruct staff to teach the patient in her wheelchair to lock and unlock the wheels. Instruct staff to ensure that patient's shoes or slippers have nonskid soles.

 

Evaluation:

After 2 hours of nursing intervention, the patient related no injuries by identifying factors that increase risk for injury. The patient related intent to use safety measures to prevent injury. The patient related intent to practice selected prevention measures.

 

This diagnosis has five subcategories: Risk for Aspiration, Poisoning, Suffocation, and Risk for Thermal Injury, and Trauma.

 

For more samples of nursing care plan you are free to check it

out in our NCP LIST page.

No comments:

Post a Comment