Risk for Injury Nursing Diagnosis: Comprehensive Care Plan for Patient Safety

Understanding Patient Safety

Patient safety, as defined by the World Health Organization (WHO), is a fundamental aspect of healthcare. It encompasses a structured framework of actions within healthcare settings designed to consistently minimize risks, prevent avoidable harm, reduce errors, and lessen the impact of errors when they do occur. This involves creating a culture of safety, implementing robust processes, establishing clear procedures, fostering safe behaviors, leveraging appropriate technologies, and cultivating secure environments.

Healthcare-associated injuries represent a significant global health challenge, impacting patient well-being and healthcare systems. Statistics reveal that approximately one in ten patients in high-income countries experience adverse events during hospital care. The situation is even more critical in low- and middle-income countries, where an estimated 134 million adverse events occur annually due to unsafe hospital care, contributing to about 2.6 million deaths each year. The global socioeconomic impact of patient harm is staggering, estimated at trillions of U.S. dollars annually (WHO Global Patient Safety Action Plan 2021-2030).

Defining Risk for Injury in Nursing

In nursing, the risk for injury is a crucial nursing diagnosis. It describes a state in which an individual is vulnerable to physical harm due to a combination of environmental factors, physiological conditions, and cognitive or psychological issues that compromise their safety.

Nurses are at the forefront of promoting patient safety. They play a pivotal role in delivering effective, safe, and patient-centered care. A key responsibility is the implementation of proactive injury prevention programs within all healthcare settings. This proactive approach is essential to mitigate risks and ensure patient well-being across all healthcare interactions.

Safety Across the Lifespan: A Nursing Perspective

By Iris Dawn Tabangcora, Expert Automotive Technician & Content Creator at xentrydiagnosis.store

As automotive experts, we understand the critical importance of safety systems in vehicles. Similarly, in healthcare, nurses are the safety experts, diligently working to prevent accidents and injuries across all patient populations. From simple yet vital reminders to patients—like using the call button for assistance—to ensuring emergency equipment is readily available, nurses are constantly acting as guardians of their patients’ safety.

Despite unwavering vigilance, accidents can happen. Nurses are also essential in caring for individuals injured in various incidents, from vehicle accidents to drownings and poisonings. A deep understanding of what constitutes a safe environment is paramount for nurses. Moreover, recognizing that many accidents are rooted in human behavior underscores the importance of preventative measures.

Here’s a comprehensive guide to promoting safety throughout different stages of life:

Infancy: Nurturing a Safe Start

Infancy is a period of heightened vulnerability to accidents. Tragically, accidents are the leading cause of mortality in infants. Their complete dependence on caregivers and inherent lack of awareness of danger make them particularly susceptible to injuries.

Common accidents during infancy include burns, choking, suffocation, falls, and poisoning. Nurses and parents can collaborate to create a secure environment for newborns and infants by implementing these crucial measures:

Car Seat Safety: Always use a federally approved car seat. It must be positioned in the back seat, facing rearward, for optimal safety.
Prevent Falls: Never leave an infant unattended on any elevated surface, such as changing tables or beds.
Bath and Feeding Safety: Carefully check the temperature of bathwater and formula before use to prevent burns.
Choking Prevention: Hold infants upright during feeding and avoid propping bottles. Cut food into very small, manageable pieces. Completely avoid feeding infants peanuts or popcorn due to choking hazards.
Safe Toys: Provide toys that are large, soft, and free of small, detachable parts or sharp edges.
Electrical Safety: Install covers on all electrical outlets and keep cords coiled and out of reach.
Poison Prevention: Store plants, household cleaners, and wastebaskets out of reach. Securely lock away potential poisons, such as medications, paints, and gasoline.

Toddlerhood: Navigating Curiosity Safely

Toddlerhood is characterized by intense curiosity. Toddlers explore their world through touch and taste, often putting anything that intrigues them into their mouths. Nurses and parents understand the constant supervision and protection toddlers require. They are actively learning about their environment and are often drawn to potential hazards like pools and busy roads.

