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RISK FOR INJURY Nursing Care Plan

Risk for Injury

ing
with the individual’s adaptive and defensive resources
Risk Factors
Presence of risk factor (see Related Factors).
Related Factors
Pathophysiologic
Related to altered cerebral function secondary to hypoxia
Related to syncope
Related to vertigo or dizziness
Related to impaired mobility secondary to:
Cerebrovascular accident
Arthritis
Parkinsonism
Related to loss of limb
Related to impaired vision
Related to hearing impairment
Related to fatigue
Related to orthostatic hypotension
Related to vestibular disorders
Related to lack of awareness of environmental hazards secondary to:
Confusion
Related to tonic–clonic movements secondary to:
Seizures
Treatment Related
Related to prolonged bed rest
Related to effects of (specify) or sensorium
Examples:
Sedatives
Phenothiazine
Hypoglycemics
Antispasmodics
Diuretics
Antihypertensives
Pain medications
Vasodilators
Psychotropics
Muscle relaxants
Related to casts/crutches, canes, walkers
Situational (Personal, Environmental)
Related to decrease in or loss of short-term memory
Related to faulty judgment secondary to:
Stress
Alcohol, drugs*
Dehydration
Depression
Related to household hazards (specify):
Unsafe walkways
Slippery floors
Bathrooms (tubs, toilets)
Stairs
Inadequate lighting
Improperly stored poisons
Unsafe toys
Faulty electric wires
Throw Rugs
Related to automotive hazards:
Lack of use of seat belts or child seats
Mechanically unsafe vehicle
Related to fire hazards
Related to unfamiliar setting (hospital, nursing home)
Related to improper footwear
Related to inattentive caretaker
Related to improper use of aids (crutches, canes, walkers, wheelchairs)
Related to history of accidents
Related to unstable gait
Maturational
Infant/Child
Related to lack of awareness of hazards
Older Adult
Related to faulty judgments, secondary cognitive deficits
Related to sedentary lifestyle and loss of muscle strength

Author's Notes
This diagnosis has five subcategories: Risk for Aspiration, Poisoning, Suffocation,
Risk for Thermal Injury, and Trauma. Interventions to prevent poisoning, suffocation,
falls, and trauma are included under the general category Risk for
Injury. Should the nurse choose to isolate interventions only for prevention
of poisoning, suffocation, or trauma, then the diagnosis Risk for Poisoning,
Risk for Suffocation, Risk for Falls, or Risk for Trauma would be useful.
Nursing interventions related to Risk for Injury focus on protecting a client
from injury and teaching precautions to reduce the risk of injury. When
the nurse is teaching a client or family safety measures to prevent injury
but is not providing on-site protection (as in the community or outpatient
department, or for discharge planning), the diagnosis Risk for Injury related
to insufficient knowledge of safety precautions may be more appropriate.

Goal
The client will relate fewer or no injuries as evidenced by the
following indicators:
• Identify factors that increase risk for injury.
• Relate intent to use safety measures to prevent injury
(e.g., remove or anchor throw rugs).
• Relate intent to practice selected prevention measures
(e.g., wear sunglasses to reduce glare).
• Increase daily activity, if feasible.