To promote toddler safety, consider these strategies:

Continued Car Seat Use: Continue using federally approved car seats in the back seat for all car travel.
Oral Safety Education: Teach children from a young age not to put objects in their mouths, especially pills, unless given by a parent or trusted adult.
Sharp Object Safety: Keep sharp objects, such as furniture corners and knives, out of children’s reach.
Kitchen Safety: Place hot pots on back burners with handles turned inward to prevent accidental spills and burns.
Secure Storage of Hazardous Materials: Store cleaning solutions, insecticides, and medications in locked cupboards, completely inaccessible to children.
Bathroom Supervision: Always supervise toddlers closely in the bathtub to prevent drowning.
Low Beds: Transition to a low-lying bed when the child begins to climb to minimize fall risks.
Outlet Covers: Maintain safety covers or plugs on all electrical outlets.

Preschool Age: Education and Surveillance

Preschool children are exceptionally active but often lack coordination, making them prone to accidents. This stage is ideal for initiating safety education, including lessons on street crossing, traffic signals, and bicycle safety. Continued careful supervision is essential as preschoolers are still not fully self-reliant in safety matters. Their rapidly developing cognitive and motor skills necessitate that safety measures evolve to keep pace with their new abilities.

Safety measures for preschoolers include:

No Running with Objects in Mouth: Discourage running with candy or other objects in their mouths to prevent choking.
Small Object Safety: Reinforce teaching children not to put small objects in their mouth, nose, or ears.
Appliance Safety: Remove doors from unused appliances like refrigerators to prevent entrapment.
Street Safety Education: Always supervise preschoolers when crossing streets and begin comprehensive safety education about obeying traffic signals and looking both ways before crossing.
Safe Play Areas: Teach children to play in designated safe areas and educate them about the dangers of playing with matches, near fire, charcoal, and heating appliances.
Stranger Awareness: Teach children to avoid strangers and to always inform parents of their whereabouts.
Playground Safety: Instruct preschoolers not to walk in front of swings or push others off playground equipment to prevent injuries.

School-Age Children: Rules and Recreation

School-age children are developing more thoughtful actions and are increasingly aware of peer influence. They respond well to rules and often engage in imaginative play, frequently imitating adult behaviors. This age group is particularly vulnerable to injuries from outdoor activities and recreational equipment.

Promote safety for school-age children through these guidelines:

Recreational and Sports Safety: Teach specific safety rules for all recreational and sports activities. Examples include never swimming alone, always wearing a life jacket in a boat, and using helmets and protective pads when needed for activities like biking and skating.
Supervised Sports: Supervise contact sports and activities that involve aiming at targets to ensure safe play.
Tool and Equipment Safety: Teach children safe methods for using stoves, garden tools, and other equipment they might encounter.
Fireworks and Firearms Safety: Strictly teach children not to play with fireworks, gunpowder, or firearms due to the severe risks.
Health Hazards Education: Educate children about the health risks associated with smoking and advocate for a smoke-free environment. If you smoke, consider quitting.
Substance Abuse Education: Teach children about the detrimental effects of drugs and alcohol on judgment and coordination.

Adolescence: Responsibility and Risk Awareness

Adolescence requires an assessment of responsibility levels, common sense, and resistance to peer pressure. This period often marks the time when teenagers may obtain a driver’s license. Beyond driving risks, sports injuries, suicide, and homicide are significant safety concerns for adolescents that nurses and parents must address.

Safety measures for adolescents include:

Driver’s Education: Ensure adolescents complete a comprehensive driver’s education course and provide ample practice driving experience in various weather conditions.
Driving Limits: Establish firm rules regarding automobile use, including a strict zero-tolerance policy for driving under the influence of drugs or alcohol.
Sports Equipment Safety: Encourage the consistent use of proper protective equipment when participating in sports.
Power Tool Safety: Teach safety protocols for the use of power tools if they are involved in such activities.
Substance Abuse and Sexual Health Education: Thoroughly inform adolescents about the dangers of drugs, alcohol, and unprotected sexual activity. Include education on date rape prevention and self-defense strategies.
Mental Health Monitoring: Be vigilant for mood and behavior changes in adolescents, which can be indicators of mental health struggles. Maintain open communication to foster trust and support.
Positive Role Modeling: Set a strong positive example of behavior for adolescents to emulate in all safety aspects.

Young Adulthood: Navigating Independence with Caution

Young adults face unique safety risks, particularly vehicle accidents, suicide, and exposure to natural radiation, drowning, and firearms. Nurses can promote safety in this age group by emphasizing:

Motor Vehicle Safety: Reinforce the importance of safe driving practices, including seatbelt use and avoiding distracted or impaired driving.
Fire Hazard Prevention: Remind young adults to maintain their living spaces to prevent fire hazards, such as checking and repairing electrical wiring.
Workplace Safety Awareness: When making career decisions, discuss the potential for workplace injuries or fatalities in different professions.
Sun Safety: Educate about the risks of excessive sun radiation and encourage sun protection measures.
Mental Health Support: Encourage individuals struggling to cope with life stresses to seek counseling and mental health support.

Middle Adulthood: Balancing Health and Responsibility

The injury rate in middle-aged adults is influenced by physiological changes, personal responsibilities, and work-related demands. Nurses can assist middle-aged adults in maintaining safety by:

Motor Vehicle Safety Reinforcement: Continue to stress the importance of motor vehicle safety, as this remains a significant risk.
Home Safety: Stairs: Ensure stairways are well-lit and free of clutter to prevent falls.
Bathroom Safety: Equip bathrooms with hand grips and non-skid bath mats to reduce the risk of slips and falls.
Smoke and Fire Safety: Regularly test smoke detectors and fire alarms to ensure they are functional.
Machinery Safety: Emphasize adherence to safety precautions when using machinery at work or home.

Older Adulthood: Prioritizing Injury Prevention

Injury prevention is a paramount concern in the care of older adults. They are at increased risk for accidents and injuries due to age-related factors such as declining vision, slowed reflexes, and increased bone fragility. Simple activities like climbing stairs or driving become more challenging. Memory impairment and a tendency to wander can also increase risks.

Nurses can significantly enhance the safety of elders in their home environments with these key actions:

Vision Correction: Ensure eyeglasses are functional and prescriptions are up-to-date to optimize vision.
Adequate Lighting: Ensure appropriate lighting throughout the home, especially in hallways and stairways, to improve visibility and reduce fall risks.
Clutter-Free Environment: Maintain a tidy and uncluttered environment to eliminate tripping hazards.
Marking Hazards: Clearly mark doorways and step edges as needed to improve visibility and spatial awareness, particularly for those with visual impairments.
Appropriate Footwear: Advise wearing shoes or well-fitted slippers with non-skid soles to provide better traction and stability.
Ambulation Assistance: Provide assistance with ambulation as needed, especially for those with mobility issues or balance problems.
Mobility and Cognitive Monitoring: Regularly monitor gait, balance, activity tolerance, orientation, and alertness status to identify and address potential risks proactively.
Low Bed Position: Keep beds in a low position to reduce the impact of falls from bed.
Bathroom Safety Features: Install grab bars in bathrooms and provide raised toilet seats to make bathroom use safer and easier.
Medication Review: Encourage annual or more frequent reviews of all prescribed medications to identify and mitigate potential side effects or interactions that could increase fall risk or cognitive impairment.

Factors Contributing to Risk for Injury

Several factors can elevate an individual’s risk for injury. Understanding these factors is crucial for effective nursing assessment and care planning:

Abnormal Blood Profile: Conditions such as anemia, leukopenia, and thrombocytopenia increase the risk of bleeding, infection, and bruising. For example, a patient with anemia may bleed more easily from minor injuries.
Impaired Psychomotor Performance: Reduced coordination, slowed reaction time, and difficulties with balance and motor skills, often seen in conditions like Parkinson’s disease, traumatic brain injury, or as a side effect of certain medications, significantly increase injury risk.
Impaired Sensory Function: Sensory impairments like blindness, deafness, and loss of sensation increase the likelihood of accidents, particularly falls. A visually impaired person, for example, is at a higher risk of tripping and falling.
Changes in Cognitive Function: Conditions like dementia, delirium, and Alzheimer’s disease can lead to confusion and disorientation, increasing the risk of falls, wandering, and other accidents. A patient with dementia may become lost or injured due to impaired judgment.
Weakened Immune System: A compromised immune system, resulting from conditions like cancer, HIV/AIDS, or treatments such as chemotherapy, increases susceptibility to infections and complications from injuries.
Physical Barriers: Environmental barriers such as stairs, narrow doorways, and uneven floors pose significant fall risks, especially for individuals with mobility limitations.
Improper Use of Assistive Devices: Incorrectly sized or improperly used assistive devices like wheelchairs, canes, or crutches can increase rather than decrease the risk of falls and injuries.
Unsafe Transportation Practices: Engaging in unsafe modes of transportation, such as not wearing seatbelts, riding motorcycles without helmets, or unsafe pedestrian or cycling habits, significantly increases the risk of severe injury or fatality.
Lack of Knowledge of Environmental Hazards: Insufficient awareness of potential hazards, including toxic chemicals, misuse of assistive devices, or lack of knowledge about fall prevention, greatly heightens the risk of injury.