Interventions
Refer to Related Factors
Reduce or Eliminate Causative or Contributing Factors, If Possible
Unfamiliar Surroundings
• Orient each client to surroundings on admission; explain the
call system, and assess client’s ability to use it.
• Closely supervise the client during the first few nights to assess
safety.
• Use a night-light.
• Encourage the client to request assistance during the night.
• Teach about side effects of certain drugs (e.g., dizziness,
fatigue).
• Keep bed at lowest level during the night.
• Consider use of a movement detection monitor (bed-based
alarm or personal alarm), if needed.
Impaired Vision
• Provide safe illumination and teach client to:
• Ensure adequate lighting in all rooms, with soft light at
night.
• Have a light switch easily accessible, next to the bed.
• Provide background light that is soft.
• Teach the client how to reduce glare:
• Avoid glossy surfaces (e.g., glass, highly polished floors).
• Use diffuse rather than direct light; use shades that darken
the room.
• Turn the head away when switching on a bright light.
• Wear sunglasses or hats with brims, or carry umbrellas, to
reduce glare outside.
• Avoid looking directly at bright lights (e.g., headlights).
• Teach the client or family to provide sufficient color contrast
for visual discrimination and to avoid green and blue:
• Color-code edges of steps (e.g., with colored tape).
• Avoid white walls, dishes, and counters.
• Avoid clear glasses (i.e., use smoked glass).
• Choose objects colored black on white (e.g., black phone).
• Avoid colors that merge (e.g., beige switches on beige walls).
• Paint doorknobs with bright colors.
Decreased Tactile Sensitivity
• Teach preventive measures:
• Assess temperature of bath water and heating pads before
use.
• Use bath thermometers.
• Assess extremities daily for undetected injuries.
• Keep the feet warm and dry and skin softened with emollient
lotion (lanolin, mineral oil). (NOTE: Use socks with grips
after just putting on lotion to prevent slips/falls).
• See Ineffective Peripheral Tissue Perfusion for additional
interventions.
Orthostatic Hypotension
• See Risk for Injury Related to Vertigo Secondary to Orthostatic
Hypotension for additional interventions.
Decreased Strength/Flexibility
• Perform ankle-strengthening exercises daily (Schoenfelder, 2000):
• Stand behind a straight chair, with feet slightly apart.
• Slowly raise both heels until body weight is on the balls of the
feet; hold for a count of 3 (e.g., 1 Mississippi, 2 Mississippi,
3 Mississippi).
• Do 5 to 10 repetitions; increase repetitions as strength
increases.
• Walk at least two or three times a week.
• Use ankle exercises as a warm-up before walking.
• Begin walking with someone at side, if needed, for 10 minutes.
• Increase time and speed according to capabilities.
Hazardous Environmental Factors
• Teach the client to:
• Eliminate throw rugs, litter, and highly polished floors.
• Ensure nonslip surfaces in bathtub or shower by applying
commercially available traction tapes.
• Install handgrips in bathroom.
• Install railings in hallways and on stairs.
• Remove protruding objects (e.g., coat hooks, shelves, light
fixtures) from stairway walls.
• Instruct staff to:
• Keep side rails on bed in place and bed at the lowest position
when the client is left unattended.
• Keep the bed at the lowest position with wheels locked when
stationary.
• Teach the client in the wheelchair to lock and unlock the
wheels.
• Ensure that client’s shoes or slippers have nonskid soles.
• If cognitively impaired, Refer to Wandering.
Pediatric Interventions
• Teach parents to expect frequent changes in infants’ and children’s
ability and to take precautions (e.g., infant who suddenly
rolls over for the first time might be on a changing table
unattended).
• Discuss with parents the necessity of constant monitoring of
small children.
• Provide parents with information to assist them in selecting a
babysitter.
• Determine previous experiences and knowledge of emergency
measures.
• Observe the interaction of the sitter with the child.
• Teach parents to expect children to mimic them and to teach
their children what they can do with or without supervision
(e.g., seat belts, helmets, safe driving).
• Explain and expect compliance with certain rules (depending
on age) concerning:
• Streets
• Playground equipment
• Water (e.g., pools, bathtubs)
• Bicycles
• Animals
• Strangers
• Instruct how to “child-proof” the home.
• Explain why children should not ride in front (air bags).
• Refer to local fire department for assistance in staging home
fire drills.
• Encourage parents to learn basic life-saving skills (e.g., CPR,
Heimlich maneuver).
• Teach children how to dial 911.
• Teach parents to assist their children in handling peer pressure
that involves risk-taking behavior.
Geriatric Interventions
• Assess for orthostatic hypotension. Compare brachial blood
pressure (e.g., supine, standing).
• Discuss physiology of orthostatic hypotension with client.
• Teach techniques to reduce orthostatic hypotension.
• Change positions slowly.
• Move from lying to an upright position in stages.
• During day, rest in a recliner rather than in bed.
• Avoid prolonged standing.
• Teach to avoid dehydration and vasodilation (e.g., hot tubs).
• Teach exercises to increase strength and flexibility.
• Perform ankle-strengthening exercises daily (Schoenfelder, 2000).
• Stand behind a straight chair, with feet slightly apart.
• Slowly raise both heels until body weight is on balls of feet;
hold for count of 3 (e.g., “1 Mississippi, 2 Mississippi,
3 Mississippi”).
• Do 5 to 10 repetitions; increase repetitions as strength
increases.
• Walk at least two or three times a week.
• Use ankle exercises as a warm-up before walking.
• Begin walking with someone at side if needed for 10 minutes.
• Increase time and speed according to capabilities.

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