Nursing Diagnosis: Risk for Injury

Following a comprehensive nursing assessment, the nursing diagnosis Risk for Injury is formulated. This diagnosis reflects the nurse’s clinical judgment about a patient’s vulnerability to harm based on their health status and circumstances. While nursing diagnoses provide a structured approach to care planning, their application in clinical practice is guided by the nurse’s expertise and the specific needs of each patient. In real-world settings, the emphasis is often on tailoring care to individual patient needs, with diagnostic labels serving as a helpful framework rather than a rigid prescription.

For situations where a nursing diagnosis label is useful, Risk for Injury serves as a clear and concise descriptor of the patient’s safety risk.

Goals and Expected Outcomes

The primary goals and expected outcomes for a patient diagnosed with Risk for Injury are:

Risk Factor Identification and Mitigation: Within 8 hours of nursing interventions, the patient will be able to identify personal risk factors that increase their susceptibility to injury and demonstrate behaviors aimed at preventing injury.
Injury Prevention: Within 4 hours of nursing interventions and patient education, the patient will remain free from new injuries.

Nursing Assessment and Rationales

A thorough nursing assessment is critical for identifying specific risks and guiding the development of an individualized care plan. Key assessment areas and their rationales include:

1. Comprehensive Patient Evaluation: Assess the patient’s age, developmental stage, health status, lifestyle, communication abilities, sensory-perceptual function, mobility, cognitive awareness, and decision-making capacity. These factors collectively influence a patient’s ability to protect themselves from injury. A detailed assessment of each area is essential for creating targeted and effective safety measures.

1.1. Age and Developmental Stage: Infants and toddlers explore through sensory experiences, often placing objects in their mouths, increasing choking risks. Older adults may have reduced sensory acuity and mobility issues, predisposing them to falls.
1.2. Health Status and Cognitive Awareness: Changes in health status, such as post-operative confusion or medication side effects (e.g., from antiseizure drugs, depressants, benzodiazepines, hypnotics, opioids), can impair judgment and increase injury risk.
1.3. Lifestyle Factors: Lifestyle elements such as unsafe working conditions, living in high-crime areas, access to weapons, lack of safety equipment due to financial constraints, and misuse of prescription drugs all contribute to injury risk.
1.4. Communication Impairment: Communication barriers, including language differences and speech or hearing difficulties, can hinder a patient’s ability to understand safety information and express needs, increasing the risk of adverse events.
1.5. Sensory-Perceptual Impairment: Loss or impairment of senses (vision, taste, hearing, smell, touch) can compromise a person’s ability to respond to environmental stimuli and hazards, increasing the risk of falls and injuries. For example, impaired smell could prevent detection of gas leaks, and vision loss increases fall risk.

2. Mobility and Fall Risk Assessment: Evaluate the patient’s ability to ambulate and specifically assess fall risk. Mobility alterations due to muscle weakness, paralysis, poor balance, or lack of coordination significantly increase fall risk. The Morse Fall Scale (MFS) is a widely used tool to quantify fall risk based on factors like fall history, secondary diagnoses, use of assistive devices, IV access, gait/transfer ability, and mental status. Scores from the MFS guide the intensity of fall prevention interventions.

For detailed fall risk assessment and interventions, refer to the nursing care plan for Risk for Falls.

3. Physical Injury and Abuse Assessment: Observe for signs of physical injury (bruises, burns, fractures, lacerations, bite marks) and behavioral indicators (social withdrawal, fearfulness). These may suggest intentional injury or abuse, requiring thorough assessment, medical attention, support services, and prevention of further harm. Healthcare providers are legally and ethically obligated to identify and report suspected abuse to social services or Child Protective Services (CPS).

4. Environmental Safety Assessment: Conduct a safety assessment of the patient’s home or care setting, looking for hazards like cords or hooks that could be used for self-harm. Removing such items is crucial for patient safety, especially in mental health settings.

5. Home Hazard Assessment: Assess the home environment for common hazards that increase injury risk, particularly for patients with mobility impairments, visual deficits, cognitive dysfunction (dementia), or a history of falls. Common hazards include throw rugs, clutter, improper storage of cleaning products or medications, and poor lighting.
Refer to the CDC checklist for common home hazards in the Recommended Resources section below.

6. Community Violence Exposure: Assess for exposure to community violence, which is linked to increased aggression and depression, both of which can indirectly increase injury risk through risky behaviors or impaired judgment. Some healthcare facilities engage in community programs to address violence prevention and support vulnerable populations.

Nursing Interventions and Rationales

Therapeutic nursing interventions for patients at risk for injury aim to create a safer environment, educate patients and caregivers, and mitigate specific risk factors:

1. Environmental Orientation and Assistance Access: Familiarize the patient with their surroundings. Ensure the call light is within easy reach and instruct them on how to use it to call for assistance. Environmental familiarity and easy access to help can prevent accidents.

2. Medical Alarm Systems and Alarm Fatigue Management: Utilize medical alert systems as appropriate to monitor physiological status and trigger alerts in emergencies. Be vigilant for alarm fatigue, a critical safety issue where healthcare providers become desensitized to frequent alarms, potentially missing critical alerts. Healthcare organizations should prioritize alarm system safety, identify essential alarms, establish alarm management guidelines, and provide staff education on safe alarm management, as per National Patient Safety Goals.

3. Restraint Alternatives and Judicious Restraint Use: Avoid physical and chemical restraints whenever possible due to associated risks like strangulation, asphyxiation, trauma, and head injury. If restraints are absolutely necessary, obtain a healthcare provider’s order and adhere to ethical principles of proportionality (least restrictive measure) and purposefulness (clear, pre-defined purpose).

4. Restraint Alternatives for Fall and Injury Prevention: Implement alternatives to restraints, such as alarm systems (ankle or wrist bracelets, bed or wheelchair alarms), frequent patient monitoring, secured unit doors, and low bed positioning.

5. Safety Beds for Disoriented Patients: For significantly disoriented patients, consider using specialized safety beds that enclose the patient to prevent falls. Emory cubicle beds may be used for patients with traumatic brain injury. Enclosure beds, requiring a physician’s order, are alternatives to restraints for confused, agitated, or restless patients but are contraindicated for combative or claustrophobic individuals.

6. Reality Orientation and Validation Therapy: For patients with new-onset confusion (delirium), provide reality orientation to reduce confusion and agitation. Encourage family to bring familiar objects and orienting items (clocks, watches). For patients with chronic confusion (dementia), use validation therapy, acknowledging their feelings without directly challenging their reality, which can reduce stress and behavioral disturbances.

7. Family/Caregiver Involvement: Involve family or significant others in patient care to prevent falls and accidental removal of tubes. Parental involvement is particularly crucial in ensuring hospitalized children’s safety and preventing medical errors.

8. Temperature Safety: Avoid temperature extremes (heating pads, excessively hot bathwater). Patients with cognitive or sensory deficits may not accurately perceive temperature extremes, increasing burn risk. Age-related physiological changes and conditions like dementia, peripheral artery disease, and diabetes further increase burn vulnerability.

9. Proximity to Nurses’ Station: Place high-risk patients in rooms near the nurses’ station for closer observation and prompt intervention in case of injury or falls.

10. Validating Patient Concerns: Acknowledge and validate the patient’s feelings and concerns regarding environmental risks. Validation strengthens the nurse-patient relationship and assures the patient that their concerns are heard and understood.

11. Visual Impairment Accommodations: For visually impaired patients, educate them and caregivers on using brightly colored labels (yellow or red) in key locations (stair edges, stove controls, light switches). Ensure adequate lighting in unfamiliar environments. Bright colors are easier to discern for those with visual impairments, aiding in safe navigation.

12. Hand Hygiene: Strictly adhere to handwashing and hand hygiene protocols. Hand hygiene is the single most effective method for preventing infection transmission.

Interventions for Patient Identification Safety

1. Standardized Identification Protocols: Establish and rigorously follow agency protocols for correct patient identification. Use at least two patient identifiers (name, date of birth, ID number, phone number) for verification during admission, transfer, and before medication administration, blood product transfusion, or any nursing care. This improves identification reliability and prevents errors, especially when verbal communication is limited (newborns, unconscious or confused patients).

2. Correct Patient Identification Practices: Consistently use two identifiers to verify patient identity before any procedure, treatment, or medication administration to prevent misidentification.

3. Medical Identification Bracelets: Provide medical identification bracelets for patients at risk, especially those with dementia, seizures, or other medical conditions. Bracelets alert healthcare providers to conditions requiring specific safety measures.

4. Standardized System for Unidentified Patients: Implement a standardized system for identifying patients lacking identification and for differentiating patients with similar names. Use additional details (date of birth, address) and computer alerts for similar names to ensure accurate patient identification.

5. Biometric Identification for Non-Verbal Patients: Use non-verbal methods like biometrics for identifying unconscious or confused patients to prevent misidentification when verbal confirmation is impossible.

6. Specimen Labeling at Bedside: Label blood and other specimen containers in the patient’s presence, including patient name, date, time of collection, and collector’s identification. Barcoding is an effective best practice for minimizing specimen identification errors in laboratory testing.

7. Active Patient Communication During Identification: When possible, use active communication by asking the patient to verbally state their name and date of birth instead of relying on yes/no questions for confirmation.

Interventions to Prevent Medication Errors

1. “10 Rights of Medication Administration”: Strictly adhere to the “10 Rights of Medication Administration” to prevent medication errors.
Learn more about the “10 Rights of Medication Administration” here.

2. Medication Labeling: Label all medications, drug containers (cups, bottles, syringes, basins), and solutions, whether in sterile areas or not, if removed from original packaging. Include drug name, concentration, amount, diluent, and volume. Discard unlabeled medications or solutions.

3. Medication Reconciliation: Ensure accurate and complete medication information transfer during admission, transfer, and discharge through medication reconciliation. This process compares current medications with newly prescribed medications to prevent discrepancies like contraindications, omissions, duplications, incorrect doses, and adverse drug events. Medication reconciliation involves:

Obtaining a complete current medication list.
Obtaining a list of newly prescribed medications.
Comparing and reconciling all medications.
Applying clinical judgment based on comparisons.
Communicating the updated list to the patient and healthcare team.
Provide written discharge instructions with medication names, purposes, doses, frequency, and routes for patients and caregivers.

4. Anticoagulant Therapy Precautions: Exercise extra caution for patients on anticoagulant therapy due to risks of bleeding and adverse drug events from complex dosing, monitoring, and compliance issues.

5. Medication Regimen Review: Regularly review the patient’s medication regimen for potential side effects and interactions that could increase injury risk. Polypharmacy (multiple medications, especially sedatives, psychotropics, hypoglycemics, antihypertensives, antiarrhythmics, diuretics, anticonvulsants) increases the risk of gait disturbances, falls, and burns, especially in older adults.

Interventions to Prevent Trauma During Seizures

1. Seizure Warning Sign Education: Teach patients and caregivers to recognize seizure warning signs and provide education on seizure care during and after events. This empowers patients to protect themselves and recognize when to seek medical attention, while also preparing caregivers to respond effectively.

2. Seizure Activity Monitoring and Documentation: Monitor and record seizure type, onset, duration, and characteristics to guide treatment, classify seizure type, and identify potential triggers.

3. Safe Thermometer Use: Avoid glass thermometers that could break during a seizure. Use tympanic thermometers for temperature measurement.

4. Bed Rest During Prodromal Phase: Enforce strict bed rest if prodromal signs or an aura occurs to ensure patient safety in a controlled environment.

5. Head Positioning and Airway Management: During a seizure, turn the patient’s head to the side to allow secretions to drain, minimizing aspiration risk. Suction airway as needed. Do not force objects into the mouth if teeth are clenched, as this can cause dental and soft tissue damage.

6. Head and Extremity Protection: Support the patient’s head, place it on a padded surface, or assist the patient to the floor if out of bed to reduce physical injury from uncontrolled movements.

7. Hazard Removal: Remove potential hazards from the patient’s room, such as razors, medications, and matches, to prevent injury during or after a seizure.

8. Avoid Restraints During Seizure: Do not restrain the patient during a seizure. Instead, gently guide movements to prevent injury from flailing.

9. Antiepileptic Drug Monitoring: Monitor and document antiepileptic drug levels, side effects, and seizure frequency to optimize medication management and seizure control.

10. Positioning and Airway Maintenance: Maintain a lying position on a flat surface and turn the head to the side during a seizure to keep the airway clear and protect the patient from injury. Remove nearby objects.

11. Clothing and Secretion Management: Loosen constrictive clothing around the neck, chest, and abdomen. Suction secretions as needed to maintain airway patency.

12. Supplemental Oxygen/Ventilation: Provide supplemental oxygen or bag ventilation postictally as needed to address potential cerebral hypoxia due to reduced circulation and oxygenation during a seizure.

13. Disease Education: Educate patients on the pathology and prognosis of their condition, the lifelong need for treatment, and individual seizure triggers (flashing lights, hyperventilation, loud noises, video games, TV). Emphasize oral hygiene, regular dental care, medication regimen adherence, and management of missed doses.
Visit our nursing care management guide for patients with seizures here.

Interventions to Prevent Injury Due to Impaired Mobility

1. Chair and Wheelchair Safety: Assist patients when sitting and standing. Limit wheelchair and Geri-chair use to transportation only, as patients may attempt to stand without locking wheels or removing footrests, increasing fall risk.

2. Proper Wheelchair Fit: Ensure chairs and wheelchairs are properly fitted to the patient’s build, abilities, and needs to allow for leg/arm propulsion and floor reach. Eliminate footrests and minimize shearing issues. Proper seating systems are essential for mobility, function, and preventing further health problems.

3. Limiting Wheelchair Use as Restraint: Minimize wheelchair use as it can act as a restraint. Use restraints only as a last resort when benefits outweigh harm. Poorly fitted wheelchairs can cause shoulder injuries and skin breakdown.

4. Assistive Transfer Devices: Use assistive devices (pillows, gait belts, slider boards) during patient transfers to reduce injury risk for both patients and healthcare providers. Slider boards are particularly helpful for patients with mobility issues, balance deficits, paraplegia, or amputations.

5. Proper Body Mechanics: Apply principles of proper body mechanics before any procedure, such as raising the head of the bed and tucking elbows, to minimize muscle and bone strain and facilitate physical mobility safely.

6. Physical and Occupational Therapy Collaboration: Coordinate with physical therapists for strengthening exercises and gait training to improve mobility and prevent falls. Consult occupational therapists for assistance with ADL performance. Collaborative care enhances patient safety and functional outcomes.

7. Home Safety Education: Educate patients on safe ambulation at home, including using grab bars in bathrooms, non-slip footwear, and requesting assistance when needed. Home safety assessments and education are vital for maximizing health outcomes and promoting independent living.

Client Teaching: Preventing Back Injuries

The lower back is crucial for balance and daily activities. Injury can impact hips and extremities. Prevention is key. Risks include poor posture, lumbar strain (obesity, high heels), and weak back muscles from sedentary lifestyles.

Tips for back injury prevention:

Maintain Good Posture: Be mindful of alignment. When standing, align head and shoulders. Shift weight or prop foot for prolonged standing. Sit straight with back support, change position every 30 minutes.
Know Lifting Limits: Avoid lifting over 51 pounds. Use leg and arm muscles. Use aids or help for heavy loads. Caution for all ages/strengths.
Lifting Best Practices: Keep center of gravity close to object. Wide base of support. Avoid twisting. Push/pull instead of lifting when possible.
Regular Exercise: Strengthen core muscles. Cardio improves spine blood flow.
Minimize Accident Risks: Wear low-heeled, non-skid shoes for balance.
Boost Overall Health: Spine health links to overall health. Stay hydrated, limit alcohol, quit smoking, ensure quality sleep.

Recommended Resources

Explore these recommended nursing diagnosis and care plan books and resources.

Disclosure: Affiliate links from Amazon are included; we may earn a small commission at no extra cost to you. See our privacy policy for more information.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care Evidence-based approach to nursing interventions. Three-step system for assessment, diagnosis, and care planning. Step-by-step instructions for implementation and outcome evaluation. Diagnostic reasoning and critical thinking skill development.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Over 200 evidence-based care plans. Includes ICNP diagnoses, LGBTQ health, electrolytes, and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick reference for diagnoses and care planning. Updated with latest nursing diagnoses and interventions. Alphabetical listing of diagnoses for over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Interventions for over 800 diseases/disorders. Subjective/objective data, clinical applications, prioritized actions, rationales, documentation section.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric-mental health. Interprofessional “patient problems” focus.

References and Sources

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